• Haemorrhage in pregnancy
    • Major cause of maternal mortality
      • Often mismanaged due to underestimation of blood loss
    • Definition
      • Blood loss >1.5L, a decrease in Hb of >4g/dL, or acute transfusion requirement of >4 units
      • APH occurs after 24 weeks and before delivery
      • PPH can be primary (within 24hr) or secondary (>24hrs)
    • Physiology considerations
      • Tachycardia may be the only sign until 40% of circuating volume is lost
      • DIC may exacerbate bleeding
    • Causes
      • Early pregnancy
        • Incomplete abortion
        • Septic abortion
        • Ectopic
      • APH
        • Placenta previa
        • Abruption
        • Uterine rupture
        • Trauma
      • Primary PPH
        • Uterine atony (80%)
        • RPOC
        • Genital tract trauma
        • Abnormally adherent placenta
        • Acute uterine inversion
      • Secondary PPH
        • Puerperal sepsis
        • RPOC
    • Anaesthesia
      • Consider GA or CSE
      • More clinicians now managing previa with regional techniques
      • May need to convert to GA
    • Treatments
      • IMMEDIATE MANAGEMENT
        • Call for help
        • 100% O₂
        • 2 Cannulae
        • Commence IVI
        • L Lateral position
        • X-match 6 units, CS, FBC
        • Alert haematologist
        • Max 2L crystalloid (warmed)
        • Consider invasive monitoring
      • Physical
        • Stimulate uterine activity by 'rubbing up' a contraction
      • Pharmacological
        • Oxytocin 5IU slow IV followed by 40IU in 500ml N/Saline over 4hrs
        • Ergometrine IV 250μcg
          • Avoid in pre-eclampsia
        • PGF2 (Carboprost) IM 250μcg rpt at 15 min intervals up to 2mg in total
          • Can cause bronchospasm
        • Misoprostol 600μcg PR
      • Surgical
        • MROP if needed
        • Uterine packing
        • B-Lynch suture
        • Hysterectomy
      • Radiological
        • Consider embolisation
      • Blood and blood products
        • Should be agreement with blood lab
        • Should be 2 units of O-ve in most units
        • Coagulation screen to aid product replacement
        • Recombinant factor VIIa (100μcg/kg)
      • Autologous blood transfusion
    • Depts should have drills, courses (MOET/ALSO) and protocols
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/5/6/195.full.pdf