Postpartum Bleeding and Infection

Question 1

Uterine atony risk factors

Answer 1

Precipitous labor
Multiparity
Twins
General anesthesia
Oxytocin use
Macrosomia
Hydramnios
Chorioamnionitis

Question 2

Placenta previa risk factors

Answer 2

Prior C-section
Myomectomy
Maternal age >35
Previous D&C

Question 2

What should you do if you discover placenta previa during 18-20 wga ultrasound?

Answer 2

Serial ultrasounds throughout pregnancy

Question 3

Which uterotonic should not be used in patient with asthma?

Answer 3

Prostaglandin F2-alpha (carboprost tromethamine) - potent smooth muscle constrictor and bronchoconstrictor

Question 4

Which uterotonic should not be used in patients with hypertension or pre-eclampsia?

Answer 4

Methylergonovine

Question 5

What are the risk factors for uterine overdistension/uterine inversion?

Answer 5

Excessive traction on umbilical cord
Grand multiparity
Multiple gestation
Polyhydramnios
Morbidly adherent placenta
Macrosomia

Question 6

Order of treatments for postpartum hemorrhage due to uterine atony

Answer 6

Uterotonics
B-Lynch stich
Hypogastric artery ligation
Cesarian hysterectomy

Question 7

How should oxytocin be delivered?

Answer 7

Diluted with IV fluids - do not give as an IV push

Question 8

When should uterine artery embolization be considered?

Answer 8

When uterine atony, retained placental products, and lacerations have been ruled out as sources of bleeding

Question 9

What do US placental lakes finding suggest?

Answer 9

Morbidly adherent placenta/placenta accreta spectrum

Often seen with history of C/S

May require hysterectomy for uncontrolled bleeding

Question 10

Delayed (48-72h) postpartum hemorrhage suggests what etiology?

Answer 10

Von Willebrand disease coagulopathy

Question 11

Risk factors for placental abruption

Answer 11

HTN
Advanced maternal age
Cocaine
Alcohol

Question 12

What is gold standard antibiotics following C/S?

Answer 12

Gentamicin (gram-negative) + clindamycin (anaerobes)

Question 13

Postpartum endometritis is a clinical diagnosis, based on what signs and symptoms?

Answer 13

Fever +:
Uterine tenderness
Abnormal vaginal discharge or odor
Delay in rate of reduction of size of uterus

Question 14

When should septic pelvic thrombophlebitis be suspected?

Answer 14

A diagnosis of exclusion, after abscess (via CT) has been ruled out

Antibiotics + anticoagulation

Question 15

What RUQ infection does pregnancy put women at risk for?

Answer 15

Cholelithiasis and cholecystitis

Question 16

What is the most common cause of fever on postpartum day 1?

Answer 16

Lungs - mostly due to general anesthesia and aspiration pneumonia

Question 17

What is the order of interventions for postpartum uterine atony?

Answer 17

Uterine massage, high-dose oxytocin
Tranexamic acid (antifibrinolytic agent)
Carboprost tromethamine (Prostaglandin F2-alpha), methylergonovine

Question 18

vWF synthesis is increased by what hormones?

Answer 18

Estrogen and thyroid hormone

Question 19

What are the diagnostic means for vWD?

Answer 19

vWF antigen, vWF activity (ristocetin cofactor activity; ristocetin promotes platelet agglutination in presence of vWF), factor VIII levels

Question 20

Describe progression of lochia after delivery

Answer 20

Rubra (dark/bright red blood with small clots) –> serosa (serosanguinous (pink), brownish (old blood)) –> alba (white/yellow, creamy, light quantity), which is up to 8 weeks

Question 21

Carboprost

Answer 21

Second-line uterotonic - prostaglandin F2a analog

Question 22

Misoprostol

Answer 22

Second-line uterotonic or induction of labor - prostaglandin E1 analog