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I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK.  I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature. 

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.



Resuscitation
  • 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
     England

     @EMDidactic



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