Postpartum Complications

Question 1

Postpartum Hemorrhage (Overview)

Answer 1

• Definition: >1000 cc of blood loss or patient has signs of hypovolemia.
• Causes: “Four Ts”
  
  • -Tone (70%): uterine muscle unable to clamp down on bleeding vessels to stop bleeding (coiled vessels stretch out during pregnancy but need to shrink back down post-birth)
  • -Trauma (20%): wounds, hematomas, uterine inversion
  • -Tissue (10%): retained POCs (membrane, placenta, etc.)
  • -Thrombin (<1%): blood is unable to clot d/t coagulopathy
• S/sxs:
  
  • Prolonged bleeding
  • Hypovolemic shock: hypotension, tachycardia, pale or clammy skin, decreased capillary refill
• PE:
  
  • Soft flaccid boggy uterus with dilated cervix
• Dx:
  
  • CBC: Hgb & Hct
  • US: to detect the bleeding source or retained POCs
• Categories:
  
  • Early: occurs within 24 hours of birth (vast majority)
  • -Late: occurs >24 hours but <6 weeks postpartum
• Tx:
  
  • Women can tolerate blood loss of approximately the volume that’s been added during pregnancy (1500-2000cc)
    *

Question 2

Uterine Atony: Risks & Tx

Answer 2

• Risks:
  
  • overdistension of uterus, conditions that affect uterine contractility, medications that are uterine relaxants, anesthesia
• Tx:
  
  • Fundal massage to maintain firmness & express clots (1^st line)
  • Uterotonics: if “boggy” uterus after massage; includes Oxytocin 20 IU per liter of NS, Misoprostol 800 mg PR, Methergine 0.2mg IM (not w/ HTN)
  • Catheterization: if mother’s bladder is full b/c doesn’t allow uterus to contract down
  • Oxygen & Double IV access: preparation for shock
  • Preparation for surgery: for worst case scenario, hysterectomy

Question 3

Hemorrhage from pregnancy trauma

Answer 3

• Incision or Lac Wounds: C-section, episiotomy, forceps, vacuum, perineal tear
• PE:
  
  • Bleeding at incision or laceration site (can be spurting or pumping)
• Categories of Episeal tear:
  
  • 1^st degree: mucosal layer, stitches
  • 2^nd degree: muscle layer, stitches
  • 3^rd degree: muscle layer & anal sphincter, repair in OR
  • 4^th degree: anal sphincter into rectal mucosa, repair in OR
• Tx:
  
  • suture the affected vessel

Question 4

Pelvic Hematoma

Answer 4

• Definition: bleeding into loose connective tissue while overlying tissue remains intact.
• PE:
  
  • Bleeding from small vessels, outline of hematoma is visible, severe pain
• Tx:
  
  • Supportive care: ice packs
  • *May resolve spontaneously

Question 5

Uterine Inversion

Answer 5

• Definition:
  
  • uterus is pulled inside out
• Causes:
  
  • rushed 3^rd stage management (excessive traction to pull placenta out of uterus), excessive fundal massage after delivery
• PE:
  
  • pain, hemorrhage, shock
• Tx:
  
  • Manual reposition of the uterus
  • -Discontinue Pitocin (Oxytocin) if used
  • -Surgery: hysterectomy
    *

Question 6

Uterine Rupture

Answer 6

• Definition:
  
  • spontaneous complete transection of the uterine wall
• Causes:
  
  • usually occurs at site of a prior C-section delivery
• Fetal mortality of 50-75%. Survival depends upon whether a large portion of placenta remains attached to the uterine wall until delivery is accomplished
• Tx:
  
  • Obstetric Emergency
  • C-section delivery: imperative to ensure neonatal survival & decrease maternal morbidity.

Question 7

Retained Tissue/Placenta

Answer 7

• Risks:
  
  • rushed 3^rd stage (placenta should naturally separate from uterine wall before removal is attempted)
• Causes:
  
  • Placental malformation
  • Placental implantation: accrete (vessels attached to uterine wall), increta (vessels invade uterine muscle), percreta (vessels gone thru the uterine wall & have attached to outside of uterus)
• Dx:
  
  • failure of placenta to detach within 30 minutes
• Tx:
  
  • Non-adherent: manual removal
  • Adherent: surgical removal

Question 8

Causes of Postpartum Fever/Infection

Answer 8

• Benign PP fever (3.8%): 1^st 24 hours PP
• Endometritis (1-2%): infection of uterine lining → abdominal pain & purulent lochia, days 2-7
• Engorged breasts: days 3-4 (when milk supply comes in, goes away with nursing)
• Mastitis: erythema/heat & flu-like sx, week 2-3
• UTI/Pyelo: urinary sxs, anytime
• URI/Viral: flu-like sxs, anytime
• Perineal wound (0.3%): odor/pus/pain, day 3-7
• DVT: +Homan’s, afebrile, anytime
• Ovarian vein thrombosis: febrile/abdominal pain/leukocytosis, rare

Question 9

Postpartum fever

Answer 9

>38.0 (100.4 F) on any 2 of the 1^st 10 days postpartum, excluding 1^st 24 hours after delivery. If fever lasts <24 hours, then it usually isn’t related to infection.

Question 10

Causes of Fever/inx with C-section

Answer 10

• Post-Op Wound: day 3-7
• -Endometritis (27%): day 2-7
• -URI/lungs: 1^st 24 hours
• -Pelvic abscess
• -Septic pelvic thrombophlebitis: day 2-4
• -DVT/PE: much higher risk than vaginal birth b/c immobile & hypercoagulable state

Question 11

Superficial Vein Thrombosis

Answer 11

• most common form of Postpartum thromboembolic issues
• S/sxs:
  
  • sxs occur 3-4 days postpartum
• PE:
  
  • tenderness at site, heat, erythema
  • fever
  • enlarged hardened vein
• Tx:
  
  • NSAIDs
  • -Rest & elevation of affected leg
  • -Compression stockings
  • -Heat therapy to site

Question 12

Deep Vein Thrombosis Postpartum

Answer 12

• Epidemiology: 2x increased risk after C-section.
• PE:
  
  • -Edema of ankle/leg
  • -Pain in lower leg or lower abdomen
  • -Decreased peripheral pulses
  • -Fever & chills
  • *More likely in left leg
• Dx:
  
  • Clinical diagnosis is notoriously insensitive & non-specific., Doppler ultrasound, d-dimer test
• Tx:
  
  • Anticoagulation until 3 months after resolution
  • -Analgesia
  • -Rest with leg elevated & compression stockings
  • *Safe to continue breastfeeding

Question 13

Pulmonary Embolism Postpartum

Answer 13

• Epidemiology: occurs in 4-5% of treated DVT, 15-25% of untreated DVT.
• S/sxs:
  
  • Dyspnea
  • -Chest pain
  • -Lightheadedness or dizziness
  • -Tachypnea
  • -Tachycardia
• Dx:
  
  • D-dimer test: sensitive but not specific
  • -Doppler ultrasound
  • -MRI (CT = contraindicated in pregnancy
• Tx:
  
  • Anticoagulation for up to 6 months
  • -Prophylactic blood thinners in future pregnancies

Question 14

Perinatal Mood Disorders Overview

Answer 14

• CA Assembly Bill 2193: all women must be screened at least once for mental health issues during pregnancy or postpartum. Most common in early pregnancy for baseline, then again PP. Some clinicians also screen in 3rd trimester and/or based on woman’s comments
• Perinatal Responses:
  
  • Healthy adaptation
  • -Baby blues: common PP, usually goes away after 2-3 weeks
  • -Depression, anxiety, PTSD, panic, OCD
  • -Bipolar Disorder
  • -Psychosis
• Tools:
  
  • PHQ9
  • -EPDS (Edinburgh Postnatal Depression Scale)
  • -GAD7 (General Anxiety Disorder 7)
  • *Each tool has a specific scoring rubric
• Tx:
  
  • Postpartum Psychosis is a Medical Emergency.

Question 15

Baby Blues

Answer 15

• Etiology:
  
  • Rapid decrease in Progesterone levels from pregnancy & Oxytocin from childbirth.
  • Onset 2-3 days PP with peak at day 5 and resolution within 2 weeks
• Epidemiology: 40-80% of women, 1/7 women
• S/sxs:
  
  • Rapid mood swings
  • -Decreased concentration
  • -Irritability
  • -Insomnia
  • -Tearfulness
  • -Concerns about baby & parenting
  • -Feeling overwhelmed
  • -Feelings of dependency
  • -Confusion about new identity
• Tx:
  
  • Symptoms resolve on their own by 4-6 weeks postpartum.

Question 16

Postpartum Depression: Def, Etiology, Risks, Incidence, Pregnancy Depression Med Guidelines

Answer 16

• Definition:
  
  • depression that begins any time after delivery & continues during the 1^st year after birth of child.
• Etiology:
  
  • genetic predisposition, hormonal changes, major life stressors
• Risks:
  
  • hx of depression or anxiety (25% reoccurrence), hx of PP depression (50% recurrence), FMHx, situational life stressors, PMDD
• Incidence:
  
  • 1-23% of pregnant women will experience a depressive disorder while pregnant, 1/7 women
• Pregnancy Guidelines for Depression Meds:
  
  • No evidence to stop medication with positive pregnancy test
  • Choose med with least maternal/ placental transfer & breast milk
  • Avoid new-to-market meds
  • Use as few meds as possible
  • Use as low as dose as possible, but a high enough dose to be therapeutic
  • Titrate up to a therapeutic dose slowly (Q3-7 days)
  • Note that higher doses may be needed in later pregnancy
  • No evidence to taper medication prior to birth
  • -SSRIs are safe during breastfeeding
    *

Question 17

Postpartum Depression: DSM V Dx, Choosing an SSRI, Pt education

Answer 17

• DSM V Dx:
  
  • *5/9 symptoms for dx including either #1 or #2
  • #1 Depressed mood most of the day nearly everyday
  • #2 Markedly diminished interest or pleasure (anhedonia)
  • -Significant weight loss or gain
  • -Insomnia or hypersomnia
  • -Psychomotor agitation or retardation
  • -Fatigue or loss of energy nearly every day
  • -Feelings of worthlessness or significant guilt
  • -Diminished ability to think or concentrate
  • -Recurrent thoughts of death
• Choosing a SSRI:
  
  • If euthymic: continue use of current SSRI
  • -If successful treatment in past year: continue that medication
  • -If no previous treatment history: choose 1) Sertraline OR 2) Citalopram; no transfer to breast milk, best SE profile, generic is available & covered by Medical; start lowest dose QD & book f/u in 4 weeks
• Patient Education:
  
  • Ideal to involve partner when available
  • -Medication SEs are short-lived (usually less than 3 days)
  • -Medication needs to be taken daily & not in response to mood changes; may take 4-6 weeks for patient to see effects
  • -Should remain on medication for 6-12 month for best chance of sustaining remission (decreased relapse)
  • -Discontinuing: titrate slow, decrease dose by 25% Q2-6 weeks, f/u Q2-6 weeks to observe for relapse

Question 18

Cracked/Bleeding Nipples

Answer 18

• Pathophysiology: generally caused by poor latch/position
• S/sxs:
  
  • cracked, bleeding nips
• Dx:
  
  • clinical
• Tx:
  
  • Mild: apply breastmilk to nipples after feeds & leave open to air, use lanolin cream for comfort +/- nipple shield
  • Moderate/severe: all-purpose nipple ointment after feeds, alternate feeding/pumping on affected side as tolerated until healing, engage lactation support

Question 19

Plugged Lactiferous Duct

Answer 19

• Risks: tight bra or underwire
• S/sxs:
  
  • -Hard, tender area on breast +/- lump
  • -More painful before a feeding & less tender after
  • -Nursing is painful on the affected side (esp. at letdown)
  • -Particulate matter in milk
  • -NO flu-like symptoms
• Dx:
  
  • clinical
• Tx:
  
  • feeding or pumping on affected side

Question 20

Breast Yeast Infection

Answer 20

• Risks: infant with thrush, nipple damage, antibiotic use in mom or baby, vaginal candidiasis, DM, immunosuppression
• S/sxs:
  
  • New onset breast or nipple pain
  • -Intense, burning, dry flaky skin
  • -Radiating through breast & sometimes to back
• Tx:
  
  • Antifungals: Nystatin, Clotrimazole, Diflucan
  • -Gentian Violet or Water Vinegar rinse
  • -Wash breast pads, bras, bottle nipples in hot water

Question 21

Mastitis

Answer 21

• **Note: the milk is NOT infected
• s/sxs:
  
  • *Usually 2-3 days PP or 2-3 weeks PP
  • -Unilateral breast pain
  • -Flu-like symptoms
• Dx:
  
  • need to r/o other sources of infection
  • Urine Cx, Milk cx if MRSA is present
• Tx:
  
  • *improves w/i 48H
  • -Bedrest, ice, increased fluids
  • -Feed, pump, or express Q1-2 hours
  • -Massage during expression/feeds
  • -Antibiotics: Dicloxacillin, Cephalexin, Clindamycin
  • -Analgesics: Tylenol or Ibuprofen

Question 22

Breast Abscess

Answer 22

• Definition:
  
  • localized collection of pus, inflammation
• PE:
  
  • Palpable, fluctuant mass with visible indurated area & fluid wave
• Dx:
  
  • US to confirm breast abscess
• Tx:
  
  • Referral to surgery for treatment/drainage
  • *Encapsulation makes antibiotics ineffective