PPH

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

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

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.

the clinical signs of shock?

tachycardia, hypotension tachypnoea oliguria delayed peripheral capillary refill

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 In cases of severe PPH, uterine artery embolisation is the suggested method of treatment (in both primary and secondary PPH.

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 (Gentamycin is recommended in more severe cases.

Complications

Complications of PPH include:

sequelae of hypovolaemia (shock, renal failure) 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.