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Postpartum care Flashcards

1
Q

Postpartum endometritis

A

infection of the uterine endometrium

an infection of the decidua (endometrial lining of pregnancy) that may extend into the myometrium and occurs in the postpartum period

typically polymicrobial with aerobic and anaerobic contributing pathogens

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2
Q

most important RF for postpartum endometritis

A

recent cesarean delivery

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3
Q

other RF postpartum endometritis

A

prolonged labor, prolonged rupture of membranes, and multiple pelvic examinations during labor

use of internal monitors, and nulliparity

bacterial vaginosis, chorioamnionitis, prolonged labor, prolonged rupture of membranes, multiple cervical examinations, HIV infection, colonization with group B Streptococcus, nasal carriage of Staphylococcus aureus, and heavy vaginal colonization by Escherichia coli

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4
Q

sx postpartum endometritis

A

lower abdominal pain, fever, tachycardia, and uterine tenderness. Patients may also have malodorous and purulent lochia

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5
Q

tx postpartum endometritis

A

the combination of clindamycin and gentamicin is used if the infection occurs after a C-section.
Ampicillin may be added if the patient is colonized with group B Streptococcus

If endometritis occurs after a vaginal delivery, the combination of ampicillin and gentamicin is preferred

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6
Q

rare complication of postpartum endometritis that occurs when a thrombus occurs in a pelvic vein and becomes infected

A

Septic pelvic thrombophlebitis

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7
Q

The two types of septic pelvic vein thrombophlebitis

A

ovarian vein thrombophlebitis and deep spontaneous pelvic thrombophlebitis

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8
Q

sx Septic pelvic thrombophlebitis

A

presents similarly to endometritis, with abdominal pain, fever, and uterine tenderness. Therefore, it is usually not suspected until a patient with postpartum endometritis does not improve after 3–5 days of antibiotics. However, the presence of a palpable cord-like mass is supportive of the diagnosis, although this finding is not usually present. It is also important to note that patients with deep spontaneous pelvic thrombophlebitis may not experience abdominal pain

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9
Q

tx septic pelvic thrombophlebitis

A

broad-spectrum antibiotics, such as gentamicin and clindamycin, and anticoagulation

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10
Q

dx septic pelvic thrombophlebitis

A

imaging with CT or MRI of the abdomen and pelvis can identify ovarian vein thrombophlebitis, but these studies are usually unable to identify deep spontaneous pelvic thrombophlebitis

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11
Q

complications septic pelvic thrombophlebitis

A

pulmonary embolism and septic emboli

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12
Q

should you obtain cultures for postpartum endometritis

A

Due to the infection being polymicrobial, it is unnecessary to obtain cultures

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13
Q

prophylaxis C-section

A

Patients who undergo C-sections are prophylactically given a dose of a first-generation cephalosporin during the C-section to reduce the incidence of endometritis

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14
Q

Which bacterium is the leading cause of endometritis-associated infertility in endemic countries?

A

Mycobacterium tuberculosis

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15
Q

Postpartum hemorrhage

A

an obstetric emergency defined by a cumulative blood loss of 1,000 mL or signs and symptoms consistent with hypovolemia within the 24 hours following delivery

It is one of the leading causes of maternal mortality worldwide, with over half of maternal deaths occurring within 24 hours following delivery

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16
Q

primary/early postpartum hemorrhage

A

occurs within 24 hours after delivery

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17
Q

secondary/late postpartum hemorrhage

A

occurs after 24 hours and up to 12 weeks later

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18
Q

The most common cause of postpartum hemorrhage

A

uterine atony, wherein the uterus fails to contract and constrict the arteries that supply the placenta following its delivery

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19
Q

uterine atony on PE

A

soft, boggy uterus

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20
Q

how is uterine atony best treated

A

uterine massage

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21
Q

what else can be used with uterine massage to treat uterine atony

A

oxytocin, methylergonovine, misoprostol, dinoprostone, 15-methyl prostaglandin F2-alpha

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22
Q

Surgical intervention for uterine atony

A

uterine compression sutures (B-lynch or multiple squares), sequential artery ligation, selective arterial embolization, and ultimately hysterectomy

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23
Q

Patients with hemodynamic compromise secondary to hemorrhage initially manifest with

A

tachycardia, tachypnea, delayed capillary refill, orthostatic changes, and narrowed pulse pressure. Further volume depletion results in overt hypotension, oliguria, shock, coma, and death

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24
Q

if hemorrhage is suspected, primary intervention should be implemented with

A

assessment of hemodynamic stability, placement of two large-bore intravenous catheters, rapid infusion of crystalloid fluids, and investigation of potential etiologies. Early infusion of packed red blood cells following a type and crossmatch of blood can help to replete blood volume

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25
Patients with hemorrhage requiring four or more units of packed red blood cells in 1 hour or 10 or more units in 12 to 24 hours should additionally receive
fresh frozen plasma and random donor platelets in a 1:1:1 unit ratio with packed red blood cells
26
During the third stage of labor, preventative measures to decrease the risk of uterine atony include
oxytocin infusion, gentle cord traction, and uterine massage
27
during what stage of labor should preventative measures for uterine atony be done
third stage of labor
28
Nonfatal cases of postpartum hemorrhage can result in
adult respiratory distress syndrome, coagulopathy, shock, loss of fertility, and pituitary necrosis (Sheehan syndrome)
29
RF postpartum hemorrhage
rapid or prolonged labor, overdistended uterus, retained placenta, or a C-section low socioeconomic status, previous history of postpartum hemorrhage, retained placenta, prolonged labor, fetal macrosomia, hypertension, and labor induction and augmentation (e.g., use of uterine stimulants and vaginal prostaglandins)
30
which type of postpartum hemorrhage is MC
early/primary
31
is there a higher risk for postpartum hemorrhage w c section or vaginal delivery?
Women are at equal risk whether they deliver vaginally or via cesarean section
32
Which of the following placental complications has the greatest risk for postpartum hemorrhage due to the depth of invasion into the uterine myometrium?
Placenta percreta (characterized by growth through the uterine wall and even into the surrounding structures (e.g., bladder))
33
episiotomy
surgical incision of the vagina performed to facilitate delivery during the second stage of labor
34
when may an episiotomy be indicated during labor
If a nonreassuring fetal heart rate tracing (e.g., category III tracing) is unresponsive to resuscitative measures and the fetus is blocked by perineal tissue, an episiotomy may help facilitate delivery. Episiotomy may be considered in certain cases of shoulder dystocia to increase the space for the obstetrician’s fingers to deliver the posterior shoulder. Episiotomy is also appropriate when the patient is at high risk for a third- or fourth-degree laceration
35
two MC types of episiotomy
median (midline) and mediolateral
36
mediolateral episiotomy
associated with a lower risk of anal sphincter injury but increased blood loss compared with the median episiotomy
37
adverse outcomes associated w episiotomy
anatomical deformities (e.g., skin tags, asymmetry, fistula, introital narrowing), increased rates of infection and dehiscence, and increased risk of severe perineal laceration in future deliveries.
38
incision for median episiotomy
a vertical incision is made into the perineum within 3 mm of the midline on the introitus
39
incision for mediolateral episiotomy
the incision is made at the introitus in a lateral direction. Providing support to the perineum at the inferior aspect of the incision during delivery reduces the risk of extensions (e.g., third- or fourth-degree lacerations)
40
what is preferred for repair of episiotomy
Absorbable synthetic suture
41
when are abx recommended for episiotomy
third- or fourth-degree lacerations
42
Which of the following is the preferred type of episiotomy to minimize the risk of anal sphincter laceration?
mediolateral episiotomy
43
first degree lacerations
extend to the skin and subcutaneous tissue of the perineum, and the perineal muscles are intact
44
second degree lacerations
extend through the fascia into the muscle of the perineum but leave the anal sphincter muscles intact
45
third degree lacerations
extend through the fascia and perineal muscles and into the anal sphincter. Third-degree lacerations are subclassified based on whether they extend through the external anal sphincter alone or into the internal anal sphincter as well
46
fourth degree lacerations
extend through the perineal muscles, external and internal anal sphincters, and the rectal mucosa
47
complications episiotomy
extension of the incision deeper into the perineum that result in more third- and fourth-degree lacerations, a higher risk of infection, a higher risk of wound dehiscence, more postpartum pain, and more dyspareunia. Additionally, episiotomy increases the risk of repeat vaginal laceration in a subsequent vaginal delivery
48
Puerperium
the 6-week time period between when the placenta is delivered to when the body returns to the nonpregnant state after the changes of pregnancy, labor, and delivery
49
lochia
The discharge is initially red (lochia rubra, which lasts about 2–3 days), becomes brownish-red and watery (lochia serosa, which lasts about 2–3 weeks), then changes to a yellowish color (lochia alba). The duration of lochia averages about 5 weeks, but it is variable, with some women experiencing the discharge for a longer period of time.
50
vaginal epithelium will appear _____ through breastfeeding
atrophic; due to decreased estrogen
51
The perineum regains muscle tone by
6 weeks
52
A mother who does not breastfeed may ovulate as early as
the next month after delivery and have a menstrual period within 7–9 weeks
53
The decision to resume intercourse after the intrapartum period should be individualized but should not be resumed for at least
2 weeks following delivery
54
Many women experience dyspareunia during the first
6-8 weeks
55
Postpartum blues is common during the first
24-72 hours after delivery but is transient
56
When should women with hypertensive disorders follow-up for a clinic visit following delivery?
within 7 days
57
screening for maternal depression
at all infant well-child visits for at least 6 months and at the 6-week postpartum follow-up visit
58
when does involution of the uterus begin
immediately after delivery
59
The uterus returns to the pelvis after
2 weeks
60
the uterus achieves a normal, nonpregnant size after
6 weeks
61
Telogen effluvium
the loss of hair in the resting stage and is a common concern 1 to 5 months following delivery. Normal hair patterns are generally restored after 6 to 15 months
62
Postpartum women additionally demonstrate loss of one-half of gestational weight gain
6 weeks after delivery
63
The normal duration of hospital stay following a vaginal birth is
48H
64
The normal duration of hospital stay following C section is
72H following operation
65
When does ovulation resume after childbirth on average?
After 45 days in nonlactating women and 189 days in lactating women.
66
what is required for the letdown reflex that thereafter allows ejection of breast milk
oxytocin
67
Colostrum
a premilk secretion that provides essential vitamins and nutrients for the newborn and is later replaced by normal breast milk
68
maternal benefits for breastfeeding
contraction of the uterus and acceleration of uterine involution, enhanced gastrointestinal motility and absorption, and increased mother-infant bonding and self-confidence. Additionally, women who breastfeed have delayed ovulatory cycles and are at a decreased risk for breast, endometrial, and ovarian cancers
69
infant benefits for breastfeeding
prevention of illnesses, such as diarrhea, otitis media, and urinary tract infections, as well as a decreased incidence of sudden infant death syndrome. Due to the immunologic properties of breast milk, infants also have a decreased risk of developing conditions such as Crohn disease, lymphoma, and allergic diseases later in life. Breastfed infants are less likely to become obese, and some studies have proposed improved cognitive development and intelligence compared to formula-fed infants
70
ACOG and APA recs breastfeeding
recommend exclusive breastfeeding for at least 6 months, optimally 1 year, of life
71
what all is in colostrum? colostrum vs mature milk
high in levels of immunoglobulins (such as secretory IgA), lactoferrin, leukocytes, and macrophages that provide passive immunity for the infant. Colostrum also has a higher protein content than mature milk. Mature milk contains much less protein but is higher in water, carbohydrate, and fat content
72
Rh incompatibility or Rh disease
a condition that occurs when a woman with an Rh-negative blood type develops Rh antibodies after she is exposed to Rh-positive blood cells. The Rh factor is a surface antigen found on the surface of red blood cells. Rh incompatibility typically refers to an Rh-negative mother who is exposed to Rh-positive fetal red blood cells during the course of the pregnancy. Exposure can occur either from spontaneous or induced abortion, trauma, iatrogenic causes (e.g., amniocentesis), or normal delivery lead to the development of maternal Rh IgG antibodies that can cross freely through the placenta to the fetal circulation to destroy Rh-positive fetal erythrocytes. The result is fetal alloimmune-induced hemolytic anemia
73
The risk and severity of sensitization and response increase with every subsequent pregnancy if the fetus has Rh-positive blood
!!!!!!!
74
If the mother has Rh-negative blood
the Rosette screening test is the initial test performed, which can detect alloimmunization (an immune response to exposure to foreign cells) caused by a small amount of hemorrhage that occurs between the maternal and fetal blood. It is a qualitative test, and if it is positive or there are higher amounts of hemorrhage suspected, the Kleihauer-Betke acid elution test should be ordered, which will provide a quantitative measurement of the amount of fetal red blood cells in maternal blood. This information allows for the determination of how much human anti-D immune globulin (Rh IgG) should be administered
75
Rh IgG is routinely given
once at 28–32 weeks gestation in pregnant women and again 72 hours after birth
76
C/I breastfeeding
Women who are HIV positive should avoid breastfeeding if replacement feeding is affordable, feasible, and sustainable. Women who are positive for human T-cell lymphotropic virus or brucellosis should not provide any breast milk to their infant. Women with active herpetic breast lesions should avoid breastfeeding until the lesions resolve but can feed their infant expressed breast milk if careful hand hygiene is observed. Women who develop varicella 5 days before delivery or 2 days after delivery or who have active tuberculosis should avoid breastfeeding but may feed their infant expressed breastmilk. Women who have H1N1 influenza should avoid breastfeeding until they are afebrile but can feed the infant expressed milk. Women who are taking illicit drugs (e.g., phencyclidine, cocaine) should avoid breastfeeding due to the risk of long-term developmental issues in their child. Infants with galactosemia should not be breastfed because they are unable to metabolize galactose and may develop failure to thrive, liver dysfunction, cataracts, and intellectual disability

EOR OB/GYN (18 decks)

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