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vaginal repairs, colposuspension, vaginal sacrospinous fixation with sutures or sacrocolpopexy with mesh, hysteropexy, sacrospinous fixation, and colpocleisis. The procedureofchoicedependsonpatientand surgeonpreference,and theexacttypeand degree of prolapse. Careful counselling and senior decision-making are required for proceduresinvolvingsyntheticmesh.Animportantconsiderationforsomeproceduresis whetherthepatientwantstohavemorechildren.

Furtherreading

1.CollinsS,ArulkumaranS,HayesK,etal.(2013).Urogynaecology.In:OxfordHandbookofObstetrics and Gynaecology, 3rd ed (pp. 653–84). Oxford: Oxford University Press. Available at:

https://doi.org/10.1093/med/9780199698400.003.0022

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Chapter65

Postpartumhaemorrhage

Guideline: RCOG GTG52 (Prevention and management of postpartum

haemorrhage): https://www.rcog.org.uk/en/guidelines-research-

services/guidelines/gtg52/

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Primarypostpartumhaemorrhage(PPH)isdefinedasthelossof>500mLofbloodfrom the genital tract within 24 hours of delivery. Secondary PPH is excessive bleeding occurringfrom24 hours to 12weekspostpartum. PPHis an obstetricemergencyanda seniorobstetricianshouldbeinformedattheearliestopportunity.

Diagnosis

History/diagnosticcriteria

MinorPPH:500–1000mL MajorPPH:>1000mL.

Riskfactors

Antenatal

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Tone:

PreviousPPH BMI>35kg/m

Uterineabnormalities,e.g.fibroids Multiparity Multiplepregnancy Polyhydramnios Macrosomia(>4kg)

Tissue:

Placentapraevia Placentaaccreta

Thrombin:

Pre-eclampsia/HELLP(haemolysis,elevatedliverenzymes,lowplatelets)syndrome Hypertension Anticoagulantuse Bleedingdisorders

Other:

Age>40years Firstpregnancy APH(seeChapter58).

Intrapartumandpostpartum

Tone:

Useofmusclerelaxantsincludinggeneralanaesthetic,magnesiumsulphate,andterbutaline Infection Rapidorprolongedlabour Bladderdistension

Tissue:

Retainedplacenta,partofplacenta,ormembranes Retainedbloodclots

Trauma:

Perinealtearsorepisiotomy Assistedvaginaldelivery Caesareansection Cervicaltears Uterineruptureorinversion

Thrombin:

DIC Intrauterinedeath Amnioticfluidembolism Sepsis Placentalabruption.

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PPHprophylaxisandriskreduction

Treatantenatalanaemia:aimforhaemoglobinconcentration>110g/Latbooking,and>105g/L at28weeks.Giveironsupplementationifneeded Inapatientwithnoriskfactors,deliveringvaginally,giveoxytocin10IUIMinthethirdstage oflabour In a patient undergoing a caesarean section, give oxytocin 5IU via a slow IV infusion, and considergivingIVtranexamicacid0.5–1g

Ergometrine-oxytocin(Syntometrine®)maybeusedinpatientsat↑riskofhaemorrhage,ifthere arenocontraindications(e.g.hypertensionandcardiacdisease).

Management

Acutemanagement

SeeTable65.1.

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Table65.1TheacutemanagementofprimaryPPH

Callforhelp!

PutoutaPPHcall—thisshouldalertthemidwifeincharge,obstetricandanaestheticteams,porters,and haematology Oneteammembershouldscribe,includingsequenceofeventsandtimingsofinterventions

MinorPPH,withnoclinicalshock MajorPPH

Checkrespiratoryrateevery15minutes Continuousrespiratoryrateandpulseoximetryrecording

Givehigh-flowoxygenirrespectiveofsaturations

Checkpulseandbloodpressureevery15 minutes GainIVaccess(minimum14G)andsend bloods for: FBC, coagulation profile includingfibrinogen,andgroupandsave Givewarmedcrystalloids

Continuouspulseandbloodpressurerecording Insert 2× large-bore cannulaeand send bloods for: FBC, U&E, LFT, VBG, coagulation profile including fibrinogen, and crossmatchaminimumof4unitsofblood Transfusebloodassoonaspossible Give2Lofwarmedisotoniccrystalloidasfastaspossible,thena further 1.5L of colloid if necessary, until blood isavailable. Do notgivemorethan3.5Ltoavoiddilutionalcoagulopathy If required use emergency group O, rhesus D-negative and Knegative blood, switch to group-specific red cells as soon as possible

Checktemperatureevery15minutes Keepthepatientwarm

E Examineforpossiblebleedingsource:

Palpateuterusforuterineatony Assessvaginaandcervixfortears Examineuterinecavityforretainedplacentaormembranes

Palpateandrubtheuterinefundustostimulatecontractions Inserturinarycatheter—emptyingthebladdermayhelptoincreas euterinetone Liethepatientflattominimizebloodlossandmaintaincentralperfusion Externalaorticcompress ionmaybuytime(usefis ttoadministerpressurejustabovetheumbilicus) Considerintraoperativecellsalvageatcaesareansection

Medications:

Oxytocin5IUbys lowIVinjection(canrepeatdoseonce) Ergometrine0.5mgbyslowIV/IMinjection(notifhypertens ive) OxytocinIVinfus ion(40IUin500mLis otoniccrystalloidat125mL/hour) Carbopros t0.25mgIM,every15minutes,max.8doses (notifasthmatic) Misopros tol800micrograms sublinguallyorrectally Tranexamicacid1gIV

Examinationandmanagementpitfalls

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Estimatingbloodloss:

Patients with PPH are usually young and fit, and pregnancy causes an increase in circulatingbloodvolume,thereforehypovolaemiaisoftennotapparentinitially.Clinicians oftenunderestimatebloodlosswhenvisuallyestimating,itisthereforeimportanttoweigh allbloodandswabsinordertoaccuratelyestimatebloodloss Approximateindicatorsofbloodvolumeloss:

Bloodpressureandheartrateinthenormalrange:lossof<1000mLblood Blood pressure ↓ (but >80mmHg systolic), heart rate ↑, and tachypnoea: loss of 1000–1500mLblood Blood pressure <80 mmHg systolic, worsening tachycardia and tachypnoea, and impairedmentalstate:lossof>1500mLblood

Point-of-carehaemoglobintests:

Thesecanbefalselyreassuringandshouldnotberelieduponifthereisclinicalconcern ofPPH.

Ifbleedingcontinuesafterinitialfluidandbloodresuscitation

FFP:

Infuse4unitsatadoseof12–15mL/kgifbleedingiscontinuingafter4unitsofredcellsand coagulationprofilearestillunavailableOR IfcoagulationprofileshowprolongedPTorAPTT,give12–15mL/kg

Platelets:

Giveonepoolifbleedingongoingandplatelets<75×109/L

Cryoprecipitate:

Givetwopoolsifbleedingongoingandfibrinogen<2g/L

Aimtomaintain:

Haemoglobin>80g/L Platelets>50×109/L

Fibrinogen>2g/L PTandAPTT<1.5×normal.

Treatmentafterstabilization

Surgicalmanagement

Ifbasicmeasuresdonotstopbleeding,initiatesurgicalinterventionspromptly:

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Intrauterineballoontamponadeisfirstlineifatonyisconsideredtobethemaincause Haemostaticsuturesmaybeused,e.g.B-lynch Stepwise uterine devascularization (successive ligation of various uterine arteries) requires a seniorgynaecologistorvascularsurgeonduetoahighriskofuretericinjury Internaliliacarteryligation,orarterialocclusion,orembolizationbyinterventionalradiology Earlyhysterectomy(usuallysubtotal)ifindicated,especiallyifuterineruptureorplacentaaccreta. Ideallyasecondobstetricconsultantshouldbeinvolvedwiththisdecision.

Monitoringanddebriefing

Considerwhetherthepatientshouldbetransferredtointensiveorhighdependencycareandifan arteriallinewouldbeappropriate Monitorobservationscloselyincludingurineoutput Recheckhaemoglobin4–6hoursafteronsetofPPH Lookforevidenceofanyfurtherbleeding Debrief the woman and her partner, PPH can be a traumatic experience and can lead to posttraumaticstressdisorderandtokophobia(fearofpregnancyandchildbirth).

Specialconsiderations

SecondaryPPH

Sendinfectionmarkers(andbloodculturesifpyrexial)withinitialbloods Takevaginalandcervicalswabs Givebroad-spectrumantibioticsforsuspectedendometritis Consider arranging a USS to rule out retained placental tissue after discussion with a senior clinician Theatremayberequiredforevacuationofretainedproductsofconception.

Furtherreading

1. MBRRACE-UK (2020). Saving Lives, Improving Mothers’ Care: Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18. Oxford: National PerinatalEpidemiology Unit,UniversityofOxford.Available

at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-

2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10_ONLINE_VERSION_1404.pdf

2.HofmeyrGJ, Abdel-AleemH,Abdel-AleemMA (2013). Uterinemassageforpreventing postpartum haemorrhage.CochraneDatabaseSystRev.7:CD006431.

3. RCOG (2015). Blood transfusion in obstetrics (GTG47). Available at:

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg47/

https://t.me/med1917

Chapter66

Sepsisinandfollowingpregnancy

Guidelines: RCOG GTG64a (Sepsis in pregnancy, bacterial):

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64a/

RCOG GTG64b (Sepsis following pregnancy, bacterial):

https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg64b/

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Sepsis during and followingpregnancy is a leadingcause ofmaternaldeath in the UK. The 2016–2018 report on maternal mortality (MBRRACE-UK1) showed that 11% of womenwhodiedduring,orinthe6weeksaftertheirpregnancy,diedfromsepsis.

Diagnosis

Riskfactors

SeeTable66.1.

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Table66.1Riskfactorsforantenatalandpostnatalsepsis

Riskfactorsforantenatalsepsis Riskfactorsforpostnatalsepsis

HistoryofgroupBstreptococcalinfection

Caesareansection

Retainedproductsofconception

Vaginaltrauma

Woundhaematoma

Anaemia

Amniocentesisandotherinvasiveprocedures

Ethnicminoritygrouporigin

GroupAstreptococcalinfectioninclosecontactsorfamilymembers

Historyofpelvicinfection

Impairedglucosetoleranceordiabetes

Impairedimmunityoruseofimmunosuppressantmedication

Obesity

Prolongedspontaneousruptureofmembranes(>24hourspriortothestartoflabour)

Vaginaldischarge

Commonorganismscausingsepsisinpregnancyandthepostpartumperiod

Escherichiacoli Staphylococcusaureus Streptococcuspneumoniae

Coliforms GroupAStreptococcus(Streptococcuspyogenes) Methicillin-resistantStaphylococcusaureusMRSA).

History

Focused history taking is paramount in determining the potential source of sepsis. Remember that non-gynaecological foci of infection must also be considered during pregnancyandthepostpartumperiod.

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Noterecentillnessesorexposuretounwellcontacts.

Table66.2Commonsourcesofantenatalandpostnatalsepsis

Causesofantenatal sepsis

Causesofpostnatalsepsis

Chorioamnionitis

Endometritis

Mastitis

Retainedproductsofconception

Skinandsofttissueinfections—fromIVcannula,caesareansection,andepisiotomy wounds

Spinalabscess(post-epidural)

Gastroenteritis

Pharyngitis

Pneumonia

UTI

Thefollowingfeaturesmaybesuggestiveofsepsis:

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