Complications of the Postpartum Period Flashcards
What is the definition of post partum hemorrhage?
EBL>500ml after a vaginal delivery
EBL>1000ml after a cesarean
What is the number one cause of post partum hemorrhages? How do you manage these patients?
uterine atony such as drugs, chorioamnionitis, uterine overdistention, and uterine malformation
Uterine massage-methergine-PGF2a
What are other causes of postpartum hemorrhages?
retained placenta (accreta- superficial)
Lacerations (vaginal and cervivcal)
coagulopathy
What are vaginal lacerations most likely from?
instrumental vaginal delivery
What are cervical lacerations most likely from? How do you manage it?
precipitous labor; repair laceration
What are examples of coagulopathy related causes of postpartum hemorrhages? How do you manage these patients?
severe preclampsia
abruptio placentae
sepsis
amniotic fluid embolism
cryoprecipitate
What are the classifications of puerperal infection?
endometritis
wound infection
UTI
What are the risk factors for endometritis?
labor ruptured membranes multiple vaginal exams preexisting vaginal infections (BV, GBS) Cesarean delivery (10-15% compared to vag delivery)
What is the main risk factor of endometritis?
Cesarean
What are the bacteriods?
anaerobic gram - rods
What are the coliforms?
aerobic gram -: e. coli and klebsiella
what are the streptococci?
GBS, Staph, Anaerobic strep
What are the requirements of dilation for a vaginal delivery?
atleast a +3- +5 dilation otherwise cesarean; need to see the babies head
What are the clinical manifestations of endometritis?
fever
tachycardia
pelvic pain and tenderness
no other localizing sign of infection
What are the antibiotic treatments for endometritis?
clindamycin plus gentamicin
**metronidazole plus penicillin or ampicillin plus gentamicin
broad spectrum cephalosporin or penicillin (cefotetan, timentin)
What is the frequency of a wound infection after a cesarean?
3-5%; usually in sub cut. fascia, dont let it spread farther
What are the principal risk factors for wound infections?
obesity
pre-existing infection- ie chorioamnionitis
emergency procedure- inadequate skin prep
diabetes
immunodeficiency disorder
What are the main organisms responsible for wound infections?
mixed flora (most)
strep
staph
What is the clinical presentation of a wound infection?
Incisional abscess- pus
cellulitis- bright red and tender
What is the treatment for a wound infection?
Surgical drainage if an abscess
modify antibiotic coverage to target staphylococci and streptococci (nafcillin and vancomycin)
What are the frequencies of UTIs after labor and delivery?
3-5%
What are the risk factors for a UTI?
Prior infection
Prolonged bladder catheterization
sickle cell dz
immunodeficiency disorder
What are the main microbes responsible for these UTIs?
E. coli**
Klebsiella
Proteus
Gram +
What are the clinical manifestations of a UTI?
Cystitis- infected bladder ( dysuria, polyuria, hesitency, hematuria, lowgrade fever, suprapubic pain)
Pyelonephritis (fever, chills, flank pain)
How do you make a diagnosis of a UTI?
Duffs way: in and out cath!
Urine analysis (pH, leukocyte esterase, nitrite test) Urine culture
What is the treatment for a UTI?
Oral abx:
trimethoprim-sulfamethoxazole- proteus
**nitrofurantoin- hits all but proteus, cheap
amoxicillin-clavulanic acid- if highly resistent but want to treat orally
How do you treat a patient via IV if the have kidney problems?
aztreonam
Virchow’s Triad
endothelial injury
venous stasis
hypercoagulable state
What is the prevelance of a thromboembolism?
<1%
What re the principal risk factors of a thromboembolism?
****Cesarean delivery obesity prolonged bedrest prior to delivery hereditary thrombophilia sickle cell disease
What are the classifications of thromboembolisms?
DVT
PE
What are the clinical manifestations of a DVT?
Erythema
Swelling
Palpable cord
What are the clinical manifestations of a PE?
Dyspnea Tachypnea Chest pain Anxiety Cardiovascular collapse
How do you diagnose a DVT?
Most widely used: dopple flow
Most definitive test: venography
How do you diagnose a PE?
***Spiral CT
Ventilation perfusion scan
pulmonary angiogram
What is the management for a DVT and PE?
Screen for hereditary thrombophilia Thrombolytic therapy- for massive embolism **Anticoagulation -unfractioned heparin -LMW heparin -coumadin (lovanax)
What are the principal risk factors for postpartum endometritis?
cesarean section
