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23 Cards in this Set

  • Front
  • Back
How many deliveries are complicated by "PPH"
5%
How many worldwide maternal deaths per minute result from PPH?
4

(99% in developing countries)
List possible sequelae of PPH
Death
Shock
Organ damage/failure
kidney, liver, GI, brain, heart, lungs
Sheehan's syndrome/poor lactation
Coagulopathy
VTE/PE
Blood product transfusion
Anemia
Iron deficiency
Increased medical and surgical interventions
List the causes of PPH
(in general, e.g. 4Ts)
Tone
Tissue
Trauma
Thrombin
What is the most common cause of PPH?
Atony (~80%)
What uterine/systemic mechanisms prevent PPH after delivery?
Myometrial contraction
(contraction around bleeding vessels)
Hemostatic factors
Decidual (e.g. tissue factor)
Systemic - coags/platelets
List causes for post-delivery uterine atony
Overdistension
multiple gestation
polyhydramnios
macrosomia
Infection
Abruption (Couvelaire uterus)
Drugs
nitroglycerin
tocolytics
MgSO4
Fatigue
prolonged labour
oxytocin augmentation
Uterine Inversion
Retained placenta
List causes for post-delivery "Thrombin"-related PPH
Bleeding diathesis (congenital)
Coagulopathy (acquired)
Drugs (heparin)
HELLP
IUFD
Infection/sepsis
Consumption (PPH)
Abruption
AFE
Thrombocytopenia
Congenital (e.g. ITP)
HELLP
Consumption
Drugs
What labour/delivery characteristics have been associated with PPH?
Retained placenta (OR 3.5)
FTP 2 (OR 3.4)
Accreta (OR 3.3)
Lacerations (OR 2.4)
Operative delivery (OR 2.3)
LGA >4000g (OR 1.9)
Hypertensive disorders (OR 1.7)
Labor induction (OR 1.4)
Oxytocin augmentation (OR 1.4)
Define PPH
1)
VD: blood loss >500ml
C/S: blood loss >1000ml

2) 10% decrease in post-partum Hb

3) early: <24h PP; late: >24h PP
True or False:
Active management of the third stage of labour has been shown to decrease PPH and it's complications
True

PPH > 500ml: OR 0.4
PPH > 1000ml: OR 0.3
need for transfusion: OR 0.3
need for more uterotonics: OR 0.2
What interventions comprise Active management of the third stage of labour?
Uterotonic with delivery of anterior shoulder (oxytocin IM preferred)
Delayed cord clamping
PTB neonate reduces anemia
Controlled cord traction to delivery placenta
What uterotonics are considered acceptable for active management of the third stage of labour?
(i.e. prophylaxis against PPH)
Oxytocin
10IU IM preferred
5IU IV push at VD, but not C/S
Ergonivine
0.2mg IM
contraindicated in HTN
> nausea, retained placenta)
Misoprostol (if others not available)
600-800ug oral/subL preferred
side effect is pyrexia
What adverse reaction to 5-10IU IV bolus oxytocin has been observed in partuients at C/S?
Transient EKG changes consistent with myocardial ischemia (all resolved within 5min)
(If given IV at C/S, oxytocin should go in over 5min not 30s)
What is the recommendation for uterotonic at C/S?
Carbetocin 100ug IV over 1 min
What interventions can be done for a retained placenta, and when should they be done?
1) Manual removal
2) Umbilical vein injection

Consider at 30-45min as waiting this long does not appear to increase the risk for PPH
What medications are available for umbilical vein injection for retained placeta at vaginal delivery?
1) 10-30IU oxytocin in 30ml saline
2) 800ug misoprostol in 30ml saline
What is the Pipingas technique and how is it done?
Used to inject the umbilical vein during retained placenta at vaginal delivery.

Size 10 NG catheter threaded through umbilical vein

Alternative is to inject and then milk up cord
For established PPH with uterine atony, what dose of oxytocin is recommended?
IV 40-80IU in 500ml, run at 500-1000ml/h

(with max dose that is 16U/min and may cause cardiac effects)

May give 10IU IM again.
For established PPH with uterine atony, what dose of hemabate is recommended?

What maternal condition is a relative contraindication to hemabate?
250ug IM q15min x 8 doses max

Asthma
For PPH at vaginal delivery, has carbetocin been found to be superior to oxytocin?
No
What surgical techniques are available to control PPH?
Compression sutures
B-Lynch
Cho
Ligation of vessels
Uterine (O'Leary stitch)
Ovarian
Internal Iliac
Hysterectomy
Outline an approach to treating an established PPH
1) Get Help: anesth, nursing, blood bank, lab
2) Assess ABCs - conscious, breathing
3) Quickly review history of gravida, pregnancy, delivery for medical hx, risk factors, allergies.
4) Vital signs
5) Blood loss (more accurate to go by clinical signs then observation of blood)
6) IV access - 2 large IVs
7) Oxygen
8) Uterine massage
9) IV fluids - RL 1-2L
10) Bloodwork: CBC, Coags, fibrinogen, T&S, Crossmatch
12) Oxytocin IV
12) Determine Cause and treat appropriately
13) Consider further management: tamponade, embolization, laparotomy
14) Massive transfusion protocol if necessary