Postpartum Care

Question 1

Differential Dx for postpartum hemorrhage

Answer 1

Bleeding from placental implantation site:
-Atony 
-Retained placental products 
Trauma to the genital tract:
-Episiotomy 
-Vaginal or cervical lacerations
-Rupture uterus 
Coagulation defects

Question 2

Postpartum hemorrhage
Atony 
Path:
Risk factors:
Tx:

Answer 2

Path: Uterus unable to contract to stop bleeding

Risk factors:

• Over-distended uterus ->Large fetus, Multiple gestation, Hydramnios
• Rapid labor
• Prolonged labor
• Use of labor augmentation agents-> Pitocin
• Chorioamnionitis
• Hx of uterine atony

Tx:

1. • Vigorous massage: bimanual exam and massage of uterine fundus
   • Oxytocin infusion
   • Manual exploration of uterine cavity for retained placental products
2. Pharmacological agents
   - Prostaglandins F2alpha (prostin, carboprost)
   - Ergot derivatives (methergine)
   - Prostaglandin E1 (misoprostol, cytotec)
3. Surgical management
   - Hypogastric artery ligation
   - Uterine compression sutures (B-lynch)
   - Uterine packing
   - Peripartum hysterectomy

Question 3

Postpartum hemorrhage
Retained placental products
Path:
Risk factors:

Answer 3

Path:

• Accreta: abnormal adherence to the uterine wall
• Increta: invade the myometrium
• Percreta: penetrates the uterine serosa and can invade surrounding organs such as bladder or rectum

Risk factors:

• Placenta previa: placenta located over/near the cervical os
• Prior cesarean delivery
• Prior uterine curettage
• Grand multiparity: women who has had >/= 5 births at >/=20w

Question 4

Postpartum hemorrhage
vaginal or cervical lacerations
Dx:

Answer 4

Dx:

• bleeding despite a well-contracted, firm uterus, hemorrhage is likely from a laceration
• Bright red blood suggests laceration
• Seen on careful inspection of vagina and cervix

Question 5

Postpartum hemorrhage

Path:

Answer 5

Path:
-separation of the previous cesarean hysterotomy scar (MC)
Others: 
-trauma
-congenital abnormality
-prior uterine surgery (myomectomy)

Question 6

Complications of blood transfusions

Answer 6

Hemolytic transfusion rxn: fever, hypotension, tachycardia, dyspnea, flushing, anxiety

Transfusion-related lung injury (TRALI): severe dyspnea, hypoxia, pulmonary edema within 6hrs of transfusion

Infection

• MC Yersinia enterocolitica
• Risk of HIV, Hep C extremely low

Question 7

Prostaglandins F2alpha
Drugs:
SE:

Answer 7

Drugs: prostin, carboprost
SE: diarrhea, hypertension, vomiting, fever, flushing, tachycardia

Question 8

Ergot Derivatives
Drugs:
SE:

Answer 8

Drugs: methergine
SE: hypertension