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OBGYN > 12: Postpartum care and complications > Flashcards

12: Postpartum care and complications Flashcards

1
Q

Two central issues in the immediate postpartum period, regardless of the mode of delivery, are ?

A

pain management and wound care

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2
Q

what contraception can be used by anyone postpartum

A

Condoms with a spermicidal foam or gel

-Diaphragms and cervical caps need to be refitted at 6 weeks. IUDs are best placed at 6 weeks as well.

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3
Q

hormonal contraceptives of choice in the puerperium because they are less likely to decrease milk production in breastfeeding patients and affect risk of venous thromboembolism.

A

Depo-Provera, Implanon, the progesterone-releasing IUD, or the progesterone-only mini-pill

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4
Q

Causes of postpartum hemorrhage

A

uterine atony, uterine rupture, uterine inversion, retained POCs, placenta accreta, and cervical or vaginal lacerations

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5
Q

treatment of PPH

A

blood products including fresh frozen plasma, cryoprecipitate, and platelets in patients who develop a consumptive coagulopathy

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6
Q

Surgical management of PPH

A

ranges from D+C to exploratory laparotomy, uterine artery ligation, hypogastric artery ligation, and, if these fail, hysterectomy.

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7
Q

In PPH patients for whom there is enough time, an alternative to exploratory laparotomy

A

uterine artery embolization (UAE) by interventional radiology

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8
Q

Diagnosis of endomyometritis

A

clinical: fever, elevated WBC count, and uterine tenderness; treatment is with broad-spectrum antibiotics and D/C for retained POCs.

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9
Q

Cesarean incisions may be complicated by

A

cellulitis, wound abscess, wound separation, or frank dehiscence (at the level of the rectus fascia). Wound healing is improved by blood glucose control and smoking cessation.

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10
Q

Mastitis is differentiated from engorgement by ?

treatment?

A

focal tenderness, erythema, and edema, and treatment is usually with oral antibiotics: dicloxacillin (x10-14)

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11
Q

the puerperium (postpartum period) is defined as

A

6 weeks after delivery

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12
Q

pain meds after vaginal delivery

A

NSAIDs, tylenol, occasionally low-dose opioids

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13
Q

pain meds after C-section

A

opioids, NSAIDs

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14
Q

benefits of breastfeeding

A

Oxytocin release stimulates postpartum uterine contractions, increases uterine tone and decreases the risk of bleeding

  • IgG transmitted to baby, lower rates of childhood obesity
  • maternal weight loss, lower risk T2DM
  • decreased risk of both breast and endometrial cancers (decreased estrogen exposure)
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15
Q

vaccines for mom/caregivers postpartum

A
  • Tdap is essential if they have not received the vaccine within the 10 years previous to pregnancy
  • MMR if low Rubella antibody titers
  • if Rh- mom and unknonwn/Rh+ baby: RhoGAM within 72 hours postpartum
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16
Q

extremely effective form of surgical contraception that should be brought up in third trimester

A

postpartum tubal ligation (PPTL) (need consent 30 days before procedure)

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17
Q

Combination estrogen–progesterone OCPs in some studies have been shown to ?

A

decrease milk production so are usually recommended only to those patients who are not interested in breastfeeding or have excellent milk production

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18
Q

if really want to use combo OCPs wait until ?

A

3 weeks postpartum, at which point the benefits of contraception and pregnancy prevention outweigh the risks of (VTE) in the puerperium
After 6 weeks, the risk of VTE decreases to that seen in the non-pregnant state.

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19
Q

Early initiation of combination OCPs should not be recommended to patients with risk factors for VTE, such as ?

A

age ≥35 years, previous VTE, thrombophilia, immobility, transfusion at delivery, BMI ≥30, postpartum hemorrhage, post-Cesarean delivery, preeclampsia, or active smoking.

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20
Q

The primary complications that arise postpartum include

A

postpartum hemorrhage (PPH) (1st 24hrs, several wks if RPOCs), endomyometritis, wound infections (w.in 7-10 days) and separations, mastitis (1-2 wks), and postpartum depression

21
Q

rare complications of vaginal delivery

A

endomyometritis, episiotomy infections, episiotomy breakdown

22
Q

complications of Cesarean delivery

A

PPH, sx blood loss, wound infection, endomyometritis, mastitis, PPD, wound separation/dehiscence

23
Q

risk factors for PPH 1

A
  • prior PPH
  • Abnormal placentation: previa, accreta, hydatidiform mole
  • Trauma during L/D : Episiotomy, Complicated vaginal delivery, Low- or mid forceps delivery, Sulcal or sidewall laceration, Uterine rupture, Cesarean delivery or hysterectomy, Cervical laceration
  • Uterine atony: Uterine inversion, Overdistended uterus, Macrosomic fetus, Multiple gestation, Polyhydramnios
24
Q

risk factors for PPH 2

A
  • Exhausted myometrium: Rapid or prolonged labor, pit or PG stimulation, chorioamnionitis
  • Coagulation defects (intensify other causes): Placental abruption, Prolonged retention of demised fetus, AFE, Severe intravascular hemolysis, Severe preE/E, Congenital coagulopathies, Anticoagulant tx
25
Q

Postpartum hemorrhage is defined as blood loss exceeding

A

500 mL in a vaginal delivery and greater than 1,000 mL in a cesarean section
-early if within 24 hrs, late/delayed if outside 24 hrs

26
Q

with blood loss greater than 2 to 3 L, patients may develop a ?

A

consumptive coagulopathy and require coagulation factors and platelets.

27
Q

Sheehan syndrome

A

pituitary infarction, may occur if patient becomes become hypovolemic and hypotensive
-may manifest with the absence of lactation secondary to the lack of prolactin or failure to restart menstruation secondary to the absence of gonadotropins

28
Q

etiology of PPH in vaginal deliveries

A 
Vaginal lacerations	
Cervical lacerations
Uterine atony	
Placenta accreta
Vaginal hematoma	
Retained POCs	
Uterine inversion	
Uterine rupture
29
Q

etiology of PPH in Cesarean deliveries

A

Uterine atony
Surgical blood loss
Placenta accreta
Uterine rupture

30
Q

If a patient has a larger than expected drop in hematocrit, an examination should be performed to rule out a ?

A

vaginal wall hematoma

  • can be managed expectantly unless it is tense or expanding, in which case it should be opened, the bleeding vessel ligated, and the vaginal wall closed
  • Rare: retroperitoneal hematoma that can lead to a large blood loss (low back/rectal pain, large drop in HCT)
  • dx: US, CT
  • tx: IR, sx ligation
31
Q

cause of cervical lacerations

A

rapid dilation of the cervix during the stage 1 of labor or maternal expulsive efforts prior to complete dilation of the cervix

  • give anesthesia via epidural, spinal, or pudendal block before using ring forceps to “walk” around cervix
  • repair with interrupted or running absorbable sutures.
32
Q

the leading cause of postpartum hemorrhage

A

uterine atony

33
Q

risk factors for uterine atony

A

chorioamnionitis, exposure to magnesium sulfate, multiple gestations, a macrosomic fetus, polyhydramnios, prolonged labor, a history of atony with any prior pregnancies, or if they are multiparous, particularly a grand multipara (more than five deliveries

34
Q

The diagnosis of atony is made by palpation of the uterus, which is ?

A

soft, enlarged, and boggy

35
Q

Atony is initially treated with ?

A
  1. ppx IV oxytocin (Pitocin), uterine massage
    2.methylergonovine (Methergine) CI in HTN pts
    3.Hemabate (also known as Prostin or PGF2), CI in asthmatics
    Misoprostol, a PGE1 may be used off-label
36
Q

if atony can’t be managed medically

A
  • D/C to rule out possible retained POCs
  • uterine packing with an inflatable tamponade (Bakri balloon) or occlusion of pelvic vessels (uterine artery embolization) by IR
37
Q

if suspicion high for RPOCs after manual exam/US, perform a ?
may lead to ?
if hemorrhage continues after r/o RPOCs, think ?

A

D/C

endomyometritis and PPH

placenta accreta

38
Q

Accreta involves bleeding that is unresponsive to ?

how to manage ?

A

uterine massage and contractile agents such as oxytocin, ergonovines, and prostaglandins

take to OR for exploratory laparotomy

39
Q

risk factors for uterine rupture

A

previous uterine surgery prior uterine scar), breech extraction, obstructed labor, and high parity

40
Q

symptoms of uterine rupture

treatment?

A

abdominal pain and a popping sensation intra-abdominally.
Treatment involves laparotomy and repair of the ruptured uterus. If hemorrhage cannot be controlled, hysterectomy may be indicated.

41
Q

risk factors for uterine inversion

A

fundal implantation of the placenta, uterine atony, placenta accreta, and excessive traction on the cord during the third stage

42
Q

how to dx uterine inversion

A

witnessing the fundus of the uterus attached to the placenta on placental delivery
can be an obstetric emergency if hemorrhage

43
Q

uterine inversion management

A
  • stabilization (may have vasovagal response)
  • manual replacement of uterus
  • Uterine relaxants such as nitroglycerin or general anesthesia with halogenated agents
  • laparotomy if unsuccessful
44
Q

if blood in abdomen, think?

how to tx?

A

uterine rupture
stabilize
bilateral O’Leary sutures to tie off the uterine arteries
-ligation of the hypogastric, or internal iliac, arteries
-B-Lynch sutures can be placed in an attempt to compress the uterus and achieve hemostasis (if atony)
-uterine incision and looped around uterus
-if fails, puerperal hysterectomy

45
Q

first step if pt delivered via C-section and there is evidence of accreta

A

place hemostatic sutures in the placental bed

46
Q

Endomyometritis most common after ?

risk factors?

A

C-sections and vaginal deliveries with manual extraction of placenta
-meconium, chorioamnionitis, and prolonged ROM

47
Q

management of complete wound dehiscence bove.

A

the fascia is usually closed and the skin incision treated like a superficial wound separation

48
Q

postpartum blues timeframe

A

within 2 to 3 days after delivery, peaking at the 5th and resolving within 2 weeks

49
Q

Endomyometritis is more common in patients with vaginal or caesarean delivery?

A

caesarean, although patients with manual removal of the placenta are also at increased risk.

OBGYN (28 decks)

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