Complications of the Postpartum Period

Question 1

What is the definition of post partum hemorrhage?

Answer 1

EBL>500ml after a vaginal delivery

EBL>1000ml after a cesarean

Question 2

What is the number one cause of post partum hemorrhages? How do you manage these patients?

Answer 2

uterine atony such as drugs, chorioamnionitis, uterine overdistention, and uterine malformation

Uterine massage-methergine-PGF2a

Question 3

What are other causes of postpartum hemorrhages?

Answer 3

retained placenta (accreta- superficial)
Lacerations (vaginal and cervivcal)
coagulopathy

Question 4

What are vaginal lacerations most likely from?

Answer 4

instrumental vaginal delivery

Question 5

What are cervical lacerations most likely from? How do you manage it?

Answer 5

precipitous labor; repair laceration

Question 6

What are examples of coagulopathy related causes of postpartum hemorrhages? How do you manage these patients?

Answer 6

severe preclampsia
abruptio placentae
sepsis
amniotic fluid embolism

cryoprecipitate

Question 7

What are the classifications of puerperal infection?

Answer 7

endometritis
wound infection
UTI

Question 8

What are the risk factors for endometritis?

Answer 8

labor
ruptured membranes
multiple vaginal exams
preexisting vaginal infections (BV, GBS)
Cesarean delivery (10-15% compared to vag delivery)

Question 9

What is the main risk factor of endometritis?

Answer 9

Cesarean

Question 10

What are the bacteriods?

Answer 10

anaerobic gram - rods

Question 11

What are the coliforms?

Answer 11

aerobic gram -: e. coli and klebsiella

Question 12

what are the streptococci?

Answer 12

GBS, Staph, Anaerobic strep

Question 13

What are the requirements of dilation for a vaginal delivery?

Answer 13

atleast a +3- +5 dilation otherwise cesarean; need to see the babies head

Question 14

What are the clinical manifestations of endometritis?

Answer 14

fever
tachycardia
pelvic pain and tenderness
no other localizing sign of infection

Question 15

What are the antibiotic treatments for endometritis?

Answer 15

clindamycin plus gentamicin
**metronidazole plus penicillin or ampicillin plus gentamicin
broad spectrum cephalosporin or penicillin (cefotetan, timentin)

Question 16

What is the frequency of a wound infection after a cesarean?

Answer 16

3-5%; usually in sub cut. fascia, dont let it spread farther

Question 17

What are the principal risk factors for wound infections?

Answer 17

obesity
pre-existing infection- ie chorioamnionitis
emergency procedure- inadequate skin prep
diabetes
immunodeficiency disorder

Question 18

What are the main organisms responsible for wound infections?

Answer 18

mixed flora (most)
strep
staph

Question 19

What is the clinical presentation of a wound infection?

Answer 19

Incisional abscess- pus

cellulitis- bright red and tender

Question 20

What is the treatment for a wound infection?

Answer 20

Surgical drainage if an abscess

modify antibiotic coverage to target staphylococci and streptococci (nafcillin and vancomycin)

Question 21

What are the frequencies of UTIs after labor and delivery?

Answer 21

3-5%

Question 22

What are the risk factors for a UTI?

Answer 22

Prior infection
Prolonged bladder catheterization
sickle cell dz
immunodeficiency disorder

Question 23

What are the main microbes responsible for these UTIs?

Answer 23

E. coli**
Klebsiella
Proteus
Gram +

Question 24

What are the clinical manifestations of a UTI?

Answer 24

Cystitis- infected bladder ( dysuria, polyuria, hesitency, hematuria, lowgrade fever, suprapubic pain)
Pyelonephritis (fever, chills, flank pain)

Question 25

How do you make a diagnosis of a UTI?

Answer 25

Duffs way: in and out cath! ``` Urine analysis (pH, leukocyte esterase, nitrite test) Urine culture ```

Question 26

What is the treatment for a UTI?

Answer 26

Oral abx: trimethoprim-sulfamethoxazole- proteus **nitrofurantoin- hits all but proteus, cheap amoxicillin-clavulanic acid- if highly resistent but want to treat orally

Question 27

How do you treat a patient via IV if the have kidney problems?

Answer 27

aztreonam

Question 28

Virchow's Triad

Answer 28

endothelial injury venous stasis hypercoagulable state

Question 29

What is the prevelance of a thromboembolism?

Answer 29

<1%

Question 30

What re the principal risk factors of a thromboembolism?

Answer 30

``` ****Cesarean delivery obesity prolonged bedrest prior to delivery hereditary thrombophilia sickle cell disease ```

Question 31

What are the classifications of thromboembolisms?

Answer 31

DVT | PE

Question 32

What are the clinical manifestations of a DVT?

Answer 32

Erythema Swelling Palpable cord

Question 33

What are the clinical manifestations of a PE?

Answer 33

``` Dyspnea Tachypnea Chest pain Anxiety Cardiovascular collapse ```

Question 34

How do you diagnose a DVT?

Answer 34

Most widely used: dopple flow | Most definitive test: venography

Question 35

How do you diagnose a PE?

Answer 35

***Spiral CT Ventilation perfusion scan pulmonary angiogram

Question 36

What is the management for a DVT and PE?

Answer 36

``` Screen for hereditary thrombophilia Thrombolytic therapy- for massive embolism **Anticoagulation -unfractioned heparin -LMW heparin -coumadin (lovanax) ```

Question 37

What are the principal risk factors for postpartum endometritis?

Answer 37

cesarean section