QuestionSBA
QuestionChoice
Following basic resuscitation measures, IV or IM ergometrine is given 2nd line for postpartum haemorrhage if IV syntocinon is unsuccessful or contraindicated
33109
b
IV ergometrine
QuestionChoice
Recombinant factor VIIa is increasingly used in the treatment and control of acute bleeding. While it can be a useful adjunct in achieving haemostasis, simple measures first with IV syntocinon must be given first
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c
Give recombinant factor VIIa
QuestionChoice
This woman is experiencing significant postpartum haemorrhage, most likely due to uterine atony. After standard resuscitation measures and bimanual uterine compression, the next step is to give IV syntocinon (oxytocin) to induce uterine contractions
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a
IV syntocinon
QuestionChoice
Selective arterial embolisation is reserved for uncontrolled postpartum haemorrhage despite physical and pharmacological measures. Embolising the artery under radiological guidance reduces the blood supply to the uterus and, therefore capacity to bleed. Conservative measures such as IV syntocinon should be imitated first in this case
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e
Selective arterial embolisation
QuestionChoice
Misoprostol is a synthetic prostaglandin E1 analogue and induces uterine contractions to combat postpartum haemorrhage from uterine atony. NICE guidance currently opts for intravenous syntocinon first, although PR misoprostol may be helpful, particularly in low resource settings as it does not need refrigeration or infusion
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d
PR misoprostol
Concept
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# Summary

Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery. The primary causes are uterine atony, birth canal injury or tear, retained placental or foetal tissue, and coagulopathies. Risk factors include a previous PPH, high BMI, multiple pregnancies, advanced maternal age, and more. Initial management involves resuscitation with an ABCDE approach and potentially activating a major haemorrhage protocol. Further management strategies may include rubbing the uterus, medication, or surgical treatment. Secondary PPH refers to bleeding from 24 hours to 12 weeks postpartum, typically caused by retained products of conception or endometritis. 


# Definition



Postpartum haemorrhage (PPH) is defined as the loss of at least 500ml of blood within the first 24 hours of delivery.


# Aetiology


The aetiology of postpartum haemorrhage (PPH) can be remembered using the mnemonic of the 4 'T's: 

- Tone: The most common cause of PPH is uterine atony, which is the failure of the uterus to contract after delivery.

- Trauma: PPH can result from a birth canal injury or tear, with risk increased in instrumented deliveries.

- Tissue: Retained placental or foetal tissue can cause continued bleeding.

- Thrombin: Coagulopathies can lead to continued bleeding due to a failure of clotting.

# Risk Factors

Risk factors for postpartum haemorrhage (PPH) include:

- PPH in previous pregnancy
- BMI >35
- Multiple pregnancy
- Parity >4
- Conditions such as placenta praevia or accreta, placental abruption, pre-eclampsia, gestational hypertension or anaemia
- Delivery via Caesarean section
- Induction of labour
- Instrumented delivery (forceps or ventouse) and episiotomy
- Prolonged labour (greater than 12 hours)
- Macrosomia (>4kg baby)
- Advanced maternal age


# Investigations


Investigations for PPH include blood tests for Group/Save and Crossmatch, and consideration of fresh frozen plasma if clotting abnormalities are present. In cases of secondary PPH, ultrasound looking for retained products and endocervical/high vaginal swabs looking for infection are recommended.

# Management


Initial management of PPH involves:

- Resuscitation with an ABCDE approach
- Consideration of activation of a major haemorrhage protocol
- Laying the woman flat 
- Inserting two large bore cannulas
- Providing oxygen
- Considering fresh frozen plasma if clotting abnormalities are present

Further management strategies may include:

- Mechanical methods such as rubbing the uterus and catheterisation
- Medical treatments including oxytocin, syntocinon, ergometrine, carboprost, misoprostol, and tranexamic acid
- Surgical treatments such as intrauterine balloon tamponade, B-lynch suture around the uterus, uterine artery ligation, or hysterectomy 

For secondary PPH, management depends on the cause and can include surgical evacuation for retained products of conception or antibiotics for infection.

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Quesmed Tutorial: Obstetric Emergencies
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IV syntocinon (oxytocin) is commonly used in the management of postpartum hemorrhage to stimulate uterine contractions, helping to reduce bleeding by promoting uterine tone.
A 29-year-old primigravida woman has delivered a healthy baby via vaginal delivery. The placenta was intact on delivery, and there were no initial complications. Unfortunately, the mother continues to bleed following delivery and has now lost 1.1L. Bimanual uterine compression is conducted and the mother is catheterised to empty the bladder. Despite this, she continues to haemorrhage and you begin transfusing blood.

Which of the following is the best next step in the management of this patient?
a