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Postpartum-Haemorrhage 2 slides.ppt
- 2. Definitions • Primary PPH – blood loss of 500ml or more within 24hours of delivery. • Secondary PPH – significant blood loss between 24 hours and 6 weeks after birth.
- 3. Why do we care? Major obstetric haemorrhage – more than 1000ml Very rapidly lead to maternal death
- 4. • 3rd highest cause of direct maternal death in the UK and Ireland (2003-2005) • 58% of these cases care was “seriously substandard” • Major cause of severe maternal morbidity in “near-miss audits”
- 5. Risk Factors Most cases have no risk factors • Previous PPH • Antepartum haemorrhage • Grand multiparity • Multiple pregnancy • Polyhydramnios • Fibroids • Placenta praevia • Prolonged labour (&oxytocin)
- 6. Prevention • Be aware of risk factors – may present antenatally or intrapartum • Treat anaemia antenatally • Active management of the 3rd stage • Prophylactic oxytocics reduce the risk of PPH by 60% (oxytocin or oxytocin & ergometrine) • 5IU IM for vaginal delivery • 5IU IV for LSCS • Consider oxytocin infusions
- 8. Causes Tone Previous PPH Prolonged labour Age > 40 years Big baby Multiple pregnancy Placenta praevia Obesity Asian ethnicity Tissue Retained placenta/ membrane/clot
- 9. Thrombin Abruption PET Pyrexia Intrauterine death Amniotic fluid embolism DIC Trauma Caesarean section (emergency > elective) Perineal trauma Operative delivery Vaginal and cervical tears Uterine rupture
- 10. • Blood loss is commonly underestimated • Loss may be well-tolerated • Beware the “trickle” and the “moderate lochia” • Minor PPH can easily progress to major PPH.
- 11. Management • Has the placenta been delivered and is it complete? • Is the uterus well-contracted? • Is the bleeding due to trauma?
- 12. Resuscitation A & B – 10 -15l/min O2 by facemask C - 2 14 gauge cannulae blood for Hb, U&E, LFTs, clotting crossmatch 4 units 2 litres of crystalloid rapidly transfuse as soon as possible – consider O – ve blood if any delays.
- 13. Uterine Contraction-First Line Drugs • Oxytocin 5IU • Oxtocin infusion – 40IU in 500mls • Ergometrine 0.5mg • Carboprost (Haemabate©) 0.25mg IM every 15 minutes x 8 doses • Misoprostol 600 mcg sublingually
- 14. Uterine Contraction – non-pharm • Empty uterus • Foley catheter • Rub up a contraction • Bimanual compression • Balloon tamponade • Brace suture • Uterine artery ligation • Internal iliac artery ligation • Interventional radiology
- 15. • Hysterectomy – before it’s too late
- 17. B-Lynch Suture
- 19. Haematological Management DIC • Transfuse without delay • Involve haematology service at an early stage • Correct coagulopathy • Liase with consultant haematologist re use of recombinant Factor V11 (Novoseven©) and Fibrinogen.
- 20. • Traumatic for patient, family and staff. • Debriefing for patient and staff. • Case analysed to ensure care was of good standard and any substandard care can be improved.
- 21. Secondary PPH • Infection • Retained placenta • Trophoblastic disease • Antibiotics • Evacuation of retained products if bleeding persistent or significant amount of tissue retained.