Postpartum Hemorrhage/ postpartum

Question 1

PPH Overview

Four T’s
| (postpartum hemorrhage)

Answer 1

Cumulative blood loss >1L within 24hrs of delivery OR blood loss with signs & symptoms of low blood volume
Leading cause of maternal mortality
11% of pregnancy-related mortality in developed countries
Up to 60% of maternal deaths in developing countries

Four Ts
TONE - Most common cause of PPH!
TRAUMA
TISSUE
THROMBIN

Question 2

PPH

S/Sx

Answer 2

Signs & sxs of blood loss
Decreased urine output

Hemodynamic instability
Tachycardia
Tachypnea
Hypotension
Decreased urine output
Skin - pale, cool, clammy and decreased cap refill
Mental status changes

Question 3

PPH

Tone
general and tx

Answer 3

Lack of active contraction of the uterine smooth muscle

Common causes
Prolonged labor >24hrs
Intraamniotic infection (chorioamnionitis)
Uterine overdistension (LGA, twins or more, polyhydramnios)
Multiparty (>4 previous vaginal deliveries)

Management
Uterine massage
Lactation/ nipple stimulation
Empty bladder

Question 4

Tranexamic Acid

Answer 4

TXA: Fibrinolytic agent
Binds to plasminogen and inhibits plasmin and fibrin formation

Usually use when initial therapies fail

Tranexamic acid, administered within 3 hours of birth, has been shown to significantly reduce maternal death due to PPH by approximately 30%

Question 5

Tissue
general and tx

Answer 5

Retained products of conception, placenta tissue
Common causes
Abnormal placentation
Blood clots within the uterus

Management
Evaluate placenta for missing lobes
Perform manual intrauterine sweep with hands for blood clots or retained placenta

Question 6

PPH

Trauma
general and tx

Answer 6

Soft tissue or vessel injury
Common causes:
Uterine, cervical, vaginal, or perineal lacerations
Risk increases if very fast labor
Hematomas
Uterine rupture

Management
Evaluate for cause of bleeding
Repair lacerations with sutures if necessary

Question 7

PPH

Thrombin
general and tx

Answer 7

Inherited or acquired bleeding disorders (unrelated to pregnancy)

Management
Increase fluid intake (iv)
Give red blood cells when indicated

Question 8

Secondary PPH

Answer 8

After 24h of delivery through 12 weeks postpartum
Causes
Retained products of conceptions
Uterine infection (endometritis)
Subinvolution of the uterus
Inherited coagulation defects

Question 9

PPH Management

Answer 9

IV fluid & blood transfusion
CBC, type and screen, coags (PT, PTT, fibrinogen)

Blood Products:
PRBC: one pack=250cc, increases Hb by 1mg/dL or HCT by 3%
PLT: 1 unit= 6 packs, increase PLT by 25-50k, give if PLT drops by 25k
FFP: 1u=200-250mL, usually 2-4u per infusion. Indicated with bleeding and abnormal coagulation (INR>1.5)
Cryoprecipitate: 1u=15-20mL, usually in pools of 6 units. Dose: 1-1.5u/10kg body weight. Increases fibrinogen by 30-60mg/dL per 6 units. Indicated when fibrinogen < 100 (DIC).

Surgical Management (after vaginal delivery)
Uterine curettage
Uterine packing
Uterine Tamponade (Bakri Balloon)
Uterine Suction (JADA device)
Surgical Management (following cesarean delivery)
Uterine Artery Ligation (O’Leary stitch)
Uterine Compression Suture (B Lynch suture)
Uterine Artery Embolization

If all else fails… proceed to Hysterectomy

Question 10

Postpartum

“The Fourth Trimester”
Follow up post vaginal and CS

Answer 10

Standard Procedure:
1-2 week postpartum check after CS
6 week postpartum visit after vaginal delivery
“Fourth Trimester” reinforces importance of 12 weeks post birth as the body is going through changes and processes to get back to its pre-pregnancy self

Lochia:
Vaginal discharge after delivery
Sloughing of decidual tissue from the endometrial lining
Starts at bleeding then as the weeks go on, turns into spotting and pink discharge

Lochia rubra: blood colored red
Lochia Serosa: pink/ more pale in color as bleeding decreases
Lochia alba: White or yellow color towards the end
Lasts about 3-6 weeks after birth

Question 11

The Fourth Trimester

urinary tract and abdomen

Answer 11

Urinary Tract:
Normal pre-pregnancy glomerular filtration returns to baseline in about 2 weeks
Dilated ureters and kidney return to prepregnancy stat 2-8 weeks
Increased risk of stress urinary incontinence due to bladder trauma and dysfunction after birth

Abdomen:
Abdominal wall remains soft and flaccid (due to stressing from the pregnant uterus)
Exercise as tolerated after vaginal delivery
After CS allow for 6-8 weeks for abdominal wall to recover before exercising
Increased risk of Diastasis Recti (marked separation of rectus abdominis muscles)

Question 12

teh fourth trimester

restrictions and cardiovascular system

Answer 12

Restrictions:
Standard recommendation: Avoid intercourse for 6 weeks
Usually coitus can resume after 2 weeks depending on desire and comfort

Cardiovascular system:
Blood volume returns to pre-pregnancy within 1 week
CO remains elevated for 2 days then returns to normal within 10 days
Systemic vascular resistance remains low for a few days, then rises to pre-pregnancy normal
Postpartum diuresis approx 2L within the first week

Question 13

Sheehan syndrome

Answer 13

Postpartum pituitary necrosis
Ischemia and infarct of pituitary gland due to postpartum hemorrhage

Presents with decrease in pituitary hormones
Decreased prolactin - difficulty with lactation & breastfeeding
Decreased FSH (follicle-stimulating hormone) and LH (luteinizing hormone) - secondary amenorrhea
Decreased TSH (thyroid stimulating hormone) - fatigue, hair loss, cold intolerance
Decreased ACTH (adrenocorticotropic hormone) - adrenal insufficiency

Management
Hormone replacement therapy - corticosteroids, levothyroxine, estrogen

Question 14

Postpartum Fever

Answer 14

Oral temp >38.7C (101.6F) in the first 24h postpartum
Oral temp >38C (100.4F) on any 2 of first 10 postpartum days (except 1st 24h)
5-7% of postpartum people
Most common time is first 2 days after birth
More common in cesarean delivery than vaginal

Etiologies
Womb - endometritis (most common)
(Woobies) - Mastitis
Wound - surgical or perineal laceration wound infection
Water - UTI
Walking - septic pelvic thrombophlebitis or DVT/PE
Wind - atelectasis, aspiration pneumonia, PE
Wonder Drug - drug fever (miso)

Question 15

Postpartum Fever

Dx

Answer 15

Diagnosis
CBC: leukocytosis (remember common to have average WBC 10,000-16,000 postpartum)
Urinalysis
Cultures - urine, wound, blood
Lactate (if sepsis suspected)
Pelvic ultrasound (for retained products of conception)
If thrombosis suspected = coagulation studies, dopplers
CXR if aspiration pneumonia suspected

Question 16

Endometritis

general and Dx

Answer 16

Different than chorioamnionitis because there is no more chorion after baby delivered
Inflammation of endometrium due to normal flora ascending up to uterus
1-10 days postpartum
More common in c-section than vaginal delivery

Diagnosis
Clinical exam:
Fever
Significant fundal tenderness on abdominal exam
Foul-smelling lochia/purulent lochia
Diarrhea (can be caused by Group A Strep, can progress to toxic shock syndrome)
Labs (CBC, cultures)

Question 17

Endometritis

Tx

Answer 17

Management
IV antibiotics until afebrile for 24-48h
IV aminoglycoside (gentamicin) and clindamycin/ or metronidazole
Add ampicillin if patient was GBS positive of GBS unknown

Switch to oral once afebrile
Amoxicillin + metronidazole
Augmentin-clavulanate

Question 18

Lactation Physiology

Answer 18

During pregnancy, estrogen prolactin and progesterone stimulate development of duct and gland tissues BUT estrogen and progesterone inhibit milk production.

During pregnancy- stage 2 mammogenesis (alveolar development and maturation of the epithelium) occurs due to increases in progesterone
After parturition, estrogen and progesterone levels are low- stimulates prolactin secretion

Prolactin is stimulated by the suckling of the infant
Suckling of infant at the nipple, causes mechanoreceptors to send inputs to the brain causes secretion of prolactin which causes milk production of the gland which causes oxytocin contractions to eject the milk
Suckling > prolactin act > contraceptives, inhibiting LH surges and ovulation

Suckling > nipple mechanoreceptors stimulation > hypothalamus increases PRF section > anterior pituitary increases prolactin secretion > gland stimulation and milk synthesis

Neural input > increases oxytocin from posterior pituitary > increases contractions > milk ejections

Question 19

Lactation Hormones

Answer 19

Prolactin
Polypeptide hormone synthesizes by lactotrophic cells in anterior pituitary
Structurally similar to GnRH and placental lactogen
Both positive and negative feedback loops
Stimulates mammary gland ductal growth and epithelial cell proliferation > induces milk synthesis
Increases with suckling of nipple

Oxytocin
Involved in the milk ejection and letdown
Nipple stimulation > hypothalamus trigger of oxytocin > contractiile myoepithelial cells, forcing milk into thr ducts and out through the nipple

Question 20

Benefits of Breast Milk

Answer 20

Ideal nutrition for infants with vitamins, proteins and fats that are usually more easily digested than formula
Contains antibodies from mother that help fight off viruses and bacteria
Breast milk contains IgA, WBCs, whey protein (lysozyme and lactoferrin) and oligosaccharides
Reduces newborn risk of allergies, asthma, ear infections, respiratory illness, and risk of diabetes and obesity

CHEST IS BEST»> FED IS BEST !

Question 21

Milk Supply

Answer 21

Colostrum:
Rich in host defense proteins, IgA, and neutrophils
Infants “first immunization”
Small volume is NORMAL
Day 1= 5-7mL
Day 2=5-15mL

When the milk “comes in”:
Day 3-5, transitional to 14 days
Milk volume increases to 60-80mL
Requires effective, frequent nursing

Mature Milk:
Day 10-14, volume increases
Milk appears more watery
Breast appears softer

Question 22

Common Breast Disorders

Mastitis
S/sx Tx

Answer 22

Regional infection of the breast, commonly caused by pt’s skin flora or the oral flora of the breast-feeding infants
Most common 3-4 weeks postpartum
Organisms enter an erosion or cracked nipple and proliferate, leading to infection

Signs & Sxs: focal tenderness, erythema, and change in temperature from one region of the breast to another
fever and ↑ WBC
May be complicated by the formation of an abscess
Evident by fluctuance (pus, induration, erythema)
May also suspect after 48 hrs of Abx refractory to rx
Requires incision & drainage (I & D)

Tx: oral antibiotics (Dicloxacillin)
IV abx until afebrile 48 hours for pts who are refractory to oral ab
If MRSA +, bactrim alternative abx
Pts should cont’d breast feeding to prevent intraductal accumulation of infected material
If pts are not breastfeeding, they should pump in the acute phase

Question 23

Galactocele
SSx

Answer 23

blocked milk duct → non-erythematous, fluctuant mass → usually resolves spontaneously (if not – aspirate)

Question 24

Breast Engorgement

Answer 24

breasts enlarged and filled with milk. Can cause breast pain, swelling and low grade fevers. More common in women whose milk is coming in and isn’t breastfeeding.

Question 25

Postpartum Mood Changes

Answer 25

Postpartum Blues
Depressed mood a few days after birth
Combination of emotional changes, fatigue, anxiety, and physical discomfort
Mild self limiting 2-3 days, can last up to 10 days
Symptoms: Crying for no reason, trouble sleeping, eating, and making choices

Postpartum Depression
Actual mood disorder that develop within 1 year of birth
Commonly starts 1-3 weeks after birth
Causes by changes in hormones, increases risk if patient has hx of depression
Screening tool: Edinburgh Postnatal depression Scale (9 questions)
Scoring 0-30
Low suspicion < 10 Possible depression > 10
Highest possible score 30
Treatment: Psychiatrist/psychologist, therapy and/or medications

Postpartum Psychosis
Metal health emergency, rare but severe
Characterised by hallucinations, delusions, paranoia, mania or hypomania, insomnia, disorganized thinking

Question 26

Postpartum Contraception

Answer 26

Women who breastfeed ovulate much less frequently
Ovulation is sporadic within the first few weeks/months postpartum
Women who are not breastfeeding have return to menses within 6-8 weeks

While immediately postpartum and breastfeeding - avoid estrogen