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Post Partum Haemorrhage Dr. Shavi Fernando Level 3 Registrar Teaching session 2011 Dandenong Hospital
Introduction • Uterine blood flow up to 750ml/min at term • Recently gravid uteri dump blood FAST • PPH needs respect and understanding!
Definitions Primary – within 24/24 Secondary – 24/24 to 6/52 Volumes NVD >500ml LUSCS >750ml
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
Causes Tone – 70-90% Tissue (retained) - Placenta/membranes/clots Trauma • Cervical/vaginal/uterine (eg inversion/rupture) Thrombin - Bleeding tendency (eg. DIC, vWD)
Management Initial/Resuscitative Medical Operative
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?
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
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
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
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
Case • 30 yo G3P2 (2 x NVD) • GDM on insulin
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