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I completed my medical school and background EM training from India (Christian Medical College, Vellore and Apollo Hospitals, Hyderabad) where I worked for 4 years. Following this, I devoted (with all my heart) about 1.5 years to do US Medical Licensing Exams. My stint towards an EM Residency in States did not work but it took me to places and it has been quite a journey. I then relocated to London, England to work as a Registrar (Non-Trainee) in A&E. This gave me an opportunity to better understand NHS, EM training pathways and more importantly the EM Mindsets in the United Kingdom. 

Currently, I am pursuing Higher Specialist Training in Emergency Medicine at South East Scotland Deanery where I have the honour and privilege of training under some of the most innovative brains in the field of Emergency Medicine. Over the past few years, I have realised that LEARNING and UNLEARNING (which can be challenging!) is equally important to deliver cutting edge care to our patients.And through this blog, I aspire to disseminate knowledge, assist trainees with exams and stay up to date with contemporary EM literature. I have always been an avid FOAMed supporter because FOAMed has always played an indispensable role during my training. 

Lakshay Chanana
ST4 EM Trainee 
Edinburgh, Scotland

Monday, December 25, 2017

Post-Partum Haemorrhage

Postpartum hemorrhage that occurs within the first 24 hours of delivery is called as primary postpartum hemorrhage. The main causes of primary postpartum haemorrhage are:
  • Uterine atony (TONE)
  • Retained placental fragments (TISSUE)
  • Lower genital tract lacerations (TRAUMA)
  • Uterine rupture (Click here to read more)
  • Uterine inversion (requires repair under general anesthesia)
  • Hereditary coagulopathy (THROMBIN)

Secondary postpartum hemorrhage occurs after the first 24 hours and up to 6 weeks postpartum. Common causes of secondary postpartum haemorrhage are:
  • Failure of the uterine lining to sub-involute at the former placental site
  • Retained placental tissue
  • Genital tract wounds
  • Uterogenital infection
Causes can be remembered as TONE, TISSUE, TRAUMA, THROMBIN

Risk Factors fro PPH
  • Primipara or Grandmultipara 
  • Previous PPH
  • Pre-eclampsia
  • Prior CS
  • Placenta Previa
  • Cervical or Uterine trauma
  • Fetal Wt >4.5Kgs
  • Prolonged 3rd stage
Excessive blood loss in the postpartum period is defined as a 10% drop in the hematocrit, a need for transfusion of packed red blood cells, or volume loss that causes symptoms of hypovolemia. The hematologic changes of pregnancy can mask the typical symptoms of hemorrhage, and the first sign may be only a mild increase in pulse rate.

  • ABC
  • IV Access x 2
  • Fluid Resuscitation 
  • Involve OBGYN ASAP
  • Keep them warm (Prevent the deadly triad of hypothermia, coagulopathy and acidosis)
  • Bimanual uterine massage - place a fist in the anterior fornix and compress the uterine fundus against the hand in a suprapubic location 
  • Uterotonics 
Oxytocin: 10U IM or 20-40 units in NS over 1 hour 
Carboprost: 250mcg IM q30min (up to 2mg if needed), Avoid in HTN, Asthma
Misoprostol: 1000mcg PR
Methylergonovine: 0.2mg IM (up to 5 doses q2-4h), Contraindicated in HTN/Pre-eclampsia
  • Consider Tranexamic Acid for critically ill 
  • Look for evidence of trauma, uterine inversion and uterine rupture
  • Inspect for missing placenta fragments 
  • Arrange blood products (Packed Cells, FFP and Cryo if in DIC)
  • Intrauterine balloon tamponade using Bakri balloon or Rusch catheter if uterine atony is the only or main cause of haemorrhage
  • Move to OR for hysterectomy or Uterine Artery Ligation

Other advanced care methods:
  • Interventional Radiology for Uterine Artery Embolisation
  • REBOA as a temporary measure 
Take Home:

  • Keep them warm (prevent Hypothermia, Coagulopathy and Acidosis)
  • Remember the 4 causes - TONE, TISSUE, TRAUMA, THROMBIN
  • Involve OBGYN ASAP

References and Further Reading:
  1. Tintinai EM 8th edition
  2. Shakur H, Elbourne D, G├╝lmezoglu M, Alfirevic Z, Ronsmans C, Allen E, Roberts I. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11(1):40.
  3. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/

Posted by:

     Lakshay Chanana
     Speciality Doctor
     Northwick Park Hospital
     Department of Emergency Medicine


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