Outline the causes and management of severe postpartum haemorrhage (PPH).
Causes can be broken down into 4 main groups: the “4 T’s”
Tone: uterine atony (most common)
Trauma: Bleeding at surgical sites including episiotomy, genital tract laceration [vagina/cervix etc], uterine rupture
Tissue: Retained tissue (placenta) and/or membranes
Thrombin: Previously present or acquired maternal coagulation defect. Examples of acquired defects
include those seen in severe pre-eclampsia, severe sepsis, amniotic fluid embolism, placental abruption or in the setting of massive transfusion.
Management can be broken down into initial resuscitation and specific treatment, with specific treatment having surgical and non-surgical modalities. Resuscitation and treatment should occur simultaneously.
ABCDE approach. Assemble team (ICU/Anaesthesia/Obstetrics etc)
Appropriate monitoring: ECG / NIBP / Arterial line / CVC if time or indication
Large bore IV access x2
Initial resuscitation with crystalloids / 4% albumin
Activation of PPH protocol
Activation of massive transfusion protocol / Use O neg blood (but likely to know blood group already and use group specific blood) early if no X matched blood available
No specific Hb triggers for when to use blood, suggested after no more than 30mls/kg resusc fluids or evidence of ongoing bleeding
Other products as required: NBA Obstetric guidelines suggest FFP 15mls/kg, platelets 1 pooled bag, cryoprecipitate 3-4g (8-10 bags): use local protocols if possible and involve specialist Haematologist. Keep fibrinogen >2.0 or replace if dropping (normal in pregnancy 4-6g/L: use cryoprecipitate or fibrinogen concentrate) Emphasis on early fibrinogen
Avoid hypothermia, hypocalcaemia and acidosis
Bimanual uterine compression
Pharmacological Therapy (uterotonics): oxytocin, misoprostol, prostaglandin F2 alpha
Tranexamic Acid (TXA): [the WOMAN trial showed a substantial mortality benefit if given within 3 hours]
Balloon tamponade (Bakri balloon)
Interventional Radiology: selective arterial embolization/balloon tamponade Consider Factor VIIa as rescue therapy
EUA: repair of lacerations / evacuation of retained placental fragments etc
Laparotomy: Uterine or iliac artery ligation, B-lynch brace suture
Aortic compression / X clamp
Causes of PPH
It is not possible to add much to the (already comprehensive) list of causes offered by the model answer.
Management of PPH
This structure and a lot of the components are borrowed from the RANZCOG statement C-Obs 43.
Oh's Manual, Chapter 64 ("General obstetric emergencies") by Winnie TP Wan and Tony Gin, p. 684
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