Postnatal complications Flashcards
Post-partum haemorrhage
>500mL blood loss after delivery
- Primary, occurs in first 24hr
- Secondary, occurs between 24hr and 12wk
Degree of blood loss:
- Minor: 500-1000mL
- Moderate: 1000mL-2000mL
- Severe: >2000mL
Complicates 6-10% pregnancies, most deaths are preventable but are a result of a lack of skilled birth attendants at deliveries and limited use of active management of labour and poor access to uterotonic drugs
Causes of post partum haemorrhage
Primary post-partum haemorrhage is cause by 4 Ts
- Tone: 70%, lack of uterine contractility
- Trauma: 20%, perineal tears of surgical trauma
- Tissue: 10%, retained placenta
- Thrombin: <1%, clotting factor deficiency or secondary to massive blood loss and disseminated intravascular coagulation
- Secondary post partum haemorrhage is caused by infection or retained placenta
Clinical features of post-partum haemorrhage
- Depends on volume of blood loss
- Maternal collapse
- Hypotension
- Tachycardia
- Tachypnoea
- Hypoperfusion of organs
- Acute kidney injury
Calculating blood volume loss based on clots
Double the volume of clot to ascertain the actual blood volume lost
Diagnosis of post partum haemorrhage
- Source of bleed identified by examination
- Uterine contractility assesses
- Perineum and vagina examined for trauma
- Placenta checked for completeness
Management of postpartum haemorrhage
Emergency management: aim is to treat cause while giving fluid and blood products. Uterine atony causes 70% of cases so rubbing up a uterine contraction or carrying out bimanual uterine compression is recommended while other causes are ruled out
- Drugs that cause the uterus to contract (syntocinon, syntometrine and misoprostol) can be given
- Trauma is repaired, retained tissue removed and if bleeding doesn’t stop, senior colleagues are needed
- Haemostatic balloon on the uterine cavity has a tamponade effect as does a compression suture
- If bleeding continues a hysterectomy is performed
- Anaemia after delivery treated with iron with blood transfusion required in cases of significant loss
To prevent disseminated intravascular haemorrhage fresh frozen plasma is given along with RBCs
What are the common causative organisms of postnatal infection?
Group A strep: perineal infection, endometritis
E.coli: pyelonephritis
Staph aureus: mastitis, wound infection
Strep pneumoniae: pneumonia
MRSA: hosp. acquired wound infection
Prevention of postnatal infection
- Antibiotic prophylaxis is given before c-section to reduce risk of endometritis and wound infections
- Advice about hygiene after delivery
Clinical features of postnatal infection
General features of infection
- Mastitis - common and overlooked symptom of sepsis
- Endometritis - cause of secondary postpartum haemorrhage, blood is offensive smelling, abdo pain and uterus fails to involute as expected
- Perineal infection - pain, discharge and wound breakdown
- Pyelonephritis - dysuria, loin pain and vomiting
- Deep infection - severe pain disproportionate to clinical signs and requires urgent debridement of dead tissue
- ***nausea and vomiting could be a sign of sepsis***
Management of postnatal infection
Management:
- Broad spectrum IV antibiotics given within 1hr of presentation to hospital if signs of sepsis - don’t wait for results of culture
- Commonly used = co-amoxiclav and metronidazole or piperacillin-tazobactam (tazocin)
- IV fluids guided by obs
- Breast and pelvic abscesses are drained of antibiotics don’t work
- Admit septic patients with organ failure to intensive care
- Baby will need septic screen if mother is septic
Prognosis:
Severe sepsis has a mortality rate of 20-40% which increases to 60% of septic shock occurs
Increased risk of VTE during pregnancy
Rates increase 10x during pregnancy and in puerperium
Leading cause of maternal death in developed countries
Aetiology of VTE in pregnancy
- VTE = collective term for DVT and PE
- Clots form because of static blood, hypercoagualibility and endothelial injury (Virchow’s triad)
- Pregnancy and childhood increase susceptibility to clots because all three factors are present:
- Static blood: compression of iliac veins by uterus
- Clotting: clotting factors are increased to prevent postpartum haemorrhage
- Endothelial injury: occurs during delivery
Prevention of VTE in pregnancy
- Low molecular weight heparin given during and after pregnancy to women at risk of VTE
- Anti-embolism stockings to reduce the risk of DVT during immobilisation (improve venous blood flow)
Investigations for VTE in pregnancy
- Imaging: lower limb Doppler - if Doppler negative and PE suspected a chest x-ray followed by V/Q scan or CT angiography
- Bloods: renal and liver function and platelet count before heparin is given because the results determine the dose
- Is D-dimer measured in pregnancy? No, it’s unhelpful because levels are increased in pregnant women even in the absence of VTE
Management of VTE in pregnancy
Management:
- Low molecular weight heparin is the mainstay and is started while investigations are ongoing
- Anti-embolism stockings reduce oedema and pain and prevent post-thrombotic syndrome
- Medication: low molecular weight heparin is given subcut. If massive PE unfractioned heparin or thrombolytics are given (streptokinase)
- Surgery: temporary vena cava filter, embolectomy
Prognosis:
Up to 60% of women develop post-thrombotic syndrome after VTE
