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Patient Evaluation > Abnormal puerperium > Flashcards

Abnormal puerperium Flashcards

1
Q

Abnormal puerperium examples ?

A

Postpartum Hemorrhage

Placenta Accreta

Uterine Inversion

Puerperal Infection

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2
Q

Postpartum hemorrhage pahto ?

A

Defined as >500 ml following vaginal delivery

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3
Q

Postpartum hemorrhage prevalence ?

A

Occurs in 5-8% of deliveries

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4
Q

Postpartum hemorrhage causes ?

A

Uterine atony

Obstetric lacerations

Retained placental tissue

Coagulation defects

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5
Q

Postpartum hemorrhage Tx.: redelivery ?

A

type and cross match

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6
Q

Postpartum hemorrhage Tx. after delivery ?

A

gentle uterine massage. If excessive, may interfere instead of aid

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7
Q

Postpartum hemorrhage Tx. placenta ?

A

Usually separates and is delivered 5-15 mins after baby

Do not attempt to speed this up

Gentle traction on umbilical cord

check and make sure both sides are smooth and intact

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8
Q

____________ is the 3rd leading cause of maternal mortality in US

A

Hemorrhage

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9
Q

Most common cause of PP hemorrhage (50%) ?

A

Uterine atony

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10
Q

Uterine atony patho ?

A

Myometrium cannot contract

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11
Q

Uterine atony causes ?

A

Excessive manipulation of the uterus

General anesthesia

Overdistention of the uterus
# gestations, etc

Prolonged labor

Fibroids

Uterine infection

Operative delivery

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12
Q

Uterine atony Tx ?

A

Uterotonic agents (oxytocin) as soon as the infant’s anterior shoulder is delivered

Bimanual uterine massage

Oral misoprostol (prostaglandin)

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13
Q

Obstetric lacerations causes ?

A

Episiotomy

Lacerations (tears) of uterus, cervix, vagina, vulva

Quick or uncontrolled delivery

Large infant

**if the keep bleeding , look for hematoma collections and they you will find the source of bleeding **

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14
Q

Obstetric lacerations Tx. ?

A

Inspect the vagina and cervix

Repair episiotomy after massage has produced a firm, contracted uterus

If hematoma is identified, open and evacuate

**if U us contracted and you still see bright red blood? think this **

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15
Q

Retained placental tissue occurs in ?

A

placenta accreta

**Accreta – implantation is too deep, the dicidua layer is missing and now there is no separation of the placenta **

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16
Q

Retained placental tissue: _____ of cases of PP hemorrhage

A

5-10%

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17
Q

Retained placental tissue increased frequency b/c of ?

A

multiple c-sections

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18
Q

Retained placental tissue Dx by ?

A

transvaginal sono

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19
Q

Placenta accreta ?

A

A decidual layer normally separates the placenta villi and the myometrium. When there is no decidua, it is termed placenta accreta vera.

**if it does not peel off it just never stopped bleeding and this leads to hysterectomy **

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20
Q

Placenta increta ?

A

villi invade the myometrium

inside the wall

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21
Q

Placenta percreta ?

A

villi penetrate the myometrium

through all layers of U

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22
Q

Most common type of placental adherence anomaly ?

A

Placenta accreta

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23
Q

Major cause of peripartum hysterectomy ?

A

Placenta accreta

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24
Q

Placenta accreta etiology ?

A

UKN

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25
Q

Placenta accreta increased with ?

A

Placenta previa
Previous uterine incision
Multiparity
Previous D&C

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26
Q

Placenta accreta dx w/ ?

A

Can be diagnosed prior to delivery – esp Color Doppler imaging

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27
Q

Placenta accreta pathophysiology ?

A

retained placental parts prevent myometrium from contracting, hemostasis cannot be achieved

Not a problem during pregnancy or delivery

Explore placenta – parts missing

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28
Q

Placenta accreta: Tx if minimal bleeding ?

A

conservative tx –

pelvic artery embolization, then

IM methotrexate.

Placenta may eventually slough

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29
Q

Placenta Accreta: Possibly retains ________, recurrence is high

A

fertility

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30
Q

Placenta Accreta Tx If placenta is totally adherent, ?

A

manual removal cannot be done

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31
Q

Placenta Accreta Tx if hemorrhage ?

A

hysterectomy

32
Q

Manual removal of placenta if ?

A

If not spontaneously delivered by 18-30 mins

33
Q

Manual removal of Placenta risks ?

A

Pain

Risk of endometritis

Causing more bleeding

**try and get behind the retain placenta and try and pull it off

careful cause you can cause more bleeding and give the prophylaxis ABS **

34
Q

Coagulation defects: acquired ?

A

Abruptio placentae

Retained dead fetus = extra thromboplastin
goes from the fetus to the mom

Amniotic fluid embolism

Eclampsia, sepsis

35
Q

Coagulation defects ?

A

Von Willebrand’s

Thrombocytopenia

Leukemia

36
Q

Control of persistent bleeding: Manual exploration of the uterus ?

A

Check for twins

Check for laceration/rupture

Check for retained placental parts

37
Q

Control of persistent bleeding: Bimanual compression and massage ?

A

For atony

May need 20-30 minutes

Foley should be in place cause she needs to be diuresing

38
Q

Control of persistent bleeding: Curettage ?

A

If massage not helpful

Risk of perforation, increased bleeding

Risk of scarring, adhesions(Asherman’s syndrome)

39
Q

Control of persistent bleeding: Intrauterine pressure ?

A

Packing no longer done ( cause TSS)

Use inflatable balloon instead

40
Q

Control of persistent bleeding: Uterotonic agents ?

41
Q

Control of persistent bleeding: Radiographic embolization of pelvic vessels
?

A

Interventional radiologist

Angiographic technique

Fluoroscopy guided – gelfoam into damaged vessel

Helps to maintain fertility (low # cases so far)

Helps to avoid hysterectomy

Risk of loss of circulation to legs, labia, buttocks with necrosis

42
Q

Uterine inversion patho ?

A

Prolapse of the fundus to or through the cervix

43
Q

Uterine inversion prevalence ?

A

1 in 2000 deliveries

44
Q

Uterine inversion RF ?

A

Placental implantation in fundus

Partial placental accreta

Weakened myometrium

Prolonged labor

Strong traction on umbilical cord

Fundal pressure - gentle massage

Hx of uterine inversion

45
Q

Uterine inversion Dx ?

A

Diagnosis is obvious – red-blue bleeding mass at the cervix, in the vagina or outside the vagina

Depressed or absent fundus

Shock, hemorrhage and pain

46
Q

Uterine inversion complications ?

A

Depends on degree of hemorrhage and how quickly and how effectively treated

Endomyometritis frequently follows

Mortality is low since usually promptly recognized and treated

47
Q

Uterine inversion Tx. ?

A

Fluid and blood replacement for hypovolemic shock

Manual repositioning of uterus

With or without IV tocolytics to relax uterus (mag sulfate or terbutaline)

After repositioned – prostaglandins for uterine contraction

Antibiotics

Rarely is surgery required

48
Q

Postpartum infections prevalence ?

A

2-8% of postpartum females

49
Q

Postpartum infections sxs. ?

A

Fever is hallmark, but not necessary

50
Q

Postpartum infections RF ?

A

Low socioeconomic status - less prenatal care

Operative delivery

PROM

Long labor

Multiple pelvic exams

51
Q

Postpartum infections examples ?

A
  • Endometritis
  • UTI

Pneumonia

Caesarean section wound infection

Episiotomy infection

52
Q

Endometritis patho ?

A

Vagina normally has pathogenic flora

Protective factors

  • Acidic pH
  • Thick cervical mucous
  • Maternal antibodies

Decidua and lochia provide nutrients to anaerobic bacteria

53
Q

Endometritis RF ?

A

Digital exams and fetal scalp monitors

Prolonged labor >24 hours

Prolonged rupture of membranes

Pre-existing vaginitis or cervicitis

Anemia

Poor nutrition

Obesity

Coitus near term

C-section or other operative delivery

54
Q

Endometritis S&S ?

A

Fever (100.4⁰ F +) on day 2-3

Soft, very tender uterus

Lochia may have foul odor

Leukocytosis (20,000 +)

Positive blood culture in 5-10%

Lochia culture must be taken intrauterine

Severe – can lead to sepsis

55
Q

Endometritis organisms: Anaerobic bacteria - 50-95% Tx. ?

A

Clindamycin, cephalosporins

56
Q

Endometritis organisms: Group B streptococci – 30%

Tx. ?

57
Q

Endometritis organisms: E.coli Tx. ?

A

Seen in more seriously ill patients

58
Q

Endometritis Tx. ?

A

High dose IV antibiotics until patient is afebrile for 24-48 hours

-Clindamycin plus aminoglycoside once daily
or
-2nd or 3rd generation cephalosporin

Monitor closely

If not improving, add ampicillin

59
Q

UTI prevalence ?

A

2-4% of women develop UTI postpartum

60
Q

UTI Patho / causes ?

A

Postpartum, bladder and lower urinary tract are hypotonic so more residual and reflux

Plus, frequent exams = contamination of perineum

61
Q

UTI S&S ?

A

dysuria, fever, frequency, urgency

62
Q

UTI Labs ?

A

UA – WBC’s and bacteria. Get a culture

Often E. coli

63
Q

UTI Tx. ?

A

sulfonamides, nitrofurantoin, TMP-SMX

Monitor for pyelo

64
Q

Pneumonia Causes ?

A

Women with COPD, smokers, general anesthesia

65
Q

Pneumonia S&S ?

A

same as non postparum woman

Cough, CP, fever, chills, rales, infiltrates on CXR

66
Q

Pneumonia Tx. ?

A

antibiotics, O2, IV hydration, pulmonary toilet

67
Q

Caesarean section wound infection prevalence ?

A

Occurs in 4-12%

68
Q

Caesarean section wound infection RF ?

A

Obesity, diabetes, prolonged hospitalization before C-section, prolonged ROM, prolonged labor, chorioamnionitis, endometritis, anemia, emergency C-section

69
Q

Caesarean section wound infection prevention ?

A

Prophylactic antibiotics

1 g IV cefazolin before skin incision

70
Q

Caesarean section wound infection S & S ?

A

Fever that lasts until day 4 or 5

Wound erythema may not be seen for several days

Drainage or skin separation

71
Q

Caesarean section wound infection Labs ?

A

Gram-stain, C&S of wound

Blood culture if suspect sepsis

72
Q

Caesarean section wound infection organisms ?

A

S. aureus is most common, MRSA

Occas strep, E coli, Bacteroides

73
Q

Caesarean section wound infection Tx. ?

A

Open incision to drain material and to see if fascia has separated

If intact - pack wound with saline-soaked gauze

If not – monitor for dehiscence

74
Q

Episiotomy infection prevalence ?

A

Low incidence – 0.5 – 3% (good blood supply)

75
Q

Episiotomy infection labs ?

A

Labs show mixed infection

76
Q

Episiotomy infection Tx. ?

A

open and clean the wound. Sitz baths

Repair sometimes undertaken 3-4 months after infection clears

Patient Evaluation (29 decks)

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