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TN Obstetrics > 14. Puerperal Complications > Flashcards

14. Puerperal Complications Flashcards

1
Q

Define: Puerperium (1)

A

6 wk period of adjustment after pregnancy when pregnancy-induced anatomic and physiologic changes are reversed

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2
Q

Name: Puerperal Complications (6)

A
  • Postpartum Hemorrhage
  • Retained Placenta
  • Uterine Inversion
  • Postpartum Pyrexia
  • Mastitis
  • Postpartum Mood Alterations
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3
Q

Define: Postpartum Hemorrhage (3)

A
  • 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
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4
Q

Describe incidence: Postpartum Hemorrhage (1)

A

5-15%

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5
Q

Name most common : Postpartum Hemorrhage (1)

A

Uterine Atony

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6
Q

Name DDX of early postpartum Hemorrhage (4)

A
  • Tone (atony)
  • Tissue (retained placenta, clots)
  • Trauma (laceration, inversion)
  • Thrombin (coagulopathy)
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7
Q

Name DDX of late postpartum Hemorrhage (3)

A
  • Retained products
  • ± endometritis
  • Sub-involution of uterus
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8
Q

Describe this etiology of Postpartum Hemorrhage: Tone (uterine atony) (2)

A
  • 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
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9
Q

What is uterine atony due to? (5)

A
  • 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)
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10
Q

Name tissue DDX of Postpartum Hemorrhage (4)

A
  • 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)
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11
Q

Name trauma DDX of Postpartum Hemorrhage (5)

A
  • laceration (vagina, cervix, or uterus)
  • episiotomy
  • hematoma (vaginal, vulvar, or retroperitoneal)
  • uterine rupture
  • uterine inversion
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12
Q

Name thrombin DDX of Postpartum Hemorrhage (3)

A
  • 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
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13
Q

Describe investigations: Postpartum Hemorrhage (3)

A
  • 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
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14
Q

Describe management: Postpartum Hemorrhage (8)

A
  • 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)
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15
Q
A
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16
Q

Describe medical therapy: Postpartum Hemorrhage (6)

A
  • 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
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17
Q

Describe local control: Postpartum Hemorrhage (3)

A
  • 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
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18
Q

Describe surgical therapy: Postpartum Hemorrhage (4)

A
  • 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
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19
Q

Define: Retained Placenta (1)

A
  • placenta undelivered after 30 min postpartum
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20
Q

Describe etiology: Retained Placenta (2)

A
  • placenta separated but not delivered
  • abnormal placental implantation (placenta accreta, placenta increta, and placenta percreta)
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21
Q

Name risk factors: Retained Placenta (5)

A
  • placenta previa
  • prior C/S
  • post-pregnancy curettage
  • prior manual placental removal
  • uterine infection
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22
Q

Describe clinical features: Retained Placenta (2)

A
  • risk of PPH
  • infection
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23
Q

Describe investigations: Retained Placenta (2)

A
  • explore uterus
  • assess degree of blood loss
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24
Q

Describe management: Retained Placenta (6)

A
  • 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
25
Q

Define: Uterine Inversion (1)

A
  • inversion of the uterus through cervix ± vaginal introitus
26
Q

Describe Etiology/Epidemiology: Uterine Inversion (4)

A
  • 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
27
Q

Describe clinical features: Uterine Inversion (2)

A
  • can cause profound vasovagal response with bradycardia, vasodilation, and hypovolemic shock
  • shock may be disproportionate to maternal blood loss
28
Q

Describe management: Uterine Inversion (8)

A
  • 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
29
Q

Define: Postpartum Pyrexia (1)

A
  • fever >38°C on any 2 of the first 10 d postpartum, except the 1st day
30
Q

Name etiologies: Postpartum Pyrexia (8)

A
  • 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
31
Q

Name investigations: Postpartum Pyrexia (3)

A
  • detailed history and physical exam, relevant cultures
  • for endometritis: blood and genital cultures
  • serum lactic acid for early detection of sepsis
32
Q

Describe tx: Postpartum Pyrexia (1)

A
  • depends on etiology
    • infection: empiric antibiotics, adjust when sensitivities available
33
Q

Describe tx: endometritis (2)

A

clindamycin + gentamicin IV

34
Q

Describe tx: mastitis (2)

A
  • cloxacillin or cephalexin
35
Q

Describe tx: wound infection (2)

A
  • cephalexin + frequent sitz baths for episiotomy site infection
  • deep vein thrombosis DVT: anticoagulants
36
Q

Describe prophylaxis against post-C/S endometritis (1)

A

administer 2 g cefazolin IV 30 min prior to skin incision

37
Q

Define: Endometritis (1)

A

inflammation of the endometrium most commonly due to infection

38
Q

Describe clinical features: Endometritis (6)

A
  • fever
  • chills
  • abdominal pain
  • uterine tenderness
  • foul-smelling vaginal discharge
  • lochia (vaginal discharge after giving birth, containing blood, mucus, and uterine tissue)
39
Q

Describe tx: Endometritis (3)

A
  • depends on infection severity
  • oral antibiotics if well
  • IV antibiotics with hospitalization in moderate to severe cases
40
Q

Name: Risk Factors for Endometritis (5)

A
  • C/S
  • intrapartum chorioamnionitis
  • prolonged labour
  • prolonged ROM
  • multiple vaginal examinations
41
Q

Define: Mastitis (3)

A
  • 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
42
Q

Differentiate Lactational vs. Non-Lactational Mastitis according to: Epidemiology (4)

A
  • Lactational:
    • More common than non-lactational
    • Often 2-3 wk postpartum
  • Non-Lactational Mastitis:
    • Periductal mastitis most common
    • Mean age 32 yr
43
Q

Differentiate Lactational vs. Non-Lactational Mastitis according to: Etiology (5)

A
  • 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
44
Q

Differentiate Lactational vs. Non-Lactational Mastitis according to: Symptoms (7)

A
  • Lactational:
    • Unilateral localized pain
    • Tenderness
    • Erythema
  • Non-Lactational Mastitis:
    • Subareolar pain
    • May have subareolar mass
    • Discharge (variable colour)
    • Nipple inversion
45
Q

Differentiate Lactational vs. Non-Lactational Mastitis according to: Treatment (5)

A
  • 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)
46
Q

Differentiate Lactational vs. Non-Lactational Mastitis according to: Abscess (8)

A
  • 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)
47
Q

Name different: Postpartum Mood Alterations (3)

A
  • POSTPARTUM BLUES
  • POSTPARTUM DEPRESSION
  • POSTPARTUM PSYCHOSIS
48
Q

Describe: Postpartum blues (4)

A
  • 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
49
Q

Describe manifestations: Postpartum blues (9)

A
  • mood lability
  • depressed affect
  • increased sensitivity to criticism
  • tearfulness
  • fatigue
  • irritability
  • poor concentration/despondency
  • anxiety
  • insomnia
50
Q

Define: Postpartum depression (9)

A

major depression occurring in a woman within 6 mo of childbirth

51
Q

Describe epidemiology: Postpartum depression (2)

A
  • 10-15%
  • risk of recurrence 50%
52
Q

Name risk factors: Postpartum depression (6)

A
  • personal or family history of depression (including PPD)
  • prenatal depression or anxiety
  • stressful life situation
  • poor support system
  • unwanted pregnancy
  • colicky or sick infant
53
Q

Name clinical features: Postpartum depression (2)

A
  • 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)
54
Q

Describe assessment: Postpartum depression (1)

A
  • Edinburgh Postnatal Depression Scale or others
55
Q

Describe tx: Postpartum depression (4)

A
  • antidepressants
  • psychotherapy
  • supportive care
  • Electroconvulsive therapy (ECT) if refractory
56
Q

Describe prognosis: Postpartum depression (1)

A
  • interferes with bonding and attachment between mother and baby, so it can have long-term effects
57
Q

Define: Postpartum psychosis (2)

A
  • onset of psychotic symptoms over 24-72 h within first month postpartum
  • can present in the context of depression
58
Q

Describe epidemiology: Postpartum psychosis (1)

A

rare (0.2%)

TN Obstetrics (16 decks)

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