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Postpartum Haemorrhage

 

There are two types of postpartum haemorrhage (PPH):

 

Primary PPH - occurs in the third stage of labour. It is defined as a loss of blood from the genital tract within the first 24 hours after birth.  

 

Secondary PPH - occurs 24h-12 weeks after birth (end of puerperium).

 

    Why do I need to know about PPH?

     

    PPH is a leading cause of peri-natal mortality in developing countries (1/1,000) and more surprisingly in developed  countries (1/100,000).

     

    It is largely preventable and adequate education of healthcare professionals in recognising and treating the condition can prevent unecessary ICU admission and mortality in these women.

     

    Risk factors for PPH

     

    Risk factors may be present in the patient's obstetric history however, in the majority of cases of both primary and secondary PPH there are no identifiable risk factors.

     

    Identifiable risk factors can be summarised as the 4Ts:

     

    What Should Happen?

       

      • Latent phase: the interval from delivery of the fetus to the beginning of myometrial contractions which lead to placental separation
      • Contraction phase: contraction of the myometrium at the placental site.
      • Detachment phase: contraction of the myometrium at the placental site leads to shearing of the placenta off of the uterus.
      • Expulsion phase: the separated placenta is extruded from the uterus into the vagina.

       

        How do I recognise PPH?

         

        How much blood is lost?

         It is normal to expect 200-300ml of blood loss

        • PPH >500ml
        • Severe PPH (SPPH) >1000ml
        • Life-threatening > 2500ml/40% total blood volume

         

           

          How do I calculate blood volume in litres?

          • Weight (kg)/12= X (L)

             

            Actual blood loss can be difficult to gauge therefore close observation of the patient for signs of shock is required. Patients may complain of lightheadedness, weakness and palpitations. On examination, they may be tachycardic and hypotensive. Vaginal bleeding is not always present, particularly when the patient has undergone a caesarean. Bleeding may also be underestimated depending on the position of the patient.

             

            What are the clinical signs of shock?

            • tachycardia,
            • hypotension
            • tachypnoea
            • oliguria
            • delayed peripheral capillary refill

             

            What else could be wrong with the patient?

            These symptoms and signs can be commonly mistaken for the side-effects of an epidural block. An epidural block does not cause tachycardia or hypotension.

             

              Clinical care of PPH

               

              Primary PPH tends to be more severe than secondary PPH and is an obstetric emergency so you must call your seniors immediately.

               

              Active management

              • Uterotonics such as oxytocin reduces the risk of PPH by 60% when given prophylactically. (Syntocinon = synthetic oxytocin and is contra-indicated in patients with hypertension). Carbetocin is used to prevent PPH in caesarean delivery

               

              • Early clamping of the umbilical cord

               

              • Controlled traction of the placenta

                 

                In a homebirth setting or where uterotropics are not available, Misoprostol (synthetic Prostaglandin E1) may be given to encourage uterine contraction. 

                 

                Primary PPH

                 

                Management of Primary PPH:

                 

                Scenario 1: the patient has lost 500-1000ml blood and has no clinical features of shock

                • ABC: oxygen and IV access
                • Clinical examination for the cause of haemorrhage
                • Investigations: FBC, coagulation screen, U&Es, group and save / cross match

                 

                In most cases of primary PPH, uterine atony is the cause. To manage this:

                 

                • bimanual uterine compression and fundal massage stimulates contractions
                • ensure the bladder is empty
                • administer Syntocinon (synthetic oxytocin) (5 units i.v), Ergometrine (0.5mg i.v/i.m) and Carboprost/Haemabate (synthetic PGF2) (0.25mg i.m)
                • 1000micrograms misoprostol (rectal) may also be used if it is suspected that uterine atony is the underlying cause
                • Hayman sutures encourage uterine tone (Ghezzi et al, 2007)
                • In cases of severe PPH, uterine artery embolisation is the suggested method of treatment (Soncini et al, 2007) in both primary and secondary PPH.

                 

                What about tranexamic acid? RCOG rarely values the use of tranexamic acid in obstetric haemorrhage.

                 

                Secondary PPH

                 

                Secondary PPH occurs between 24h and 12 weeks after delivery. Bleeding is less severe than in primary PPH. The cause is often uterine atony or retained products of conception. Secondary PPH commonly presents to primary care where a full obstetric and haematological history should be obtained. 

                 

                Investigations:

                • FBC
                • Blood cultures
                • Midstream Urine
                • High vaginal swab
                • Ultrasound can also be used to detect retained products of conception

                 

                Long and complicated labour increase the risk of translocation of flora. Group B Streptococcus (gram +ve) organisms often cause endometritis. Endometritis is often polymicrobial and if endometritis is suspected then broad-spectrum antibiotics are required.

                • in a primary care setting, amoxicillin or co-amoxiclav is indicated
                • in a secondary care setting, ampicillin or clindamycin and metronidazole is recommended (RCOG, 2009). Gentamycin is recommended in more severe cases.

                   

                  Complications

                   

                  Complications of PPH include:

                   

                  • sequelae of hypovolaemia (shock, renal failure)
                  • DIC
                  • sepsis
                  • tranfusion or anaesthetic reaction
                  • fluid overload (pulmonary oedema)
                  • DVT, VTE
                  • anaemia (normocytic normochromic)
                  • Sheehan syndrome (postpartum hypopituitarism from pituitary necrosis) which can present as failure to lactate.

                   

                    Example cases

                     

                    Case 1

                     A 25 year old female presents to her GP with thick, smelly and bloody discharge two weeks after the delivery of her first child. She was otherwise well and was recovering at home from the uncomplicated birth of her child. On examination, the lady was pyrexial and was tender over the suprapubic region. 

                     

                    Q1. What sort of PPH is this?

                    Q2. What is the likely pathology?

                    Q3. What was the GP's course of management?

                     

                     

                    Case 2

                    A 38 year old female undergoes IVF abroad. She has two embryo transfers and subsequent triplets (One singleton and monochorionic diamniotic twins). Having been listed for an elective lower segment caesarean section, she goes into spontaneous labour at 32+3 weeks. The patient immediately becomes tachycardic and hypotensive and there is blood on the floor.

                     

                    Q1. This case is an example of what type of PPH?

                    Q2. What is the likely cause of the PPH and what are the associated risk factors which are likely to have contributed to this case?

                    Q3. Which drugs were likely to be administered?

                    Q4. It is estimated that this patient lost 2.7L of blood. Was she likely to need a blood transfusion?

                     

                    References

                    F. Ghezzi, A. Cromi, S. Uccella, L. Raio, P. Bolis and D. Surbek. The Hayman technique: a simple method to treat postpartum haemorrhage. International Journal of Obstetrics and Gynaecology (2007).

                    A. Jacobs, Overview of Postpartum Haemorrhage. www.uptodate.com (2011)

                    F. Silverman and E. Bornstein. Management of the Third Stage of Labour. www.uptodate.com (2011)

                    E. Soncini, A Pelicelli, P. Larini, C. Marcato, D. Monaco and A. Grignaffini. Uterine artery embolization in the treatment and prevention of postpartum haemorrhage. International Journal of Gynaecology and Obstetrics (2007) 96, 181-185

                    Royal College of Obstetricians and Gynaecologists. Prevention and Management of Postpartum Haemorrhage. Green-top Guideline No.52 (2009).

                    L. Vorvick, S. Storck. Sheehan syndrome (2010)

                    Further information

                     

                     

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