Gab Kovacs1 and Paula Briggs2
(1)
Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia
(2)
Sexual and Reproductive Health, Southport and Ormskirk Hospital, Southport, UK
Definition
Incidence
Aetilogy and Pathogenesis
Clinical Assessment
History
Examination
Investigations
Treatment
Primary PPH
Secondary PPH
Complications
Prognosis
Definition
Bleeding from the genital tract in excess of 500 ml, associated with delivery. Blood loss of over 1000 ml is classified as major, and more than 2,000 ml as severe.
PPH occurs within 3 months of delivery and is considered primary within 24 h and secondary after 24 h.
Incidence
It is estimated globally that about one in ten births are associated with PPH. It is more common in primigravidae, after multiple pregnancy, in association with an APH, a large baby, prolonged or augmented labour, pre-eclampsia, previous APH, and is influenced by how the third stage of labour is managed (use of oxytocics decreases risk).
Aetilogy and Pathogenesis
There are three broad causes of PPH:
1.
2.
3.
This is sometimes known as the four “T”s- Tone/Tissue/Trauma/Thrombosis
A number of steps should routinely be taken to decrease the risk of PPH:
· Active management of the third stage of labour – use of oxytocics, early cord clamping and controlled cord traction all reduce the risk of PPH.
Clinical Assessment
History
Did the placenta appear complete at delivery
Examination
Vital signs (Pulse, BP, O2 saturation)
Investigations
· Full blood count
· Coagulation screen
· Consider baseline renal and liver function tests
· Monitor urine output (catheter and fluid balance)
Treatment
Primary PPH
Medical
· Hormonal/Medical
· Ergometrine 0.5 mg (if no hypertension) intramuscular injection or slow intravenous injection
· Syntocinon 5 Units IV if BP elevated (can be repeated)
· Syntocinon infusion to keep the uterus contracted (40 units in 500 ml at a 4 hourly rate)
Ensure adequate intravenous access
Cross match blood and transfuse as needed
If bleeding continues one or more of the following options can be used:
· Misoprostol 1,000 ug rectally
· Carboprost (a prostaglandin) 0.25 mg given intramuscularly every 15 min (maximum 8 doses)
· Carboprost 0.5 mg by intramyometrial injection (off license)
Surgical
· Minor – Examination under anaesthesia (EUA) and evacuation of retained products of conception (ERPC)
· Balloon tamponade
· Major – Bilateral ligation of the uterine arteries
· Hysterectomy
Secondary PPH
This is almost always associated with infection (endometritis)
Medical
After appropriate swabs/?blood cultures have been taken, antibiotics should be administered
Surgical
EUA and ERPC with due care as there is an increased risk of perforation
Complications
Hypovolaemic shock, renal failure, disseminated intravascular clotting (DIC), hepatic failure, adult respiratory distress syndrome and death.
Prognosis
If adequate resuscitation and management is undertaken, there should be no long term sequelae.