Postpartum Problems and Disease

Question 1

When should you suspect retained placenta?

Answer 1

If 3rd stage of labour does not complete within 30 mins with active management or an hour with physiological management. If not delivered by this point the placenta is unlikely to delivery spontaneously. Biggest risk is of haemorrhage.

Question 2

What are the risk factors for retained placenta?

Answer 2

Previous retained placenta 
Preterm delivery 
Maternal age >35 
Placental weight < 600g
Parity > 5
Induced Labour 
Pethidine used in Labour

Question 3

How is retained placenta best managed?

Answer 3

Avoid excessive cord traction
Check the placenta is not in the vagina
Palpate the abdomen
Rub up a contraction
Put the baby to the breast to release oxytocin
Give oxytocin and saline into the umbilical vein and proximally clamp cord
Empty the bladder
If another 30min passes, then offer examination to see if it can be removed manually
If yes then consent and take to theatre
After manual removal give antibiotics and oxytocin

Question 4

What is uterine inversion?

Answer 4

Rare, usually due to mismanagement of the third stage. May be completely revealed or partial. Even without haemorrhage mother may be in shock due to increased vagal tone.

Question 5

How should uterine inversion be managed?

Answer 5

Call for help
Immediate replacement – push fundus through the cervix with palm of hand

If this fails insert 2 large bore cannulas and take FBC, Us and Es, clotting and cross match 4-6 units.
IV fluid

Transfer to theatre for anaesthesia

If placenta still attached leave in place or risk haemorrhage

Tocolytic drugs such as terbutaline to relax the uterus

Infuse warm saline into the vagina sealing the labia with another hand

Failing this laparotomy to pull the uterus up

Question 6

Describe normal physiology of the uterus, vagina, cervix and cardiac output in the weeks post-partum?

Answer 6

Uterus – undergoes rapid involution, by 2 weeks it is back in the pelvis and not palpable
Vagina – wall initially swollen but rapidly regains tone. Lochia discharge normal for 4-6 weeks. Mixture of mucus, blood and uterine tissue. If persists after 6 weeks then US.
Cervix – remains dilates by 3-6cm at 4-6 days but after 2 weeks is less than 1cm
Cardiac output – initially increased due to return of blood from contracted uterus. Plasma volume rapidly decreases via diuresis

Question 7

When is the VTE risk highest for pregnant women?

Answer 7

Note VTE most commonly occurs post-Nataly, so there should be a high level of suspicion.

Question 8

What is post partum thyrotoxicosis?

Answer 8

The condition is associated with TPO (thyroid peroxidase) antibodies and the hyperthyroid stage occurs due to antibody-mediated destruction of thyroid tissue, leading to the release of excess thyroid hormones. A small proportion (~5% of TPO positive women) may go on to permanently develop hypothyroidism.

Question 9

How does post partum thyrotoxicosis progress?

Answer 9

Postpartum thyroiditis initially causes a period of hyperthyroidism, followed by hypothyroidism at around 4 months postpartum, finally followed by a return to normal thyroid function.

Three stages

1. Thyrotoxicosis
2. Hypothyroidism
3. Normal thyroid function (but high recurrence rate in future pregnancies)

Question 10

How should post partum thyrotoxicosis be managed?

Answer 10

The thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive. Propranolol is typically used for symptom control
The hypothyroid phase is usually treated with thyroxine

Question 11

What is pueperal pyrexia?

Answer 11

Puerperal pyrexia is defined as a temperature of > 38ºC in the first 14 days following delivery.

Question 12

What are the causes of puerpal pyrexia?

Answer 12

• Endometritis (most common cause)
• Urinary tract infection – usually due to hypotonic bladder
• Wound infections (perineal tears + caesarean section)
• Mastitis
• Venous thromboembolism
• Respiratory – atelectasis, aspiration or pneumonia (usually after CS)

Question 13

What are the predisposing factors to endometritis?

Answer 13

Predisposing factors include: CS, prelabour rupture of membranes, intrapartum chorioamnionitis, prolonged labour and multiple pelvic examinations.

Question 14

How does endometritis present?

Answer 14

Clinical signs

Pyrexia, foul smelling, profuse and bloody discharge, tender uterus on examination

Question 15

How should puerperal pyrexia be investigated?

Answer 15

Must rule out sepsis and endometritis
FBC, blood cultures and MSU
Swabs from cervix, wounds and throat

Question 16

How is Endometritis managed?

Answer 16

If endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
Analgesia and NSAIDs