12: Postpartum care and complications Flashcards
Two central issues in the immediate postpartum period, regardless of the mode of delivery, are ?
pain management and wound care
what contraception can be used by anyone postpartum
Condoms with a spermicidal foam or gel
-Diaphragms and cervical caps need to be refitted at 6 weeks. IUDs are best placed at 6 weeks as well.
hormonal contraceptives of choice in the puerperium because they are less likely to decrease milk production in breastfeeding patients and affect risk of venous thromboembolism.
Depo-Provera, Implanon, the progesterone-releasing IUD, or the progesterone-only mini-pill
Causes of postpartum hemorrhage
uterine atony, uterine rupture, uterine inversion, retained POCs, placenta accreta, and cervical or vaginal lacerations
treatment of PPH
blood products including fresh frozen plasma, cryoprecipitate, and platelets in patients who develop a consumptive coagulopathy
Surgical management of PPH
ranges from D+C to exploratory laparotomy, uterine artery ligation, hypogastric artery ligation, and, if these fail, hysterectomy.
In PPH patients for whom there is enough time, an alternative to exploratory laparotomy
uterine artery embolization (UAE) by interventional radiology
Diagnosis of endomyometritis
clinical: fever, elevated WBC count, and uterine tenderness; treatment is with broad-spectrum antibiotics and D/C for retained POCs.
Cesarean incisions may be complicated by
cellulitis, wound abscess, wound separation, or frank dehiscence (at the level of the rectus fascia). Wound healing is improved by blood glucose control and smoking cessation.
Mastitis is differentiated from engorgement by ?
treatment?
focal tenderness, erythema, and edema, and treatment is usually with oral antibiotics: dicloxacillin (x10-14)
the puerperium (postpartum period) is defined as
6 weeks after delivery
pain meds after vaginal delivery
NSAIDs, tylenol, occasionally low-dose opioids
pain meds after C-section
opioids, NSAIDs
benefits of breastfeeding
Oxytocin release stimulates postpartum uterine contractions, increases uterine tone and decreases the risk of bleeding
- IgG transmitted to baby, lower rates of childhood obesity
- maternal weight loss, lower risk T2DM
- decreased risk of both breast and endometrial cancers (decreased estrogen exposure)
vaccines for mom/caregivers postpartum
- Tdap is essential if they have not received the vaccine within the 10 years previous to pregnancy
- MMR if low Rubella antibody titers
- if Rh- mom and unknonwn/Rh+ baby: RhoGAM within 72 hours postpartum
extremely effective form of surgical contraception that should be brought up in third trimester
postpartum tubal ligation (PPTL) (need consent 30 days before procedure)
Combination estrogen–progesterone OCPs in some studies have been shown to ?
decrease milk production so are usually recommended only to those patients who are not interested in breastfeeding or have excellent milk production
if really want to use combo OCPs wait until ?
3 weeks postpartum, at which point the benefits of contraception and pregnancy prevention outweigh the risks of (VTE) in the puerperium
After 6 weeks, the risk of VTE decreases to that seen in the non-pregnant state.
Early initiation of combination OCPs should not be recommended to patients with risk factors for VTE, such as ?
age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30, postpartum hemorrhage, post-Cesarean delivery, preeclampsia, or active smoking.
The primary complications that arise postpartum include
postpartum hemorrhage (PPH) (1st 24hrs, several wks if RPOCs), endomyometritis, wound infections (w.in 7-10 days) and separations, mastitis (1-2 wks), and postpartum depression
rare complications of vaginal delivery
endomyometritis, episiotomy infections, episiotomy breakdown
complications of Cesarean delivery
PPH, sx blood loss, wound infection, endomyometritis, mastitis, PPD, wound separation/dehiscence
risk factors for PPH 1
- prior PPH
- Abnormal placentation: previa, accreta, hydatidiform mole
- Trauma during L/D : Episiotomy, Complicated vaginal delivery, Low- or mid forceps delivery, Sulcal or sidewall laceration, Uterine rupture, Cesarean delivery or hysterectomy, Cervical laceration
- Uterine atony: Uterine inversion, Overdistended uterus, Macrosomic fetus, Multiple gestation, Polyhydramnios
risk factors for PPH 2
- Exhausted myometrium: Rapid or prolonged labor, pit or PG stimulation, chorioamnionitis
- Coagulation defects (intensify other causes): Placental abruption, Prolonged retention of demised fetus, AFE, Severe intravascular hemolysis, Severe preE/E, Congenital coagulopathies, Anticoagulant tx
Postpartum hemorrhage is defined as blood loss exceeding
500 mL in a vaginal delivery and greater than 1,000 mL in a cesarean section
-early if within 24 hrs, late/delayed if outside 24 hrs
with blood loss greater than 2 to 3 L, patients may develop a ?
consumptive coagulopathy and require coagulation factors and platelets.
Sheehan syndrome
pituitary infarction, may occur if patient becomes become hypovolemic and hypotensive
-may manifest with the absence of lactation secondary to the lack of prolactin or failure to restart menstruation secondary to the absence of gonadotropins
etiology of PPH in vaginal deliveries
Vaginal lacerations Cervical lacerations Uterine atony Placenta accreta Vaginal hematoma Retained POCs Uterine inversion Uterine rupture
etiology of PPH in Cesarean deliveries
Uterine atony
Surgical blood loss
Placenta accreta
Uterine rupture
If a patient has a larger than expected drop in hematocrit, an examination should be performed to rule out a ?
vaginal wall hematoma
- can be managed expectantly unless it is tense or expanding, in which case it should be opened, the bleeding vessel ligated, and the vaginal wall closed
- Rare: retroperitoneal hematoma that can lead to a large blood loss (low back/rectal pain, large drop in HCT)
- dx: US, CT
- tx: IR, sx ligation
cause of cervical lacerations
rapid dilation of the cervix during the stage 1 of labor or maternal expulsive efforts prior to complete dilation of the cervix
- give anesthesia via epidural, spinal, or pudendal block before using ring forceps to “walk” around cervix
- repair with interrupted or running absorbable sutures.
the leading cause of postpartum hemorrhage
uterine atony
risk factors for uterine atony
chorioamnionitis, exposure to magnesium sulfate, multiple gestations, a macrosomic fetus, polyhydramnios, prolonged labor, a history of atony with any prior pregnancies, or if they are multiparous, particularly a grand multipara (more than five deliveries
The diagnosis of atony is made by palpation of the uterus, which is ?
soft, enlarged, and boggy
Atony is initially treated with ?
- ppx IV oxytocin (Pitocin), uterine massage
2.methylergonovine (Methergine) CI in HTN pts
3.Hemabate (also known as Prostin or PGF2), CI in asthmatics
Misoprostol, a PGE1 may be used off-label
if atony can’t be managed medically
- D/C to rule out possible retained POCs
- uterine packing with an inflatable tamponade (Bakri balloon) or occlusion of pelvic vessels (uterine artery embolization) by IR
if suspicion high for RPOCs after manual exam/US, perform a ?
may lead to ?
if hemorrhage continues after r/o RPOCs, think ?
D/C
endomyometritis and PPH
placenta accreta
Accreta involves bleeding that is unresponsive to ?
how to manage ?
uterine massage and contractile agents such as oxytocin, ergonovines, and prostaglandins
take to OR for exploratory laparotomy
risk factors for uterine rupture
previous uterine surgery prior uterine scar), breech extraction, obstructed labor, and high parity
symptoms of uterine rupture
treatment?
abdominal pain and a popping sensation intra-abdominally.
Treatment involves laparotomy and repair of the ruptured uterus. If hemorrhage cannot be controlled, hysterectomy may be indicated.
risk factors for uterine inversion
fundal implantation of the placenta, uterine atony, placenta accreta, and excessive traction on the cord during the third stage
how to dx uterine inversion
witnessing the fundus of the uterus attached to the placenta on placental delivery
can be an obstetric emergency if hemorrhage
uterine inversion management
- stabilization (may have vasovagal response)
- manual replacement of uterus
- Uterine relaxants such as nitroglycerin or general anesthesia with halogenated agents
- laparotomy if unsuccessful
if blood in abdomen, think?
how to tx?
uterine rupture
stabilize
bilateral O’Leary sutures to tie off the uterine arteries
-ligation of the hypogastric, or internal iliac, arteries
-B-Lynch sutures can be placed in an attempt to compress the uterus and achieve hemostasis (if atony)
-uterine incision and looped around uterus
-if fails, puerperal hysterectomy
first step if pt delivered via C-section and there is evidence of accreta
place hemostatic sutures in the placental bed
Endomyometritis most common after ?
risk factors?
C-sections and vaginal deliveries with manual extraction of placenta
-meconium, chorioamnionitis, and prolonged ROM
management of complete wound dehiscence bove.
the fascia is usually closed and the skin incision treated like a superficial wound separation
postpartum blues timeframe
within 2 to 3 days after delivery, peaking at the 5th and resolving within 2 weeks
Endomyometritis is more common in patients with vaginal or caesarean delivery?
caesarean, although patients with manual removal of the placenta are also at increased risk.
