Peripartum Complications Flashcards
Peripartum
The period shortly before, during, and immediately after giving birth.
Common postnatal issues
Infected perineum
Infected post-CS
Raised BP
Pain
Mastitis
What infections can occur post CS?
Endometritis (infected womb)
Cellulitis (infected skin)
NB: BOTH TREATED WITH PO ABx
How does indomeritis present?
Heavier lochia, smelly discahrge, fever
1st line management for postnatal hypertension
Enalapril
Treatment of mastitis
Encourage breastmilk expression, then PO flucloxacillin
AB for mastitis
Fluclox
What is endometritis?
Infection of the endometrium occurring in the post-partum period
RFs of endometritis
Antenatal
Instrumentation during delivery
Gestational diabetes mellitus
Immunocompromise
Intrapartum
Prolonged rupture of membranes (> 18 hours)
Chorioamnionitis
Postpartum
Retained products of conception
Important cause of endometritis to consider
Retained products of conception (RPOC)
Causes of endometritis
Gram-negative anaerobes
Streptococci
Clinical features of endometritis
Fever
Foul vaginal discharge or lochia
Persistent vaginal bleeding
Lower abdominal pain
Systemic upset (sepsis)
Investigations of endometritis
Bedside
High vaginal swab and endocervical swab
Urine Dipstick and MC&S
Imaging & Other
Ultrasound (check for retained products of conception)
What investigation done to check for retained products of conception?
Ultrasound (check for retained products of conception)
How is endometritis managed?
Sepsis 6 Protocol
What Abx are used as part of the sepsis 6 protocol in endometritis?
Gentamicin STAT + Cefotaxime + Metronidazole
Penicillin Allergy: Gentamicin + Clindamycin + Ciprofloxacin
What are retained products of conception?
Condition in which pregnancy-related tissues (e.g. placenta) remains in the uterus after delivery, miscarriage or termination of pregnancy.
RFs for retained products of conception
Placenta accreta
Previous retained products of conception
Instrumental delivery
Clinical features of retained products of conception
Placenta accreta
Previous retained products of conception
Instrumental delivery
Investigations for retained products of conception
Bloods
FBC, CRP (check inflammatory markers)
Blood Cultures
G&S, Clotting
Imaging & Other
Ultrasound
High Vaginal and Endocervical Swabs
Management of retained products of conception
Conservative Management
Suitable if < 50 mm on scan, no active bleeding and adequate starting haemoglobin
Medical Management
Misoprostol can be used to help expel any retained products
Consider broad-spectrum antibiotic cover
Surgical Management
Evacuation of Retained Products of Conception (ERPC)
Dilation & Curettage
After any form of management of retained products of conception, advise taking a urinary pregnancy test in 3 weeks’ time (if positive, this is likely suggestive of remaining tissue)
What is the conservative management of retained products of conception?
Suitable if < 50 mm on scan, no active bleeding and adequate starting haemoglobin
What is the medical management of retained products of conception?
Misoprostol can be used to help expel any retained products
Consider broad-spectrum antibiotic cover
What is the surgical management of retained products of conception?
Evacuation of Retained Products of Conception (ERPC)
Dilation & Curettage
What medication can be used to help expel any retained products in RPOC?
Misoprostol
What should be advised after any form of management of retained products of conception?
advise taking a urinary pregnancy test in 3 weeks’ time (if positive, this is likely suggestive of remaining tissue)
What does a positive pregnancy test after management of retained products of conception suggest?
remaining tissue
What is PPH defined as?
Postpartum haemorrhage: loss of more than 500ml (vaginal) or 1L (C-section) of blood after delivery
How can PPH be classified?
Primary PPH – within the first 24 hours
Secondary PPH – after the first day and up to 6 weeks later
Causes of primary PPH
Causes (4Ts)
Tone (uterine atony) - MOST COMMON
Thrombin (coagulopathy)
Tissue (retained products of conception)
Trauma (perineal tears)
Causes of secondary PPH
Causes include endometritis and retained placenta
NB: Management is same as for endometritis and RPOC
Clinical features of PPH
Haemodynamic collapse
Reduced consciousness
Rising fundus
Investigations for PPH
Primarily a clinical diagnosis
Bloods:
Blood Gas (check Hb)
Group & Save
Clotting Screen
FBC
How to minimise risk for PPH?
Prophylactic uterotonics should be offered to all women during the third stage of labour
IM Oxytocin is generally considered the first-line agent
Syntometrine may be used in patients who have an increased risk of PPH (provided that they are not hypertensive)
What is 1st line agent given to all women during third stage of labour to minimise risk of PPH?
IM Oxytocin
NOTE:
Management of Minor PPH (500-1000 mL blood loss without evidence of shock)
Gain large bore IV access
Commence warmed crystaloid infusion
Minor PPH
500-1000 mL blood loss without evidence of shock
Major PPH
> 1000 mL blood loss
Management of major PPH
Call for help (obstetric major haemorrhage call)
A to E Approach and Resuscitation
Lie the patient flat
Apply high flow oxygen
Gain large bore IV access
Administer blood transfusions
Initial: Bimanual Compression
Pharmacological and Surgical
Step 1: IV/IM Syntocinon or IM Ergometrine or Syntometrine
Step 2: IM Carboprost (caution in patients with a background of asthma)
Step 3: Bakri Balloon Tamponade
Step 4: Other Surgical Measures (e.g. B-Lynch suture, Hysterectomy)
EMERGENCY: Bimanual Compression
Pharmacological and surgical management of major PPH
Step 1: IV/IM Syntocinon or IM Ergometrine or Syntometrine
Step 2: IM Carboprost (caution in patients with a background of asthma)
Step 3: Bakri Balloon Tamponade
Step 4: Other Surgical Measures (e.g. B-Lynch suture, Hysterectomy)
EMERGENCY: Bimanual Compression
When should carboprost bee avoided?
Patients with asthma
What is the initial management of major PPH?
CALL FOR HELP, then A-E approach
When should bimanual compression be carried out in major PPH?
Initially, before pharmacological and surgical management and in an emergency
Contraindication for ergometrine
Hypertension
1st pharmacological step in management of major PPH
Step 1: IV/IM Syntocinon or IM Ergometrine or Syntometrine
Followed by Step 2: IM Carboprost (caution in patients with a background of asthma)
Mnemonic for PPH RFs
Postpartum haemorrhage risk factors (PARTUM)
Prolonged labour/ Polyhydramnios/ Previous C-section
APH
Recent Hx of bleeding
Twins
Uterine fibroids
Multiparity
Reversible causes of cardiac arrest
4Hs
Hypoxia
Hypothermia
Hypovolaemia
Hypo- and Hyperkalaemia
4Ts
Toxins
Thromboembolic
Tension Pneumothorax
Tamponade
Pregnancy specific causes of maternal cardiac arrest
Haemorrhage
Pulmonary Embolism
Eclampsia
Sepsis
Specific management in maternal cardiac arrest in pregnancy
Aortocaval Compression
The weight of the uterus beyond 20 weeks’ gestation means that it can compress the IVC and aorta resulting in reduced venous return and, hence, reduced cardiac output
Therefore, pregnant women should be tilted to the left hand side or the uterus should be manually displaced to the left if the patient is difficult to lift
What side should the pregnant women be tilted to in maternal cardiac arrest?
pregnant women should be tilted to the left hand side
What side should the uterus be displaced to in maternal cardiac arrest?
uterus should be manually displaced to the left if the patient is difficult to lift
How should delivery of foetus be managed in matnerla cardiac arrest?
Immediate caesarean section required if no response after 4 mins of CPR
Caesarean section should be performed within 5 minutes of beginning CPR to increase chances of maternal survival
After how long of CPR should a CS be carried out if no response?
4 mins
NOTE: Caesarean section should be performed within 5 minutes of beginning CPR to increase chances of maternal survival
What is an amniotic fluid embolism?
Abnormal systemic reaction to the entry of foetal cells and amniotic fluid into the maternal blood stream.
RFs of amniotic fluid embolism
Increasing maternal age
Induction of labour
Polyhydramnios
Assisted/operative delivery
Uterine rupture
Placental abruption
Rapid labour/precipitate labour
Prolonged labour
Meconium-stained amnionic fluid
Tears into uterine and other large pelvic veins
Clinical features of amniotic fluid embolism
The three classical features of amniotic fluid embolism are the following:
- Abrupt onset of hypotension
- Hypoxia
- Severe consumptive coagulopathy
How can amniotic fluid embolism present?
Sudden collapse
Usually presents during labour or in the immediate post-partum period
Shivering and chills
Hypotension
Shortness of breath (due to bronchospasm)
Arrhythmia
Investigations for amniotic fluid embolism
MAINLY A CLINICAL DIAGNOSIS
Management of amniotic fluid embolism
Patients are often critically unwell and need ITU-level care
Treatment is supportive (fluids, oxygen, inotropes and vasopressors)
What is chorioamnionitis?
Inflammation of the amniochorionic membranes usually due to a bacterial infection. It is dangerous for both the mother and the foetus.
When does chorioamnionitis often occur?
after preterm premature rupture of membranes (PPROM)
What are most chorioamnionitis cases due to?
ascending infection from the mothers genital tract
Common causes of chorioamnionitis
Common Causes: E. coli, Group B Streptococcus, anaerobes
RFs for chorioamnionitis
Prolonged and Preterm Rupture of Membranes
Prolonged Labour
Nulliparity
Group B Streptococcus Colonisation
Alcohol Use
Smoking
Epidural Anaesthesia
Clinical features of chorioamnionitis
Fever
Lower abdominal pain
Offensive vaginal discharge
Foetal distress on CTG
Maternal tachycardia during labour
Investigations for chorioamnionitis
Bedside
CTG
Bloods
FBC and CRP (raised inflammatory markers)
VBG (check lactate)
Blood Cultures
Imaging & Other
Vaginal Swabs
Urine Culture
What might be seen on CTG on chorioamnionitis?
Foetal distress
What might be seen in the mother during labour in chorioamnionitis?
Tachycardia
Management of chorioamnionitis
Follow the sepsis 6 protocol
Early senior input
Regarding Delivery
If the pregnant woman is critically unwell, urgent delivery should be considered
If preterm delivery is anticipated, cautious consideration should be given when deciding about giving antenatal corticosteroids in view of the intercurrent infection
Continuous foetal monitoring throughout
Epidural and spinal anaesthesia should be avoided in women with sepsis (can worsen haemodynamic instability)
Antibiotics
Use broad-spectrum antibiotics (e.g. ampicillin and gentamicin)
IVIG
May be considered in severe invasive streptococcal or staphylococcal infection if other therapies have failed
What decisions must be made regarding delivery in chorioamnionitis?
If the pregnant woman is critically unwell, urgent delivery should be considered
If preterm delivery is anticipated, cautious consideration should be given when deciding about giving antenatal corticosteroids in view of the intercurrent infection
Continuous foetal monitoring throughout
Epidural and spinal anaesthesia should be avoided in women with sepsis (can worsen haemodynamic instability)
What should be done if the pregnant women is critically unwell in chroioamnionitis?
urgent delivery should be considered
What should caution be taken before administering in preterm delivery with chorioamnionitis?
If preterm delivery is anticipated, cautious consideration should be given when deciding about giving antenatal corticosteroids in view of the intercurrent infection
What should be avoided in women with sepsis? Why?
Epidural and spinal anaesthesia should be avoided in women with sepsis (can worsen haemodynamic instability)
Why should epidural and spinal anaesthesia be avoided in women with sepsis?
can worsen haemodynamic instability
What ABx should be used in chorioamnionitis management?
Use broad-spectrum antibiotics (e.g. ampicillin and gentamicin)
When may IVIG be considered in chorioamnionitis?
in severe invasive streptococcal or staphylococcal infection if other therapies have failed
Is GBS part of routine antenatal screening?
It is NOT part of routine antenatal screening
What is GBS infection in pregnancy?
Invasive infection caused by Group B Streptococcus during pregnancy.
How many women is GBS carried in commensally?
Group B Streptococci are vaginal commensals that are carried by 20-40% of women
Clinical features of GBS in pregnancy
GBS carriage is asymptomatic when it is present as a commensal
May be noted on routine antenatal urine testing
Neonatal sepsis
What life threatening condition can GBS present with in neonates?
Sepsis
Investigation of GBS in pregnancy
May be identified upon routine urine dipstick testing and subsequent MC&S
Patients with previous pregnancies complicated by GBS should be considered to be at high risk of recurrence
Offered testing at 35-37 weeks’ gestation
Likelihood of carrying GBS into current pregnancy if previous infection
50%
How is GBS in pregnancy maanged?
Intrapartum Antibiotic Prophylaxis
First-Line: IV Benzylpenicillin
Penicillin Allergy: Clindamycin
NOTE: Patients should receive antibiotics at the time of diagnosis in addition to intrapartum antibiotic prophylaxis
What is used in GBS in pregnancy that is effective at reducing rates of early onset neonatal GBS infeciton
Intrapartum Antibiotic Prophylaxis
First-Line: IV Benzylpenicillin
Penicillin Allergy: Clindamycin
1st line AB for GBS in pregnancy
IV BenPen
Indications for intrapartum AB prophylaxis in GBS in pregnancy
Preterm labour irrespective of GBS carrier status
GBS bacteriuria in current pregnancy
Incidental test result positive for GBS
When should patients receive ABx in GBS in pregnancy?
Patients should receive antibiotics at the time of diagnosis in addition to intrapartum antibiotic prophylaxis
What management should be done post-partum in GBS in pregnancy?
Newborns should receive antibiotics therapy (IV penicillin and gentamicin) and a full septic screen if deemed to be at high risk
NOTE: Features of increased risk
Previous baby with GBS disease
Discovery of of maternal GBS carriage through bacteriological investigation during pregnancy (e.g. swab taken to investigate vaginal discharge)
Preterm birth
Prolonged rupture of membranes
Maternal intrapartum infection (including chorioamnionitis)
Pyrexia
What is a perineal tear?
Tearing of the perineum during childbirth.
RFs for perineal tears
Large for Gestational Age
Abnormal Lie
Instrumental Delivery
Primiparity
Classification of perineal tears
1st Degree
Superficial tear with NO muscle involvement
2nd Degree
Injury to perineal with NO anal sphincter involvement
3rd Degree
Injury to perineum involving the anal sphincter complex
3a: < 50% of external anal sphincter involved
3b: > 50% of external anal sphincter involved
3c: involvement of the internal anal sphincter
4th Degree
Injury to perineum involving the anal sphincter complex (external and internal anal sphincter) and rectal mucosa
1st degree perineal tear
Superficial tear with NO muscle involvement
2nd degree perineal tear
Injury to perineal with NO anal sphincter involvement
3rd degree perineal tear
Injury to perineum involving the anal sphincter complex
3a: < 50% of external anal sphincter involved
3b: > 50% of external anal sphincter involved
3c: involvement of the internal anal sphincter
4th degree perineal tear
Injury to perineum involving the anal sphincter complex (external and internal anal sphincter) and rectal mucosa
What degree tear does the internal anal sphincter become involved in?
3c
NOTE: 3a: < 50% of external anal sphincter involved
3b: > 50% of external anal sphincter involved
3c: involvement of the internal anal sphincter
What degree of perineal tear does the rectal mucosa become involved in?
4
NOTE:Injury to perineum involving the anal sphincter complex (external and internal anal sphincter) and rectal mucosa
How are perineal tears managed?
Antibiotics
Laxatives
Physiotherapy
Surgical Repair and Suturing
1st or 2nd Degree: Repaired by midwife on labour ward
3rd or 4th Degree: Repaired by obstetrician in theatre
Who repairs 1st or 2nd degree perineal tears?
Repaired by midwife on labour ward
Who repairs 3rd or 4th degree perineal tears?
Repaired by obstetrician in theatre
What degree of perineal tear is repaired by midwife on labour ward?
1st or 2nd Degree
What degree of perineal tear is repaired by obstetrician in theatre?
3rd or 4th Degree
What is placenta accreta?
A condition in which the placenta invades deep into the wall of the uterus resulting in difficulty detaching following childbirth.
Difference between placenta accreta/increta/percretea
Accreta attaches to myometrium
Increta invades the myometrium
Percreta percolates through the myometrium (goes through entire wall of uterus)
What is is that extends beyond the endometrium in placenta accreta?
Chorionic villi
RFs for placenta accreta
Previous placenta accreta
Previous C-section
Maternal age
Previous endometrial curettage
Clinical features of placenta accreta
May be identified during an antenatal ultrasound scan
Usually identified in the context of prolonged 3rd stage of labour or post-partum haemorrhage
How is placenta accreta usually identified?
Usually identified in the context of prolonged 3rd stage of labour or post-partum haemorrhage
What does placenta accreta usually cause?
prolonged 3rd stage of labour or post-partum haemorrhage
Investigations for placenta accreta
Bloods
Group & Save (as patient is likely to bleed heavily)
Clotting Screen
Imaging
Ultrasound or MRI (to assess depth and invasion)
Management of placenta accreta
Blood Transfusion
Likely to need planned C-section if identified during routine antenatal assessments
Surgical Management
Uterus-preserving surgery (involves resecting the myometrium that is invaded by the placenta)
Hysterectomy
What mode of delivery is patient likely to need if accreta need during routine antenatal assessments?
planned C section
What is the surgical management of placenta accreta?
Uterus-preserving surgery (involves resecting the myometrium that is invaded by the placenta)
Hysterectomy
What is puereral pyrexia?
Fever that arises within 6 weeks of giving birth.
Most common cause of puerperal pyrexia
Endometritis (MOST COMMON)
Causes of puerperal pyrexia
Endometritis (MOST COMMON)
UTI
Wound Infections (e.g. from C-section scars and perineal tears)
Mastitis
RFs for puerperal pyrexia
Prolonged labour
Regular vaginal examinations during labour
Preterm prelabour rupture of membranes
Instrumental delivery
Clinical features of puerperal pyrexia
Depends on the source
Fever
Abnormal vaginal discharge or lochia
Dysuria
Oozing from scars
Investigations of puerperal pyrexia
Bedside
Urine Dipstick and MC&S
Wound Swab
Genital Swabs
Bloods
FBC and CRP (check inflammatory markers)
Blood Cultures
Management of puerperal pyrexia
Depends on cause and severity
Usually resolves with antibiotics
What is Sheehan syndrome?
Rare complication of post-partum haemorrhage resulting in ischaemic necrosis of the pituitary gland.
Clinical features of sheehan syndrome
Prolactin –> Reduced lactation
ACTH –> Adrenal insufficiency (electrolyte derangement, fatigue, postural hypotension)
TSH –> Hypothyroidism
LH and FSH –> Amenorrhoea
Growth Hormone –> Fatigue
Investigations of sheehan syndrome
Tests of Pituitary Hormones
Prolactinoma –> Serum prolactin concentration
Growth Hormone –> Insulin-like Growth Factor 1 (IGF-1 Level), glucose tolerance test
ACTH –> serum cortisol levels, ACTH levels, short synacthen test (if hyposecretion suspected)
Gonadotrophins –> measure serum LH and FSH levels
TSH –> TFTs
Imaging & Other
MRI - Pituitary ring sign ( halo around empty sella)
Pituitary ring sign of MRI
sheehan syndrome
halo around empty sella on MRI
Pituitary ring sign –> Sheehan
Management of sheehan syndrome
Lifelong Hormone Replacement
NOTE: steroids should be started before thyroxine in patients with suspected cortisol and thyroxine deficiency
In management of sheehan, what medication should be started first?
steroids should be started before thyroxine in patients with suspected cortisol and thyroxine deficiency
What is stillbirth defined as?
Death of a foetus after 24 weeks’ gestation.
Death of a foetus after 24 weeks is known as
stillbirth
Causes of stillbirth
Pre-eclampsia
Placental abruption
Systemic disease (e.g. diabetes mellitus, thyroid disease)
Congenital infections
Genetic abnormalities and congenital malformations
RFs for stillbirth
Maternal smoking
Maternal alcohol use
Maternal age
Obesity
Multiple pregnancy
Investigations for stillbirth
Ultrasound is used to diagnose intrauterine foetal death (check for foetal movements and foetal heart beat)
Auscultation and cardiotocography should not be used to investigate suspected IUFD.
A second opinion should be obtained whenever practically possible.
Clinical assessment and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of death, the chance of recurrence and possible means of avoiding further pregnancy complications.
What investigation should be used to diagnose intrauterine foetal death?
Ultrasound is used to diagnose intrauterine foetal death (check for foetal movements and foetal heart beat)
What investigations should not be used to investigate suspected intrauterine foetal death?
Auscultation and cardiotocography should not be used to investigate suspected IUFD.
What should be recommended to assess maternal wellbeing in stillbirth
Clinical assessment and laboratory tests
Management of stillbirth
Anti-D prophylaxis should be given to Rhesus negative mothers
Vaginal birth is first-line (expectant management or induction of labour with mifepristone and misoprostol)
How to investigate cause of stillbirth?
Genetic testing
Post-mortem examination
Testing for congenital infection
Screening for systemic maternal diseases (e.g. diabetes mellitus)
PACES: Postnatal care of stillbirth
Memory box
Referral to bereavement midwife
Debriefing
Consultant-led care in future pregnancies
What is uterine inversion?
Complication that occurs during delivery where the fundus of the uterus inverts and prolapses through the cervix and vagina.
What can uterine inversion lead to?
massive post-partum haemorrhage
NOTE: It is a life-threatening complication of childbirth because it can lead to massive post-partum haemorrhage
RFs for uterine inversion
Macrosomia
Prolonged labour
Use of uterine relaxants
Anatomical abnormalities of the uterus
Fibroids
Mismanaged third stage of labour
How can mismanaged third stage of labour lead to uterine inversion?
Usually involves pulling too early on the umbilical cord before the placenta begins to naturally separate from the wall of the uterus
Clinical features of uterine inversion
Uterus palpated or visualised within the vagina
Can follow Vaginal or Cesarean birth
Uterine fundus collapses into the endometrial cavity
Hypovolaemic shock due to post-partum haemorrhage
Signs and Sx of uterine inversion
Signs and symptoms include one or more of the following:
Mild to severe vaginal bleeding
Mild to severe lower abdominal pain
A smooth, round mass protruding from the cervix or vagina
Urinary retention
Investigations for uterine inversion
Clinical diagnosis
Management of uterine inversuin
Discontinue uterotonic drugs
Johnson Manoeuvre: manual replacement of the uterus into its correct anatomical position
If the Johnson Manoeuvre is unsuccessful, consider hydrostatic methods
Surgical Management
Considered if the above approaches fail
Laparotomy to return uterus to the normal position
If bleeding cannot be controlled or the uterus cannot be returned to its correct anatomical position, a hysterectomy is likely to be performed
Johnson manoeuvre
Manual replacement of uterus into its correct anatomical position. USED IN UTERINE INVERSION.
What is 1st line management of uterine inversion?
Discontinue uterotonic drugs
Followed by: Johnson Manoeuvre: manual replacement of the uterus into its correct anatomical position
When is surgical management done in uterine inversion?
If discontinuation of uterotonic drugs, johnson manoeuvre and hydrostatic methods fail
