Post Partum Hemorrhage and Infections and other shit

Question 1

list risk factors for PPH

Answer 1

1. abnormal placentation–> placenta previa, placenta accreta, hyaditiform mole
2. trauma during labour and delivery –> episiotomy, complicated vaginal delivery, low or mid-forceps delivery, sulcal or sidewall lacerations, uterine rupture, C/S or hysterectomy, cervical laceration
3. uterine atony–> uterine inversion, overdistended uterus (i.e due to macrosomic fetus, multiple gestation, polyhydramnios), exhausted myometrium (rapid labour, prolonged labour, oxytocin or prostaglandin stimulation, chorioamnionitis)
4. coagulation defects–> these intensify other causes–> placental abruption, prolonged retention of demised fetus, amniotic fluid embolism, severe intravascular hemolysis, severe preeclampsia and eclampsia, congenital coagulopathies, anticoagulant treatment

Question 2

when does PPH usually occur

Answer 2

within the first 24 hours while patient still in hospital

however, can also occur in those with retained POCs for up to several weeks postpartum

Question 3

define PPH

Answer 3

blood loss above 500 mL in vaginal delivery and above 1000 mL in C/S

if within first 24 hours–> early PPH

after, it is late/delayed PPH

Question 4

what are the common causes of PPH

Answer 4

UTERINE ATONY

retained POCs

placenta accreta

cervical lacerations

vaginal lacerations

Question 5

how should you manage a PPH acutely

Answer 5

while investigating the cause, start on fluid rescusitation and make preparations for blood transfusion

with blood loss above 2-3 L, patients may develop consumptive coagulopathy and require coagulation factors and platelets

if become hypovolemic and hypotensive–> consider SHEEHAN syndrome

may have to investigate and/or treat several causes of PPH simultaneously

Question 6

what is sheehan syndrome

Answer 6

pituitary infarction

manifests with absence of lactation secondary to the lack of prolactin or failure to restart menstruation secondary to the absence of gonadotropins

Question 7

what is the etiology of PPH in vaginal births

Answer 7

vaginal lacerations

cervical lacerations

uterine atony

placenta accreta

vaginal hematoma

retained POCs

uterine inversion

uterine rupture

Question 8

what is the etiology of PPH in C/S delivery

Answer 8

uterine atony

surgical blood loss

placenta accreta

uterine rupture

Question 9

what usually causes cervical laceration

Answer 9

rapid dilation of the cervix in stage 1 of labour or maternal expulsive efforts prior to complete dilation of the cervix

Question 10

what is the leading cause of PPH

Answer 10

uterine atony

Question 11

what factors increase the risk for uterine atony

Answer 11

chorioamnionitis

exposure to magnesium sulfate

multiple gestation

macrosomic fetus

polyhydramnios

prolonged labour

history of atony

multiparous (especially grand multipara)

Question 12

how is the diagnosis of uterine atony made

Answer 12

palpation of the uterus –> soft, enlarged, boggy

fundus may be well contracted but the lower uterine segment (less contractile tissue) may not be

Question 13

how do you treat uterine atony initially

Answer 13

IV oxytocin (Pitocin)

while oxy is being administered, strong uterine massage should be performed to assist with contraction

Question 14

what should you do it uterine atony persists after IV oxytocin and vigorous uterine massage

Answer 14

Methergine (not in HTN patients)

Question 15

what should you do it uterine atony persists after IV oxytocin, vigorous uterine massage and methergine

Answer 15

Hemabate (PGF2) (not in asthma patients)

thought to be more effective if injected directly into uterine musculature either transabdominally or transcervically

can also give misoprostol SL or rectally (off label)–> can help decrease the blood loss associated with atony when patients are without IV access

Question 16

what should you do it uterine atony persists after maximal medical management (with IV oxytocin, uterine massage, methergine, hemabate, and maybe misoprostol)

Answer 16

go to OR for dilation and curretage to rule out possible retained POCs

patients unresponsive to these conservative measures but are not bleeding TOO much may benefit from uterine packing with an inflatable tamponade (Bakri balloon) or occlusion of pelvic vessels (uterine artery embolization) by IR to prevent hysterectomy

if this is unsuccessful, can do exploratory laparotomy with ligation of pelvic vessels and possible hysterectomy if required

Question 17

what should you do if suspicion is high for retained POCs

Answer 17

uterus should be explored either manually if cervix not contracted down or by U/S

if there is evidence of a normal uterine stripe, probability of retained products is lower

however, if still suspected, do D and C

if hemorrhage continues after confirmation of no retained POCs, suspect placenta accreta

Question 18

when should you suspect placenta accreta and what do you do

Answer 18

if PPH persists despite management with uterine massage, oxytocin, methergine etc

take them to OR for surgical management via exploratory laparotomy

Question 19

treatment of uterine rupture

Answer 19

laparotomy and repair of uterus–if hemorrhage not controlled, may have to do hysterectomy

Question 20

risk factors for uterine inversion

Answer 20

fundal implantation of placenta

uterine atony

placenta accreta

excessive traction on cord during third stage

Question 21

how do you diagnose uterine inversion

Answer 21

witnessing the fundus of the uterus attached to the placenta on placental delivery

patients often experience an intense vasovagal episode from the inversion and may require stabilization with aid of anesthesiologist before manual replacement can be attempted

Question 22

how do you manage uterine inversion

Answer 22

stabilize patient, maybe with help of anesthesiologist of have vagal episode

first, attempt manual replacement of uterus

uterine relaxants like nitroglycerin of general anesthesia with halogenated agents may be given to aid uterine relaxation and replacement

if this is unsuccessful, laparotomy is required to surgically replace the uterus

Question 23

describe the approach to PPH after a vaginal delivery

Answer 23

1. stabilize the patient
2. quickly investigate causes:
3. rule out vaginal and cervical lacerations first
4. attempt uterotonic agents and massage
5. if unresponsive to above, move to the OR and attempt a D and C
6. if this fails to stop bleeding, place an inflatable balloon in the uterine cavity to limit further hemorrhage
7. if these measures fail–> laparotomy

Question 24

describe the operative management of PPH once the decision has been made to do a laparotomy

Answer 24

1. on entering abdo–> note whether there is blood in abdo–> suggests uterine rupture
2. unless unstable and coagulopathic secondary to excessive blood loss, first surgical procedure is usually bilateral O’LEARY SUTURES to tie off the uterine arteries
3. ligate the hypogastric or internal iliac arteries
4. if uterine atony is cause–> B-LYNCH SUTUREScan be placed to attempt to compress the uterus and achieve hemostasis
5. if all this fails, often require hysterectomy

Question 25

why might seizure frequency increase during pregnancy in women with seizure disorders

Answer 25

increased levels of circulating estrogens during pregnancy may increase function of the CYP450 enzymes which leads to more rapid hepatic metabolism of AEDs. renal function also increases in pregnancy--> 50% rise in Cr clearance which affects metabolism of carbamazepine, primidone and the benzodiazepines increase in total blood volume leads to decreased levels of circulating AEDs hormonal changes, added stress and decreased sleep occur during pregnancy--> may lower seizure threshold and increase seizure frequency decreased compliance with AEDs in pregnancy due to concerns over fetal effects estrogen is epileptogenic and decreases seizure threshold

Question 26

list seizure meds that have known fetal congenital effects

Answer 26

phenytoin (REALLY bad...causes all the bad things) phenobarbitol (also really bad) primidone valproate carbamazepine trimethadione

Question 27

what fetal anomalies are associated with AEDS

Answer 27

``` NTDs IUGR microcephaly low IQ ptosis cardiac anomalies distal digital hypoplasia low set ears epicanthal folds short nose long philtrum lip abnormalities hypertelorism developmental delay ``` * 4x increased risk of cleft palate * 3-4x increased risk of cardiac anomalies

Question 28

what congenital anomaly is associated specifically with carbamazepine and valproate

Answer 28

NTDs

Question 29

how should you manage an epileptic patient during pregnancy

Answer 29

1. check total and free levels of AEDs on a monthly basis 2. consider early genetic counseling 3. check MSAFP 4. level II U/S for fetal survey at 19-20 weeks 5. consider amniocentesis for AFP and acetylcholinesterase 6. supplement with oral vitamin K 20 mg QD starting at 37 weeks

Question 30

if a woman with a seizure disorder develops preeclampsia, what drug do you use to prevent seizures

Answer 30

phenytoin (instead of magnesium in the non epileptic patient)

Question 31

what common cardiac drugs are contraindicated in pregnancy

Answer 31

ACEi diuretics warfarin

Question 32

what are the two main sources of massive fluid shift that occur in the immediately post partum woman (and are of particular concern to those who have underlying cardiac disease)

Answer 32

increased venous return as no longer have an enlarged uterus compressing the vena cava uterus clamps down after placental expulsion, and demands less circulation, leading to effective autotransfusion of its blood supply (approx 500 mL)

Question 33

what is the risk of pregnancy in a woman with marfan's

Answer 33

hyperdynamic state of pregnancy can cause increased risk of aortic dissection and/or rupture particularly in those with an aortic root diameter greater than 4 cm should be encouraged to pursue sedentary lifestyle and be started on beta blockers

Question 34

what are the risks to the mother who gets pregnancy with pre-existing renal disease

Answer 34

increased risk of requiring dialysis preeclampsia preterm delivery IIGR worsening renal disease

Question 35

how do you treat DVT in pregnancy

Answer 35

use adjusted dose LMWH (enoxaparin 1mg/kg BID) or unfractionated heparin (goal aPTT of 1.5 to 2.5 times normal) LMWH better

Question 36

what congenital abnormalities are caused by warfarin

Answer 36

nasal hypoplasia and skeletal abnormalities as well as diffuse CNS abnormalities including optic atrophy

Question 37

what are two signs on CXR that can indicate PE

Answer 37

abrupt termination of a vessel as it is traced distally area of radiolucency in the region of the lung beyond the PE

Question 38

what diagnostic tool is best for PE

Answer 38

spiral CT (same as non pregnant)

Question 39

how do you treat PE in the hemodynamically stable pregnant patient

Answer 39

LMWH (enoxaparin)

Question 40

how do you treat PE in the hemodynamically UNSTABLE pregnant patient

Answer 40

IV heparin

Question 41

how do you treat PE in a patient with massive PE leading to unstable hypoxic states

Answer 41

streptokinase for thrombolysis in addition to supportive measures

Question 42

what is the most common cause of hyperthyroidism

Answer 42

graves disease

Question 43

how do you manage patients with hyperthyroidism in pregnancy

Answer 43

can continue with PTU or methimazole (which decrease production of T4) use minimum dosage due to risk of fetal goiter TSH should be kept netween 0.5 and 2.5, and closer to 0.5 if possible

Question 44

what is the most common etiology for hypothyroid

Answer 44

hashimoto thyroiditis second is ablation or removal of thyroid due to graves or cancer

Question 45

how do you manage the hypothyroid woman in pregnancy

Answer 45

increase dose of levothyroxine 25-30% due to increased demand for thyroid hormone in pregnancy keep TSH low normal and follow levels throughout pregnancy

Question 46

what is the natural history of SLE in pregnancy

Answer 46

rule of 1/3--> 1/3 improve 1/3 worsen 1/3 remain unchanged

Question 47

how do you manage SLE in pregnancy

Answer 47

continue meds like aspirin and corticisteroids | stop cyclophosphamide and methotrexate *remember methotrexate has a long half life*

Question 48

why do patients with SLE and antiphospholipid antibody syndrome have a higher rate of first and second trimester pregnancy loss

Answer 48

placental thrombosis * high rate of second trimester loss is hallmark of these diseases and they will often show symmetric IUGR by 18-20 weeks gestation * treatment with low dose aspirin, heparin and corticosteroids have been tried with some improvement in prognosis

Question 49

what cardiac complication is of concern in fetuses developing in SLE positive or Sjogrens positive mothers

Answer 49

AV block, irreversible due to anti-Ro and anti-La antibodies that can cross the placenta and are tissue specific to the fetal cardiac conduction system