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.