see also: [[antepartum haemorrhage]] see: - [RWH - postpartum haemorrhage](x-devonthink-item://48E6DE33-34DE-45F0-9CB2-BA2E8A27916B) - [Dunn - postpartum haemorrhage](x-devonthink-item://67C489C2-8D51-4C56-BDEB-0BA924E89B17) > [!key points] > **definition**: haemorrhage of more than 500 mL after vaginal delivery. *major PPH* is 1000mL blood loss or any blood loss that causes significant haemodynamic compromise. > **mnemonic**:: four Ts - Tone, Trauma, Tissue, Thrombin - most common complication of labour and delivery - most common cause is uterine atony - Primary PPH = first 24h - Secondary PPH = > 24h - 6-12 weeks # Causes ![[Pasted image 20240311225621.png]] **Tone** (70%): atonic uterus - Prolonged labour and particularly prolonged 2nd stage of labour - Increasing Parity - Oxytocin withdrawal - Uterine overdistension - Multiple pregnancy, Polyhydramnios, Macrosomia Instrumental Birth Retained Products of Conception **Trauma** (20%) - Laceration of the cervix, vagina and perineum - Uterine rupture or inversion - Non-genital tract trauma (e.g. subcapsular liver rupture) **Tissue** (10%) - [[antepartum haemorrhage#Placenta praevia|placenta previa]], placenta accreta (part of placenta attaches abnormally to myometrium) - uterine inversion Retained products, placental (cotyledons or succenturiate lobe), membranes or clots, abnormal placenta **Thrombin** (<1%) - Coagulation abnormalities - DIC - HELLP - Amniotic fluid embolism - Maternal blood disorders: von Willebrand disease, idiopathic thrombocytopaenic purpura, thrombocytopaenia caused by pre-eclampsia/ gestational hypertension ## Tone *uterine atony* - ## Trauma - uterine rupture - laceration of perineum, rectum, cervix, vagina, vulva, or urethra ## Tissue - ==placenta accreta==, placenta increta, and placenta percreta describe various degrees of abnormal placental attachment to the uterus. - *placenta accreta* -- the placenta adheres to the myometrium without invading the decidua basalis. - placenta increta, the villi extend into the myometrium - placenta percreta the placenta penetrates the full thickness of the myometrium. - retained products of conception ## Thrombin - [[DIC]] can occur as a consequence of [[placental abruption]], [[Pre-eclampsia|Eclampsia]], [[amniotic fluid embolism]], postpartum infections, and dilution of clotting factors caused by aggressive volume resuscitation. Also, retained products of conception and dead fetal tissue contain excess thromboplastin, which can precipitate DIC # Treatment - uterine compression - **empty bladder**, **fundal massage**, firm bimanual compression - TXA 1g IV over 10 min - **oxytocin 10 units** IM or IV OR **Syntocinon** 10 IU IM/IV or **Syntormeterine** (which is oxytocin/ergometrine) 1mL IM (Syntometerine/ergometrine contraindicated if HTN) - after initial resus will start oxytocin infusion 40 units in 1L NacL at 250mL/H - **ergometrine** 0.25mg IV and IM - ondansetron 4mg IV - carboprost 250mcg (1mL) IM + loperimide 4mg oral to deal with side effect of diarrhoea - misoprostol 600mcg buccal for PPx - pelvic vessel embolisation via IR vs uterine haemostatic suture/ligation/hystrectomy in theatre - uterine packing -- risk of infection - uterine exploration and removal of placenta - likely give [[cryoprecipitate]] as part of [[Massive blood transfusion]] with target fibrinogen >2 ![[Pasted image 20240311230546.png]] # complications - sheehan syndrome (pituitary infarction) if significant blood loss causing shock and needing transfusion → can present with lethargy, anorexia, weight loss, and inability to lactate during the first days or weeks after delivery. Results in acquired [[Adrenal insufficiency]] # Related Questions ## labour - [ ] 3Q: [Shoulder dystocia](x-devonthink-item://4134DDB3-6E12-474A-9F6F-64135C0C6048?page=8) -- [Answer](x-devonthink-item://AC92B5F1-8EE6-461A-B03E-F70AE7DC1275?page=8) - [ ] 4Q: [Delivery in the Emergency Department](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=7) -- [Answer]() - [x] 5Q: [Delivery](x-devonthink-item://85167CB5-A7B5-4BF3-9BC7-AC46D5538A42?page=9) -- [Answer](x-devonthink-item://5B03E66C-E043-4EB7-A5F6-7389CB927BD7?page=12) - [ ] 6Q: [Precipitous labour](x-devonthink-item://1A2C485F-D4AD-4821-AFF2-452BA753717F?page=28) -- [Answer](x-devonthink-item://FD716379-1A77-4B5B-B257-1154995ECA6E?page=16) ## post partum haemorrhage - [ ] 7Q: [Post partum haemorrhage](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=80) -- [Answer](x-devonthink-item://554C45F7-8661-4467-BD61-8A79B6ECABF4?page=81) - [x] DUPLICATE Q: [Delivery in the Emergency Department](x-devonthink-item://EE8AC47E-BE40-4377-885E-FA9C91C8C262?page=7) -- [Answer]() - [ ] 8Q: [Post partum haemorrhage](x-devonthink-item://5DC0999B-D537-4002-86AF-FD7B54B45E2E?page=10) -- [Answer](x-devonthink-item://406AF611-5CD4-4B3B-9795-327E8F4E3626?page=4) - [ ] 9Q: [Delivery in an Ambulance](x-devonthink-item://FE3157C2-07B3-43F2-9ECE-AFACE1355E13?page=20) -- [Answer](x-devonthink-item://DDC959EB-0C1E-448A-8380-C397BF734322?page=9) - [ ] 10Q: [Post partum haemorrhage](x-devonthink-item://EF003416-CCE0-4A7D-AE59-F054D2880322?page=14) -- [Answer](x-devonthink-item://30A6ADA2-CC99-445A-B901-7117A6AEB2CC?page=16) - [ ] 11Q: [Post Partum Haemorrhage](x-devonthink-item://335900F2-D054-4D3D-983F-04A22741BF68?page=5) -- [Answer](x-devonthink-item://E3D816B5-653D-4DC6-A389-8C69022A6062?page=19) ## third stage of labour - [x] DUPLICATE Q: [Post partum haemorrhage](x-devonthink-item://EF003416-CCE0-4A7D-AE59-F054D2880322?page=14) -- [Answer](x-devonthink-item://30A6ADA2-CC99-445A-B901-7117A6AEB2CC?page=16) # OSCE - [RMH 2024 PPH](x-devonthink-item://5A3F4148-B64A-4C08-80C7-DC76BF8EE8AB) - Obstetric history- parity, singleton/multiple pregnancy, complications, GDM/pre-eclampsia/HELLP-risk of PPH History surrounding birth: - Prolonged rupture of membranes- risk of infection, sepsis & subsequent PPH - Precipitous labour, obstructed labour - prolonged 2nd stage- higher risk of uterine atony - active management 3rd stage done, placenta delivered/complete - PPH - difficult to determine/quantify given water birth - Timing of collapse- soon/immediately after birth concerning for AFE - Past medical history- cardiac disease/congenital cardiac abnormalities, bleeding diathesis/pro-coagulation risk factors e.g. factor V Leiden - Allergies- ?anaphylaxis, medication/latex