post partum haemorrhage n.
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Post Partum Haemorrhage
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  1. Post Partum Haemorrhage Dr. Shavi Fernando Level 3 Registrar Teaching session 2011 Dandenong Hospital

  2. Introduction • Uterine blood flow up to 750ml/min at term • Recently gravid uteri dump blood FAST • PPH needs respect and understanding!

  3. Definitions

  4. Definitions Primary – within 24/24 Secondary – 24/24 to 6/52 Volumes NVD >500ml LUSCS >750ml

  5. Risk Factors

  6. Risk Factors Maternal • Multigravida • Prolonged labour/second stage • Instrumental delivery/Caesarean • Past history (PPH/manual removal etc) • Previous uterine surgery • Uterine abnormalities (eg fibroids) Fetal • Polyhydramnios/Macrosomia • Multiple gestation Placental • Praevia/accreta/percreta • Retained placenta

  7. Causes

  8. Causes Tone – 70-90% Tissue (retained) - Placenta/membranes/clots Trauma • Cervical/vaginal/uterine (eg inversion/rupture) Thrombin - Bleeding tendency (eg. DIC, vWD)

  9. Management

  10. Management Initial/Resuscitative Medical Operative

  11. Initial Management

  12. Initial Management Call for help Resuscitation – DRABC IV Cannulae • Bloods (Which ones?) • Fluids (Which ones?) IDC Evacuation of clots Bimanual compression Father and baby What do you do if the placenta is still in situ?

  13. Medical Management

  14. Medical Management Syntocinon injection • 10units IM (3rd stage) Syntometrine (IM) /ergometrine (IV) • Beware in hypertension, asthma, cardiac disease • Ergo faster, but needs IV Syntocinon infusion - Quick acting, well tolerated Misoprostol - Beware in asthmatics PGF2a - Contraindicated in asthma

  15. Operative Management

  16. Operative Management Multidisciplinary • Anaesthetics/haematologist/gynae onc/ICU - EUA • remove retained products etc - Bakri Balloon – 300-500ml water • Maximum 24/24 - B Lynch - Iliac artery ligation - Hysterectomy

  17. What about afterwards? • Consider need for ICU • FBE the next day (or after 6/24 depending on loss) • Debrief • Patient • Partner • Staff • Yourself • Document and reflect

  18. Secondary PPH • Generally caused by Retained products • Primary management is with antibiotics (IV or oral) • Ultrasound ONLY if heavy bleeding or failure of antibiotic therapy • Suction curette if loss >500ml and not controlled by uterotonics

  19. Case • 30 yo G3P2 (2 x NVD) • GDM on insulin

  20. Summary • Recently gravid uteri dump blood FAST • Get help EARLY • Start management EARLY • DON’T forget simple resuscitative measures • Assess need for and attend theatre EARLY • May be useful to give medical uterotonics simultaneously while instituting other measures • Secondary PPH – generally managed with antibiotics