Question 22

Last updated 15/10/2021 - 05:24
 Topic: Pregnancy, Obstetrics and Gynaecology
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Outline the causes and management of severe postpartum haemorrhage (PPH).

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College answer

Not available.

Discussion

This question is identical to Question 17 from the second paper of 2018, and is almost identical to the very similarly structured Question 3 from the second paper of 2020. Why they went back to the 2018 format is a mystery.

Causes of PPH

It is not possible to add much to the (already comprehensive) list of causes offered by the model answer. 

  • Uterine atony
    • Prolonged labor
    • Polyhydramnios
    • Multiple gestations
    • Chorioamnionitis
    • Oxytocin augmentation of labor
  • Peripartum uterine trauma
    • Instrumental delivery
    • Surgical mishap
    • Laceration during labour (including episiotomy)
    • Uterine rupture
  • Postpartum retained products
    • Placenta 
    • Membranes
  • Coagulopathy
    • DIC
    • Amniotic fluid embolism
    • Sepsis 
    • Intrauterine foetal demise
    • HELP
    • Massive transfusion
  • Placental abnormality
    • Placenta previa
    • Placental abruption

Management of PPH

This structure and a lot of the components are borrowed from the RANZCOG statement C-Obs 43.

Resuscitation

  • A: either secure the airway if unprotected,  or prepare to do so with appropriate expertise (i.e. get an anaesthetist)
  • B: preoxygenate with high flow oxygen
  • C: establish IV access and give a fluid bolus; avoid hypothermia and use fluid warmers
  • D: reassure patient and ensure analgesia is adequate
  • E: correct ionised calcium (essential component of clotting); corrrect acidosis
  • F: monitor fluid resuscitation efficacy by observing urine output
  • G: fast the patient in preparation for surgery
  • H: correct coagulopathy and commence transfusion
    • Activate massive transfusion protocol: the college answer to Question 17 from the second paper of 2018 mentions the National Blood Authority's obstetric guidelines, which are endoresed by CICM. The guidelines recommend:
      • FFP: 15 mL/kg
      • platelets: 1 adult therapeutic dose
      • cryoprecipitate: 3–4 g
    • Fibrinogen is all-important- the same NBA guidelines recommend a fibrinogen level of > 2.0 as a therapeutic  target
    • Tranexamic acid is also known to be beneficial (WOMAN trial -Shakur et al, 2017) - to be given within 3 hours of haemorrhage
  • I: antibiotics are not routinely indicated for primary PPH outside of the scenario of septic abortion or endometritis. 

Specific management

  • Uterine massage
  • Bimanual compression
  • Manual aortic compression
  • Oxytocin
  • Ergometrine
  • Carboprost
  • Misoprostol
  • Gause pack or balloon tamponade
  • Angioembolisation
  • Brace sutures
  • Ligation of the uterine artery
  • Hysterectomy

References

Oh's Manual, Chapter 64 ("General obstetric emergencies") by Winnie TP Wan and Tony Gin, p. 684

Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage." The Cochrane Library (2014).

Tunçalp, Özge, G. Justus "Prostaglandins for preventing postpartum haemorrhage."Hofmeyr, and A. Metin Gülmezoglu. "Prostaglandins for preventing postpartum haemorrhage." Cochrane Database Syst Rev 8.8 (2012): CD000494.

Alfirevic, Zarko, et al. "Use of recombinant activated factor VII in primary postpartum hemorrhage: the Northern European registry 2000–2004." Obstetrics & Gynecology 110.6 (2007): 1270-1278.

Dahlke, Joshua D., et al. "Prevention and management of postpartum hemorrhage: a comparison of 4 national guidelines." American journal of obstetrics and gynecology 213.1 (2015): 76-e1.

Doumouchtsis, S. K., et al. "Menstrual and fertility outcomes following the surgical management of postpartum haemorrhage: a systematic review." BJOG: An International Journal of Obstetrics & Gynaecology 121.4 (2014): 382-388.

Smith, J., and H. A. Mousa. "Peripartum hysterectomy for primary postpartum haemorrhage: incidence and maternal morbidity." Journal of obstetrics and gynaecology 27.1 (2007): 44-47.

World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage. World Health Organization, 2012.

Weeks, A. "The prevention and treatment of postpartum haemorrhage: what do we know, and where do we go to next?." BJOG: An International Journal of Obstetrics & Gynaecology122.2 (2015): 202-210.

Edhi, Muhammad Muzzammil, et al. "Post partum hemorrhage: causes and management." BMC research notes6.1 (2013): 236.

Sheiner, Eyal, et al. "Obstetric risk factors and outcome of pregnancies complicated with early postpartum hemorrhage: a population-based study." The Journal of Maternal-Fetal & Neonatal Medicine 18.3 (2005): 149-154.

Mousa, Hatem A., and Steven Walkinshaw. "Major postpartum haemorrhage." Current opinion in Obstetrics and Gynecology13.6 (2001): 595-603.

Mousa, Hatem A., et al. "Treatment for primary postpartum haemorrhage." Cochrane Database Syst Rev 2.2 (2014): CD003249.

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