Postpartum Haemorrhage (PPH)

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CLINICAL DESCRIPTIONBlood loss of greater than 500 mL after giving birth vaginally or a blood loss of greater than 1,000 mL after a cesarean section, or any amount of bleeding following delivery, that is significant enough to cause hemodynamic instability. 

CLINICAL FEATURES

SIGNS AND SYMPTOMS

  • Vaginal bleeding, pallor, hypotension, tachycardia, thirst, cold and clammy peripherals, increased capillary refill time.

INVESTIGATIONS

  • FBC, sickling status
  • Bedside clotting test
  • Blood grouping and cross-matching
  • Ultrasound scan (if patient is stable to check for retained placenta tissue)
  • Thorough physical examination to look for genital tract trauma

PRIMARY PPH: Treatment 

  • Abnormal vaginal bleeding within 24 hours of delivery
  • Set up an IV line and empty bladder
    • Replace blood loss with IV fluids (isotonic crystalloids) and blood when available
  • Identify and treat the cause
  • If uterine atony:
    • Rub up a contraction
    • Give 10 units Oxytocin IV stat then 40 units in 1 litre N/S, infuse over 4 hours
    • If oxytocin not available, give Misoprostol 800mcg rectally or sublingually stat
    • Tranexamic acid (1g IV over 10 minutes) is recommended if oxytocin does not rapidly stop the bleeding, to be used within 3 hours of delivery.  
    • Use of non-pneumatic anti-shock garment as temporizing measure
  • Refer to hospital with nurse accompaniment if at the health centre
  • If bleeding does not stop despite uterine massage and uterotonics then consider:
  • Bimanual uterine compression or external aortic compression
  • Additional uterotonics such as ergometrine if available
  • Intrauterine balloon tamponade
  • A second dose of Tranexamic acid IV, 1g over 10 minutes can be given 30 minutes after the 1st dose
  • Examination under anesthesia: repair any genital tract trauma and proceeding to exploratory laparotomy, and surgical management including B-Lynch suture or hysterectomy if bleeding continues.
    • If retained placenta, attempt manual removal or evacuation in theatre
    • If ruptured uterus suspected, proceed to laparotomy and assess need / possibility for repair versus hysterectomy.

SECONDARY PPH: Clinical Description

Bleeding from the genital tract 24 hours post-delivery until 42 days

Causes:

  • Retained products, often with infection, endomyometritis

TREATMENT

PHARMACOLOGICAL

  • Set up an IV line and resuscitate
  • Replace blood loss with IV fluids/blood
  • Empty bladder
  • Rub up a contraction
  • Give Oxytocin 10 units IM
  • If patient is septic start antibiotics
    • Give Ceftriaxone 2g iv daily and Metronidazole 400 mg 8 hourly
    • OR Ampicillin 1g 6 hourly/ Benzyl penicillin 2 MU IV 6 hourly, Gentamycin 240mg daily, Metronidazole 500mg 8 hourly
    • Second line: Meropenem 1 g 8 hourly