Tn: Puerperal Complications

Front 1

Define puerperium?

Back 1

6 wk period of adjustment after pregnancy when pregnancy-induced anatomic and physiologic changes are reversed

Front 2

Postpartum hemorrhage definition?

Back 2

• loss of >500 mL of blood at the time of vaginal delivery, or >1,000 mL with C/S
  
• early – within first 24 h postpartum
• late – after 24 h but within first 6 wk

Front 3

Incidence of postpartum hemorrhage?

Back 3

5-15%

Front 4

Etiology of postpartum hemorrhage?

Back 4

4 Ts:

• Tone
  
• Tissue
  
• Trauma
  
• Thrombin
  

Front 5

Tone

Back 5

uterine atony

• most common cause of PPH
  
• avoid by giving oxytocin with delivery of the anterior shoulder or placenta
  
• occurs within first 24 h
  

Front 6

Tissue

Back 6

• retained placental products
  
• retained blood clots in an atonic uterus
• gestational trophoblastic neoplasia

Front 7

Trauma

Back 7

• laceration (vagina, cervix, uterus),
  
• episiotomy,
  
• hematoma (vaginal, vulvar, retroperitoneal),
• uterine rupture, uterine inversion

Front 8

Thrombin

Back 8

coagulopathy

Front 9

Investigations for PPH?

Back 9

• • assess degree of blood loss and shock by clinical exam
  
• • explore uterus and lower genital tract for evidence of tone, tissue, or trauma
• • may be helpful to observe red-topped tube of blood – no clot in 7-10 min indicates coagulationproblem

Front 10

Management of PPH?

Back 10

• ABCs
  
• 2 large bore IVs and crystalloids
  
• CBC, coagulation profile, cross and type 4 units pRBCs
• treat underlying cause

Front 11

Med therapy for PPH?

Back 11

• oxytocin
  
• ergotamine
  
• caroprost
  
• misoprostol
  
• tranexamic acid
  

Front 12

Local therapy for PPH?

Back 12

• bimanual compression: elevate the uterus and massage through patient’s abdomen
  
• uterine packing (mesh with antibiotic treatment)
• Bakri Balloon for tamponade: may slow hemorrhage enough to allow time for correction ofcoagulopathy or for preparation of an OR

Front 13

Surgical therapy for PPH?

Back 13

• D&C
  
• embolization of uterine artery
  
• laparotomy
  
• hysterectomy
  

Front 14

Definition of retained placenta

Back 14

placenta undelivered after 30 min postpartum

Front 15

Etiology of retained placenta?

Back 15

• placenta separated but not delivered
• abnormal placental implantation (placenta accreta, placenta increta, placenta percreta)

Front 16

Risk factors of retained placenta?

Back 16

• placenta previa
  
• prior CS
  
• post-pregnancy curettage
  
• prior manual placental removal
  
• uterine infection
  

Front 17

Clinical features of retained placenta?

Back 17

• incomplete placenta removed
  
• risk of PPH and infection
  

Front 18

Investigations for retained placenta?

Back 18

explore uterus

assess degree of blood loss

Front 19

Management of retained placenta?

Back 19

• • 2 large bore IVs, type and screen
  
• • Brant maneuver (firm traction on umbilical cord with one hand applying suprapubic pressure toavoid uterine inversion by holding uterus in place)
  
• • oxytocin 10 IU in 20 mL NS into umbilical vein
  
• • manual removal if above fails
• • D&C if required

Front 20

Uterine inversion definition

Back 20

inversion of the uterus through cervix ± vaginal introitus

Front 21

Etiology of uterine inversion?

Back 21

• often iatrogenic
  
• excessive use of uterine tocolytics
  
• more common in grand multiparous
  

Front 22

Clinical features of uterine inversion?

Back 22

can cause profound vasovagal response with vasodilation and hypovolemic shock

shock may be disproportionate to maternal blood loss

Front 23

Management of uterine inversion?

Back 23

• • urgent management essential, call anesthesia• ABCs: initiate IV crystalloids
  
• • can use tocolytic drug or nitroglycerin IV to relaxuterus and aid replacement
  
• • replace uterus without removing placenta
  
• • remove placenta manually and withdraw slowly
  
• IV oxytocin infusion (only after uterus replaced)
  
• • re-explore uterus
  

• may require general anesthetic ± laparotomy

Front 24

Definition of postpartum pyrexia?

Back 24

fever >100.4°F on any 2 of the first 10 d postpartum, except the first day

Front 25

Etiology of postpartum pyrexia?

Back 25

• • endometritis
  
• • wound infection secondary to C/S
  
• • mastitis/engorgement
  
• • UTI
  
• • atelectasis
• • pneumonia

Front 26

Investigation of postpartum pyrexia?

Back 26

detailed Hx and PE

relevant cultures

for endometritis: blood and genital cultures

Front 27

Treatment

Back 27

depends on etiology

prophylaxis against post CS endometritis

Front 28

Endometritis definition?

Back 28

infection of uterine myometrium and parametrium

Front 29

Clinical features of endometritis?

Back 29

• fever
  
• chills
  
• abdo pain
  
• uterine tenderness
  
• fould smelling discharge/lochia
  

Front 30

Treatment of endometritis?

Back 30

• Depends on infection severity
  
• oral ABx if well
  
• IV with hospitalization in moderate to severe cases
  

Front 31

Mastitis definition?

Back 31

inflammation of mammary glands

Front 32

Mastitis

Back 32

must rule out inflammatory carcinoma as indicated

Front 33

What to differentiate mastitis?

Back 33

mammary duct ectasia:

mammary duct(s) beneath nipple clogged and dilated± ductal inflammation ± nipple discharge (thick, gray to green), often postmenopausal women

Front 34

Table for mastitis

Back 34

Front 35

Kinds of postpartum mood alterations?

Back 35

• Postpartum blues (85% of new moms)
  
• Postpartum depression (10-20%)
  
• Postpartum psychosis (0.2%)
  

Front 36

How long for pp blues to resolve?

Back 36

2 wks

Front 37

PP depression definition?

Back 37

major depression occurring in a woman within 6 mo of childbirth

Front 38

Postpartum psychosis?

Back 38

onset of psychotic symptoms over 24-72 h within first month postpartum, can present in the context of depression