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Abnormal puerperium Flashcards

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1
Q

Abnormal puerperium examples ?

A

Postpartum Hemorrhage

Placenta Accreta

Uterine Inversion

Puerperal Infection

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2
Q

Postpartum hemorrhage pahto ?

A

Defined as >500 ml following vaginal delivery

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3
Q

Postpartum hemorrhage prevalence ?

A

Occurs in 5-8% of deliveries

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4
Q

Postpartum hemorrhage causes ?

A

Uterine atony

Obstetric lacerations

Retained placental tissue

Coagulation defects

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5
Q

Postpartum hemorrhage Tx.: redelivery ?

A

type and cross match

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6
Q

Postpartum hemorrhage Tx. after delivery ?

A

gentle uterine massage. If excessive, may interfere instead of aid

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7
Q

Postpartum hemorrhage Tx. placenta ?

A

Usually separates and is delivered 5-15 mins after baby

Do not attempt to speed this up

Gentle traction on umbilical cord

check and make sure both sides are smooth and intact

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8
Q

____________ is the 3rd leading cause of maternal mortality in US

A

Hemorrhage

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9
Q

Most common cause of PP hemorrhage (50%) ?

A

Uterine atony

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10
Q

Uterine atony patho ?

A

Myometrium cannot contract

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11
Q

Uterine atony causes ?

A

Excessive manipulation of the uterus

General anesthesia

Overdistention of the uterus
# gestations, etc

Prolonged labor

Fibroids

Uterine infection

Operative delivery

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12
Q

Uterine atony Tx ?

A

Uterotonic agents (oxytocin) as soon as the infant’s anterior shoulder is delivered

Bimanual uterine massage

Oral misoprostol (prostaglandin)

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13
Q

Obstetric lacerations causes ?

A

Episiotomy

Lacerations (tears) of uterus, cervix, vagina, vulva

Quick or uncontrolled delivery

Large infant

**if the keep bleeding , look for hematoma collections and they you will find the source of bleeding **

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14
Q

Obstetric lacerations Tx. ?

A

Inspect the vagina and cervix

Repair episiotomy after massage has produced a firm, contracted uterus

If hematoma is identified, open and evacuate

**if U us contracted and you still see bright red blood? think this **

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15
Q

Retained placental tissue occurs in ?

A

placenta accreta

**Accreta – implantation is too deep, the dicidua layer is missing and now there is no separation of the placenta **

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16
Q

Retained placental tissue: _____ of cases of PP hemorrhage

A

5-10%

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17
Q

Retained placental tissue increased frequency b/c of ?

A

multiple c-sections

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18
Q

Retained placental tissue Dx by ?

A

transvaginal sono

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19
Q

Placenta accreta ?

A

A decidual layer normally separates the placenta villi and the myometrium. When there is no decidua, it is termed placenta accreta vera.

**if it does not peel off it just never stopped bleeding and this leads to hysterectomy **

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20
Q

Placenta increta ?

A

villi invade the myometrium

inside the wall

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21
Q

Placenta percreta ?

A

villi penetrate the myometrium

through all layers of U

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22
Q

Most common type of placental adherence anomaly ?

A

Placenta accreta

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23
Q

Major cause of peripartum hysterectomy ?

A

Placenta accreta

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24
Q

Placenta accreta etiology ?

A

UKN

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25
Placenta accreta increased with ?
Placenta previa Previous uterine incision Multiparity Previous D&C
26
Placenta accreta dx w/ ?
Can be diagnosed prior to delivery – esp Color Doppler imaging
27
Placenta accreta pathophysiology ?
retained placental parts prevent myometrium from contracting, hemostasis cannot be achieved Not a problem during pregnancy or delivery Explore placenta – parts missing
28
Placenta accreta: Tx if minimal bleeding ?
conservative tx – pelvic artery embolization, then IM methotrexate. Placenta may eventually slough
29
Placenta Accreta: Possibly retains ________, recurrence is high
fertility
30
Placenta Accreta Tx If placenta is totally adherent, ?
manual removal cannot be done
31
Placenta Accreta Tx if hemorrhage ?
hysterectomy
32
Manual removal of placenta if ?
If not spontaneously delivered by 18-30 mins
33
Manual removal of Placenta risks ?
Pain Risk of endometritis Causing more bleeding **try and get behind the retain placenta and try and pull it off careful cause you can cause more bleeding and give the prophylaxis ABS **
34
Coagulation defects: acquired ?
Abruptio placentae Retained dead fetus = extra thromboplastin goes from the fetus to the mom Amniotic fluid embolism Eclampsia, sepsis
35
Coagulation defects ?
Von Willebrand’s Thrombocytopenia Leukemia
36
Control of persistent bleeding: Manual exploration of the uterus ?
Check for twins Check for laceration/rupture Check for retained placental parts
37
Control of persistent bleeding: Bimanual compression and massage ?
For atony May need 20-30 minutes Foley should be in place cause she needs to be diuresing
38
Control of persistent bleeding: Curettage ?
If massage not helpful Risk of perforation, increased bleeding Risk of scarring, adhesions(Asherman’s syndrome)
39
Control of persistent bleeding: Intrauterine pressure ?
Packing no longer done ( cause TSS) Use inflatable balloon instead
40
Control of persistent bleeding: Uterotonic agents ?
Oxytocin
41
Control of persistent bleeding: Radiographic embolization of pelvic vessels ?
Interventional radiologist Angiographic technique Fluoroscopy guided – gelfoam into damaged vessel Helps to maintain fertility (low # cases so far) Helps to avoid hysterectomy Risk of loss of circulation to legs, labia, buttocks with necrosis
42
Uterine inversion patho ?
Prolapse of the fundus to or through the cervix
43
Uterine inversion prevalence ?
1 in 2000 deliveries
44
Uterine inversion RF ?
Placental implantation in fundus Partial placental accreta Weakened myometrium Prolonged labor Strong traction on umbilical cord Fundal pressure - gentle massage Hx of uterine inversion
45
Uterine inversion Dx ?
Diagnosis is obvious – red-blue bleeding mass at the cervix, in the vagina or outside the vagina Depressed or absent fundus Shock, hemorrhage and pain
46
Uterine inversion complications ?
Depends on degree of hemorrhage and how quickly and how effectively treated Endomyometritis frequently follows Mortality is low since usually promptly recognized and treated
47
Uterine inversion Tx. ?
Fluid and blood replacement for hypovolemic shock Manual repositioning of uterus With or without IV tocolytics to relax uterus (mag sulfate or terbutaline) After repositioned – prostaglandins for uterine contraction Antibiotics Rarely is surgery required
48
Postpartum infections prevalence ?
2-8% of postpartum females
49
Postpartum infections sxs. ?
Fever is hallmark, but not necessary
50
Postpartum infections RF ?
Low socioeconomic status - less prenatal care Operative delivery PROM Long labor Multiple pelvic exams
51
Postpartum infections examples ?
* Endometritis * UTI Pneumonia Caesarean section wound infection Episiotomy infection
52
Endometritis patho ?
Vagina normally has pathogenic flora Protective factors - Acidic pH - Thick cervical mucous - Maternal antibodies Decidua and lochia provide nutrients to anaerobic bacteria
53
Endometritis RF ?
Digital exams and fetal scalp monitors Prolonged labor >24 hours Prolonged rupture of membranes Pre-existing vaginitis or cervicitis Anemia Poor nutrition Obesity Coitus near term C-section or other operative delivery
54
Endometritis S&S ?
Fever (100.4⁰ F +) on day 2-3 Soft, very tender uterus Lochia may have foul odor Leukocytosis (20,000 +) Positive blood culture in 5-10% Lochia culture must be taken intrauterine Severe – can lead to sepsis
55
Endometritis organisms: Anaerobic bacteria - 50-95% Tx. ?
Clindamycin, cephalosporins
56
Endometritis organisms: Group B streptococci – 30% | Tx. ?
PCN
57
Endometritis organisms: E.coli Tx. ?
Seen in more seriously ill patients
58
Endometritis Tx. ?
High dose IV antibiotics until patient is afebrile for 24-48 hours -Clindamycin plus aminoglycoside once daily or -2nd or 3rd generation cephalosporin Monitor closely If not improving, add ampicillin
59
UTI prevalence ?
2-4% of women develop UTI postpartum
60
UTI Patho / causes ?
Postpartum, bladder and lower urinary tract are hypotonic so more residual and reflux Plus, frequent exams = contamination of perineum
61
UTI S&S ?
dysuria, fever, frequency, urgency
62
UTI Labs ?
UA – WBC’s and bacteria. Get a culture Often E. coli
63
UTI Tx. ?
sulfonamides, nitrofurantoin, TMP-SMX Monitor for pyelo
64
Pneumonia Causes ?
Women with COPD, smokers, general anesthesia
65
Pneumonia S&S ?
same as non postparum woman Cough, CP, fever, chills, rales, infiltrates on CXR
66
Pneumonia Tx. ?
antibiotics, O2, IV hydration, pulmonary toilet
67
Caesarean section wound infection prevalence ?
Occurs in 4-12%
68
Caesarean section wound infection RF ?
Obesity, diabetes, prolonged hospitalization before C-section, prolonged ROM, prolonged labor, chorioamnionitis, endometritis, anemia, emergency C-section
69
Caesarean section wound infection prevention ?
Prophylactic antibiotics 1 g IV cefazolin before skin incision
70
Caesarean section wound infection S & S ?
Fever that lasts until day 4 or 5 Wound erythema may not be seen for several days Drainage or skin separation
71
Caesarean section wound infection Labs ?
Gram-stain, C&S of wound Blood culture if suspect sepsis
72
Caesarean section wound infection organisms ?
S. aureus is most common, MRSA Occas strep, E coli, Bacteroides
73
Caesarean section wound infection Tx. ?
Open incision to drain material and to see if fascia has separated If intact - pack wound with saline-soaked gauze If not – monitor for dehiscence
74
Episiotomy infection prevalence ?
Low incidence – 0.5 – 3% (good blood supply)
75
Episiotomy infection labs ?
Labs show mixed infection
76
Episiotomy infection Tx. ?
open and clean the wound. Sitz baths Repair sometimes undertaken 3-4 months after infection clears

Patient Evaluation (29 decks)

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