14. Puerperal Complications Flashcards
Define: Puerperium (1)
6 wk period of adjustment after pregnancy when pregnancy-induced anatomic and physiologic changes are reversed
Name: Puerperal Complications (6)
- Postpartum Hemorrhage
- Retained Placenta
- Uterine Inversion
- Postpartum Pyrexia
- Mastitis
- Postpartum Mood Alterations
Define: Postpartum Hemorrhage (3)
- loss of >1000 ml of blood or bleeding associated with signs/symptoms of hypovolemia within 24 hours of birthing process regardless of mode of delivery
- primary – within first 24 h postpartum
- secondary – after 24 h but within first 12 wk
Describe incidence: Postpartum Hemorrhage (1)
5-15%
Name most common : Postpartum Hemorrhage (1)
Uterine Atony
Name DDX of early postpartum Hemorrhage (4)
- Tone (atony)
- Tissue (retained placenta, clots)
- Trauma (laceration, inversion)
- Thrombin (coagulopathy)
Name DDX of late postpartum Hemorrhage (3)
- Retained products
- ± endometritis
- Sub-involution of uterus
Describe this etiology of Postpartum Hemorrhage: Tone (uterine atony) (2)
- most common cause of PPH (70-80%)
- avoid with active management of 3rd stage of labour with 1) oxytocin administration 2) uterine massage 3) umbilical cord traction
What is uterine atony due to? (5)
- overdistended uterus (polyhydramnios, multiple gestations, and macrosomia)
- uterine muscle exhaustion (prolonged or rapid labour, grand multiparity, oxytocin use, and general anesthetic)
- uterine distortion (fibroids)
- intra-amniotic infection (fever or prolonged ROM)
- bladder distension (preventing uterine contraction)
Name tissue DDX of Postpartum Hemorrhage (4)
- retained placental products (membranes, cotyledon, or succenturiate lobe)
- retained blood clots in an atonic uterus
- gestational trophoblastic neoplasia
- abnormal placentation (e.g. placenta previa or placental abruption)
Name trauma DDX of Postpartum Hemorrhage (5)
- laceration (vagina, cervix, or uterus)
- episiotomy
- hematoma (vaginal, vulvar, or retroperitoneal)
- uterine rupture
- uterine inversion
Name thrombin DDX of Postpartum Hemorrhage (3)
- coagulopathy (pre-existing or acquired)
- most identified prior to delivery (low platelets increases risk)
- includes hemophilia, disseminated intravascular coagulation (DIC), idiopathic thrombocytopenic purpura (ITP), thrombotic thrombocytopenic purpura (TTP), and von Willebrand disease vWD (most common)
- therapeutic anti-coagulation
Describe investigations: Postpartum Hemorrhage (3)
- assess degree of blood loss and shock by clinical exam
- explore uterus and lower genital tract for evidence of atony, retained tissue, or trauma
- may be helpful to observe red-topped tube of blood – no clot in 7-10 min indicates coagulation problem
Describe management: Postpartum Hemorrhage (8)
- ABCs, call for help
- 2 large bore IVs, run crystalloids wide open
- CBC, coagulation profile, cross and type pRBCs
- treat underlying cause
- Foley catheter to empty bladder and monitor urine output
- Medical Therapy
- Local Control
- Surgical Therapy (Intractable PPH)
Describe medical therapy: Postpartum Hemorrhage (6)
- oxytocin 10 IU IM is preferred in low-risk vaginal deliveries, oxytocin IV infusion (20-40 IU in 1000 mL crystalloid at 150 mL/h) is an acceptable alternative. Oxytocin 5-10 IU IV bolus (20-40 IU in 250 mL crystalloid) can be used after vaginal birth, but not with elective C/S
- carbetocin, a long-acting oxytocin, 100 µg IV bolus over 1 min for elective C/S or 100 ug IM for vaginal deliveries with 1 risk factor for PPH (instead of a continuous oxytocin infusion)
- methylergonavine maleate (ergotamine) 0.25 mg IM/IMM q15min up to 1.25 mg; can be given as IV bolus of 0.125 mg (may exacerbate HTN)
- carboprost (Hemabate®), a synthetic PGF-1α analog, 250 µg IM/IMM q15min to max 2 mg (major prostaglandin side effects and contraindicated in cardiovascular, pulmonary, renal, and hepatic dysfunction)
- misoprostol 600-800 µg PO/SL (faster) or PR/PV (side effect: pyrexia if >600 µg)
- tranexamic acid (Cyklokapron®), an antifibrinolytic, 1 g IV
Describe local control: Postpartum Hemorrhage (3)
- bimanual massage: elevate the uterus and massage through patient’s abdomen
- uterine packing (mesh with antibiotic treatment)
- Bakri Balloon for tamponade: may slow hemorrhage enough to allow time for correction of coagulopathy or for preparation of an OR
Describe surgical therapy: Postpartum Hemorrhage (4)
- D&C (beware of vigorous scraping, which can lead to Asherman’s syndrome)
- embolization of uterine artery or internal iliac artery by interventional radiologist
- laparotomy with bilateral ligation of uterine artery (may be effective), ovarian artery, or hypogastric artery, compression sutures (B-Lynch or Cho sutures)
- hysterectomy last option, with angiographic embolization if post-hysterectomy bleeding
Define: Retained Placenta (1)
- placenta undelivered after 30 min postpartum
Describe etiology: Retained Placenta (2)
- placenta separated but not delivered
- abnormal placental implantation (placenta accreta, placenta increta, and placenta percreta)
Name risk factors: Retained Placenta (5)
- placenta previa
- prior C/S
- post-pregnancy curettage
- prior manual placental removal
- uterine infection
Describe clinical features: Retained Placenta (2)
- risk of PPH
- infection
Describe investigations: Retained Placenta (2)
- explore uterus
- assess degree of blood loss
Describe management: Retained Placenta (6)
- 2 large bore IVs, type and screen
- Brandt maneuver (firm traction on umbilical cord with one hand applying suprapubic pressure cephalad to avoid uterine inversion by holding uterus in place)
- oxytocin 10 IU in 20 mL NS into umbilical vein
- manual removal if above fails
- D&C if required (U/S guidance if available)
- cefazolin 2 g IV if manual removal or D&C
Define: Uterine Inversion (1)
- inversion of the uterus through cervix ± vaginal introitus
Describe Etiology/Epidemiology: Uterine Inversion (4)
- often iatrogenic (excess cord traction with fundal placenta)
- excessive use of uterine tocolytics
- more common in grand multiparous women (lax uterine ligaments)
- 1/1500-1/2000 deliveries
Describe clinical features: Uterine Inversion (2)
- can cause profound vasovagal response with bradycardia, vasodilation, and hypovolemic shock
- shock may be disproportionate to maternal blood loss
Describe management: Uterine Inversion (8)
- urgent management essential, call anesthesia
- ABCs: initiate IV crystalloids
- can use tocolytic drug or nitroglycerin IV to relax uterus and aid replacement
- replace uterus without removing placenta
- remove placenta manually and withdraw slowly
- IV oxytocin infusion (only after uterus replaced)
- re-explore uterus
- may require general anesthetic ± laparotomy
Define: Postpartum Pyrexia (1)
- fever >38°C on any 2 of the first 10 d postpartum, except the 1st day
Name etiologies: Postpartum Pyrexia (8)
- endometritis
- wound infection (check C/S and episiotomy sites)
- mastitis/engorgement
- UTI
- atelectasis
- pneumonia
- deep vein thrombosis DVT or pelvic thrombophlebitis
-
B-5W
- Breast: engorgement, mastitis
- Wind: atelectasis, pneumonia
- Water: UTI
- Wound: episiotomy, C/S site infection
- Walking: DVT, thrombophlebitis
- Womb: endometritis
Name investigations: Postpartum Pyrexia (3)
- detailed history and physical exam, relevant cultures
- for endometritis: blood and genital cultures
- serum lactic acid for early detection of sepsis
Describe tx: Postpartum Pyrexia (1)
- depends on etiology
- infection: empiric antibiotics, adjust when sensitivities available
Describe tx: endometritis (2)
clindamycin + gentamicin IV
Describe tx: mastitis (2)
- cloxacillin or cephalexin
Describe tx: wound infection (2)
- cephalexin + frequent sitz baths for episiotomy site infection
- deep vein thrombosis DVT: anticoagulants
Describe prophylaxis against post-C/S endometritis (1)
administer 2 g cefazolin IV 30 min prior to skin incision
Define: Endometritis (1)
inflammation of the endometrium most commonly due to infection
Describe clinical features: Endometritis (6)
- fever
- chills
- abdominal pain
- uterine tenderness
- foul-smelling vaginal discharge
- lochia (vaginal discharge after giving birth, containing blood, mucus, and uterine tissue)
Describe tx: Endometritis (3)
- depends on infection severity
- oral antibiotics if well
- IV antibiotics with hospitalization in moderate to severe cases
Name: Risk Factors for Endometritis (5)
- C/S
- intrapartum chorioamnionitis
- prolonged labour
- prolonged ROM
- multiple vaginal examinations
Define: Mastitis (3)
- definition: inflammation of mammary glands
- must rule out inflammatory carcinoma, as indicated
- differentiate from mammary duct ectasia: mammary duct(s) beneath nipple clogged and dilated ± ductal inflammation ± nipple discharge (thick, grey to green), often postmenopausal women
Differentiate Lactational vs. Non-Lactational Mastitis according to: Epidemiology (4)
- Lactational:
- More common than non-lactational
- Often 2-3 wk postpartum
- Non-Lactational Mastitis:
- Periductal mastitis most common
- Mean age 32 yr
Differentiate Lactational vs. Non-Lactational Mastitis according to: Etiology (5)
- Lactational: S. aureus
- Non-Lactational Mastitis:
- May be sterile
- May be infected with S. aureus or other anaerobes
- Smoking is risk factor
- May be associated with mammary duct ectasia
Differentiate Lactational vs. Non-Lactational Mastitis according to: Symptoms (7)
- Lactational:
- Unilateral localized pain
- Tenderness
- Erythema
- Non-Lactational Mastitis:
- Subareolar pain
- May have subareolar mass
- Discharge (variable colour)
- Nipple inversion
Differentiate Lactational vs. Non-Lactational Mastitis according to: Treatment (5)
- Lactational:
- Heat or ice packs
- Continued nursing/pumping
- Antibiotics (cloxacillin/cephalexin) (erythromycin if penicillin-allergic)
- Non-Lactational Mastitis:
- Broad-spectrum antibiotics and I&D
- Total duct excision (definitive)
Differentiate Lactational vs. Non-Lactational Mastitis according to: Abscess (8)
- Lactational:
- Fluctuant mass
- Purulent nipple discharge
- Fever, leukocytosis
- Discontinue nursing, IV antibiotics (nafcillin/oxacillin), I&D usually required
- Non-Lactational Mastitis:
- If mass does not resolve, fine-needle aspiration to exclude cancer and U/S to assess presence of abscess
- Treatment includes antibiotics, aspiration, or I&D (tends to recur)
- May develop mammary duct fistula
- A minority of non-lactational abscesses may occur peripherally in breast with no associated periductal mastitis (usually S. aureus)
Name different: Postpartum Mood Alterations (3)
- POSTPARTUM BLUES
- POSTPARTUM DEPRESSION
- POSTPARTUM PSYCHOSIS
Describe: Postpartum blues (4)
- 40-80% of new mothers
- onset day 3-10
- extension of the “normal” hormonal changes and adjustment to a new baby
- self-limited, should resolve by 2 wk
Describe manifestations: Postpartum blues (9)
- mood lability
- depressed affect
- increased sensitivity to criticism
- tearfulness
- fatigue
- irritability
- poor concentration/despondency
- anxiety
- insomnia
Define: Postpartum depression (9)
major depression occurring in a woman within 6 mo of childbirth
Describe epidemiology: Postpartum depression (2)
- 10-15%
- risk of recurrence 50%
Name risk factors: Postpartum depression (6)
- personal or family history of depression (including PPD)
- prenatal depression or anxiety
- stressful life situation
- poor support system
- unwanted pregnancy
- colicky or sick infant
Name clinical features: Postpartum depression (2)
- suspect if the “blues” last beyond 2 wk
- or if the symptoms in the first 2 wk are severe (e.g. extreme disinterest in the baby, suicidal or homicidal/infanticidal ideation)
Describe assessment: Postpartum depression (1)
- Edinburgh Postnatal Depression Scale or others
Describe tx: Postpartum depression (4)
- antidepressants
- psychotherapy
- supportive care
- Electroconvulsive therapy (ECT) if refractory
Describe prognosis: Postpartum depression (1)
- interferes with bonding and attachment between mother and baby, so it can have long-term effects
Define: Postpartum psychosis (2)
- onset of psychotic symptoms over 24-72 h within first month postpartum
- can present in the context of depression
Describe epidemiology: Postpartum psychosis (1)
rare (0.2%)
