Exam 3 - Late Postpartum Complications Flashcards
What would be considered a postpartum infection?
Any infection of the genital tract following childbirth, spontaneous abortion, pregnancy termination
- Commonly occur during first few weeks postpartum
Common sites of infection following vaginal delivery
- Perineal laceration
- Episiotomies
- Placental implantation site
Common causative agents of postpartum infections
- Steptococcus species, s. aureus, s. epidermidis
- Gram negative aerobes
- E. coli
- Klebsiella pneumoniae
- Enterobacter cloacae
- Proteus mirabilis
- Mycoplasma, chlamydia, gonorrhea
Signs and symptoms of postpartum infection
- Elevated temperature
- Malaise
- Pain
- Malodorous lochia
Risk factors of endometritis
- C-section
- Prolonged labor
- Frequent vaginal exams
- Retained placental fragments
Signs and symptoms of endometritis
- Generalized malaise
- Fever
- Chills
- Flu-like symptoms
- Foul smelling lochia
- Uterine tenderness
Labs and imagins used to manage endometritis
- Urine culture and sensitivity
- Blood cultures
- CBC
- Chest x-ray to rule out PNA
Pharmacological treatment for endometritis
IV antibiotics - clindamycin and gentamicin
What happens to patients with undiagnosed/untreated endometritis?
Can lead to salpingitis, septic thrombophlebitis, peritonitis, necrotizing fascitis
What causes postpartum women to develop UTI and pyelonephritis?
Urinary stasis from decreased bladder tone, increased bladder volume
- Particularly following epidural anesthesia, incomplete bladder emptying during labor, urethral catheterization
UTI symptoms
- Urinary frequency
- Urgency
- Dysuria
- Super pubic pain or pressure
Pyelonephritis symptoms
- Low grade fever
- Flank pain
- CVA tenderness
- N/V
What is uterine subinvolution?
Failure of uterus to return to pre-pregnancy size during 4-6 week postpartum period
What causes uterine subinvolution?
Uterine myometrium does not contract effectively
- Due to retained placental fragments, infection, excessive maternal activity
Subinvolution occuring at placental site can cause bleeding due to?
Inadequate sloughing and regeneration of endothelial lining up to 4-6 weeks after birth
- Involution normally occurs by week 2
Clinical presenation of uterine subinvolution
- Extended period of lochial discharge followed by heavy irregular bleeding
- Boggy uterus or larger than expected
- Symptoms resemble uterine infection
- Malodorous discharge
- Adnexal, cervical, uterine tenderness
What should be done for a patient with uterine subinvolution and infection is suspected?
Obtain cultures and treat with broad spectrum antibiotics
If retained placental fragments are a concern for patients with uterine subinvolution, what should be done?
Obtain ultrasound and refer
Pharmacological treatment for women with uterine subinvolution and excessive bleeding
Ergonovine (ergotrate) or methylergonovine (methergine)
What counts as delayed (secondary) postpartum hemorrhage?
Increased bleeding after first 24 hours to 12 weeks
- Most commonly occurs during first 2 weeks due to subinvolution
Signs and symptoms of delayed (secondary) postpartum hemorhage
- Excessive vaginal bleeding
- Signs of shock
- Anemia
Delayed (secondary) postpartum hemorrhage: risk factors
- Retained placental fragments
- Previously undiagnosed vaginal/cervical laceration
- Hematoma
- Uterine infection
- Uterine atony
- Coagulopathy (vWD)
What labs should be collected for patients with delayed (secondary) postpartum hemorrhage?
If no other source of bleeding can be identified, consider
- CBC, platelet count, PTT, PT in fibrinogen
What causes DVT during the postpartum period?
- Venous stasis from relaxed vascular walls in pregnancy
- Hormonal influence
- Hypercoagulopathy
- Vascular trauma from inflammation
Clinical presentation for pulmonary embolism
Greatest concern is pulmonary embolism
- Tachypnea, dyspnea, chest pain of sudden onset
- Altered lung and heart sounds
- Apprehension as oxygen level decreases
Clinical presentation for DVT
- Abrupt severe leg or calf pain with/without ambulation
- Generalized edema in extremity
- Slight fever
- Tachycardia
How does SVT and DVT present on the lower extremeties?
Localized extremity pain in a palpable cord-like structure
- Edema, erythema, warmth
Risk factors for postpartum thrombophlebitis
- Obesity
- Maternal age >35 years
- History of thrombosis
- Anti-phospholipid antibody syndrome
- Sickle cell disease
- Heart disease
- Diabetes
SVT and DVT management (severe)
- Avoid massage, manipulation, use of Homan’s sign to assess (test used to detect DVT)
- Anticoagulant therapy
- Rest
SVT and DVT management (when symptoms resolve)
- Light activity
- Compression stockings
- Analgesia (NSAIDs)
What imaging should be ordered when the provider suspects DVT?
Ultrasound with doppler imaging to confirm diagnosis
What is postpartum thyroiditis?
Inflammation of thyroid gland with alternating hyper and hypothyroidism
- Excessive release of thyroid hormone followed by insufficient amounts of thyroid hormone secretion
Postpartum thyroiditis signs and symptoms
Difficult to recognize because they are similar to symptoms experienced during postpartum
- No recognizable pain or swelling of thyroid gland
What is considered the hyperthyroid phase during postpartum?
1-4 months postpartum
What causes the hyperthyroid phase (1-4 months postpartum) with postpartum thyroiditis?
Low TSH and lack of thyroid perioxidase antibodies and TSH receptor antibodies
Signs and symptoms of hyperthyroidism
- Fatigue
- Palpitations
- Anxiety
- Difficulty sleeping
- Irritability
- Weight loss
What is considered the hypothyroid phase during postpartum period?
4-8 months postpartum
What causes the hypothyroid phase (4-8 months) postpartum?
Elevated TSH noted and positive for antibodies
Signs and symptoms of hypothyroidism
- Fatigue
- Difficulty focusing
- Depression
- Goiter
- Constipation
- Weight gain
Postpartum thyroiditis management
- Refer to endocrinologist
- Hyperthyroid –> beta blockers
- Hypothyroid –> thyroid supplementation (levothyroxine)
Breastfeeding can continue
What is thyroid storm (thyrotoxicosis)?
Abrupt, acute, potentially fatal exacerbation of hyperthyroidism
- Normally occurs during first month postpartum –> elevated T4 levels
Signs and symptoms of thyrotoxicosis
- Fever
- N/V/D
- Tremors
- Tachycardia
- Dehydration
- Seizures
- Cardiomyopathy
- HF
- Coma
- Death
How are thyrotoxicosis and preeclampsia different?
Thyroid storm clinical presenation is similar to preeclampsia
- Differ by high fever and neuropsych symptoms with thyroid storm
Management of thyroid storm
Immediate ICU admission to reduce thyroid hormone levels and hydrate
What what point would postpartum preeclampsia occur?
48 hours postpartum but before 4 weeks
Risk factors for postpartum preeclampsia
- Gestational hypertension
- Preeclampsia during pregnancy
What could the postpartum patient be at risk for after IV fluid therapy during labor and delivery?
Pulmonary edema and renal dysfunction
Clinical presenation of postpartum preeclampsia
- Headache
- Visual disturbances
- N/V
- Epigastric pain
Management of postpartum preeclampsia
- Antihypertensive thearpy
- Magnesium sulfate to prevent eclamptic seizures
