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IP Exam 3 > Postpartum complications > Flashcards

Postpartum complications Flashcards

1
Q

Define puerperal morbidity

A

Morbidity related to the genital tract following childbirth, miscarriage, or pregnancy termination

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2
Q

Define puerperal mortality

A

Death of pregnant or postpartum woman within 42 days of to childbirth, miscarriage, ectopic pregnancy, or termination from any cause related to pregnancy or its treatment (according to WHO)

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3
Q

Discuss predisposing factors to puerperal infection

A

Maternal characteristics

  • Obesity
  • Diabetes
  • Severe anemia
  • Immunocompromised: HIV infection
  • BV
  • GBS or Group A strep +
  • Co-occurring infection: TB, pneumonia, meningitis
  • Smoking
  • Poor maternal hygiene, nutrition, oxygenation, tissue perfusion

Pregnancy characteristics

  • Preterm birth
  • Post-term pregnancy

Labor Characteristics

  • C/S
  • Chorio
  • Internal monitoring
  • Manual placenta removal
  • Thick mec / meconium staining
  • Operative vaginal delivery
  • Prolonged labor
  • Prolonged ROM
  • Frequent vaginal exams
  • Foley catheter
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4
Q

What is a puerperal Infection?

A

Fever of 38C or higher for over 24 hours, from onset of ROM or labor to 42 days after childbirth or abortion with one or more of the following:

  • Abnormal vaginal discharge
  • Pelvic pain
  • Odor
  • Delay in uterine involution
  • Other s/s: general malaise, chills, pain, inc’d HR, abd pain, malodorous lochia
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5
Q

S/S of external genitalia, vaginal and cervical infection

A
  • Increasing tenderness, erythema, edema
  • Malodorous lochia
  • Often accompanied by dysuria
  • Severe infection: perineal abscess, purulent drainage, systemic symptoms
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6
Q

Pathophys of external genitalia, vaginal, and cervix infection

A

Laceration or episiotomy becomes infected. Infection generally confined to skin and subcutaneous tissue
Severe complication – necrotizing fasciitis can develop

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7
Q

Treatment of external genitalia, vaginal, and cervix infection

A

Localized perineal infection (+heat, redness, erythema, absence of systemic s/s)
- Expectant management and perineal wound care – frequent sitz baths, meticulous attention to perianal hygiene.
In absence of comorbidities, abx rarely indicated

Serious perineal wound infection – prompt referral for eval and treatment

  • Removal of sutures, plus opening, debriding and cleansing wound to allow area to heal by granulation
  • Antibiotics may be administered if cellulitis present
  • Most perineal wound infections not repaired again unless a 3rd or 4th degree perineal extension present
  • Reduction in incidence of wound infections reported w/ prophylactic abx for 3rd & 4th degree tears
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8
Q

Cause of infections originating in the genital tract

A

Infections may occur from organisms that normally exist in the lower genital tract or bowel

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9
Q

Pathophys for endometritis

A
  • Usually from GBS, enterococcus, E. coli, Klebsiella pneumoniae, Proteus, Bacteroides, Prevotella
  • Endogenous cervicaovaginal flora enter the uterine cavity, contaminating its contents.
  • Be more alert to it if there was something extra done to get the placenta or membranes (ie manual removal, etc)

Incidence: most common PP infection
SVD=1-3%
C/S=15-20% * much higher risk for endometritis *

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10
Q

S/S of endometritis

A
  • Classic triad: fever, tachy, uterine tenderness
  • Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, purulent/foul smelling lochia, tachycardia, subinvolution
  • If Group A or B Strep → scant odorless lochia, no signs except fever
  • Lab findings: Leukocytosis
  • Complications: Salpingitis, oophoritis, may result in infertility issues
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11
Q

Tx of endometritis

A

Treat empirically—

  • Usually don’t manage this by yourself - comanage, or at least consult
  • Clindamycin 900mg + Gentamicin 1.5mg/kg, q8h IV (endometrial infxn usually polymicrobial, so need broad-spectrum abx).
  • Administer until woman is afebrile for 24-48 hrs (usually women respond to IV tx within 48-72 hrs)
  • Add Ampicillin if suspect sepsis or enterococcal infection
  • Gentamicin is poorly excreted in breastmilk, w/Clinda you need to observe infant for GI sx, and Ampicillin is ok w/breastfeeding
  • R/o other sources of infection i.e. pneumonia, mastitis, pyelonephritis, or surgical site infection.
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12
Q

What is septic thrombophlebitis?

A

Venous thrombosis + inflammation + bacteremia

Usually associated with postpartum endometritis/parametritis following C/S in setting of chorio. Can occur in setting of pelvic vein endothelial damage, venous stasis, and hypercoagulability.

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13
Q

S/S septic thrombophlebitis

A
  • fever , erythema, tenderness, a palpable tender cord, purulent drainage at site of involved vessel
  • Complications: septic PE, secondary pneumonia
  • Should be suspected in patients with persistent fever at least 3-5 days despite abx tx, and no evidence of abscess
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14
Q

Pathophys septic thrombophlebitis

A
  • Postpartum women fulfil virchow’s triad for thrombosis (endothelial damage, venous stasis, hypercoagulability) + presence of infection → septic pelvic thrombophlebitis
  • Can occur as extended site of local puerperal infection
  • Most commonly caused by staph aureus
  • Rare complication of pregnancy (1 in 9000 vag deliveries, 1 in 800 C/S)
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15
Q

Tx septic thrombophlebitis

A
  • R/o more common causes of infection (wound or surgical site infection, resp tract infection, UTI)
  • IV Antibiotics, maybe systemic anticoagulation (heparin)–Usually pt’s will already be on abx to empirically treat endometritis

Abx treatment:
Clindamycin 900mg + Gentamicin 1.5mg/kg, q8h IV (same as endometritis)
or ampicillin-sulbactam (unasyn)

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16
Q

What is pelvic cellulitis?

A

Inflammation of parametrium (connective tissue adjacent to uterus i.e. broad ligaments)

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17
Q

S/S of pelvic cellulitis

A

same as endometritis –
- Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, purulent/foul smelling lochia, tachycardia

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18
Q

Pathophys pelvic cellulitis

A
  • Can occur as extended site of local puerperal infection (i.e. deep cervical laceration extending to parametrium)
  • Inflammatory process from endometritis may invade the myometrium and parametrium
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19
Q

Tx pelvic cellulitis

A

IV abx, same as endometritis

clindamycin 900mg + gentamicin 1.5mg/kg q8, or ampicillin-sulbactam (unasyn

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20
Q

S/S & Tx Peritonitis

A
  • Abdominal pain, tenderness, guarding, rigidity
  • Rebound tenderness
  • Fever, tachy

Tx: IV abx

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21
Q

What is peritonitis?

A

Inflammation of membranes that line the abdomen

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22
Q

Discuss common pathogens in puerperal infection

A

Gram positive aerobes

  • Strep A, B & D * fever >=39.0 C within 24 hrs of C/S may indicate Grp A infection
  • Enterococcus, Staph aureus (also common w/ wound infections), Epidermis

Gram negative aerobes
- E-coli, Klebsiella, Enterobacter, Proteus

Gram variable organisms
- Gardnerella vaginallis

Anaerobes
- Peptostreptococcus, peptococcus, bacteroides species, clostridium, fusobacterium

Other
Mycoplasma, chlamydia, gonorrhea

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23
Q

Discuss methods of diagnosing puerperal infection and difficulties establishing a diagnosis

A

Most common causes - endometritis, wound infections, UTI
- Consider possibility of extended infections – localized infection that extends via path of venous circulation or lymphatics to produce bacterial infection to more distant sites

Labs/diagnostics

  • UA/UC (r/o UTI, pyelo)
  • Phys exam (r/o ddx i.e. appendicitis, mastitis, pyelo)
  • CBC
  • CXR as indicated to r/o pneumonia
  • Blood cultures not routinely recommended if woman not acutely ill, as most women respond well to empiric therapy
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24
Q

S/S mastitis

A
  • one or more segments of the breast are hot, red, tender, and inflamed.
  • s/s may include chills, malaise, fever, flu-like symptoms, WBC < 4,000 or >12,000, and N/V
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25
Q

Pathophys of mastitis

A

Occurs d/t ineffective and/or obstructed drainage of milk from the breast.
Infectious mastitis results from untreated milk stasis and/or colonization with pathogenic bacteria. bacteria may be introduced from cracked or traumatised nipples.

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26
Q

Plugged ducts vs. mastitis

A

Plugged ducts

  • Lump of localized milk stasis
  • can be resolved with frequent feeding to empty breast, positioning infant’s chin toward blocked area, manual massage and warm water soaks
  • may occur w/ painful white bleb on the nipple
  • no fever or systemic s/s

Mastitis

  • erythematous breast, painful, may be accompanied by systemic s/s
  • not resolved w/ adequate emptying
27
Q

Mastitis management

A
  • Breast support– Complete, frequent emptying of affected breast, assist with nursing technique, warm compresses or warm shower
  • Appropriate intake of fluids

Antibiotic Tx
1st line tx:
- Dicloxacillin (dynapen) 500mg 4x/day for 10-14 days
- Cephalexin (keflex) 500mg 4x/day for 10-14 days
OR if PCN allergy – clindamycin 300mg 4x/day or erythromycin 250mg (or 500mg) 4x/day for 10-14 days

  • When to send milk culture & consult
  • If s/s don’t resolve within 48 hrs of initiating abx
  • s/s worsen despite tx
  • maternal acute illness
  • high suspicion of MRSA
  • bilateral mastitis
  • Infant may need to be treated concurrently, particularly if infxn with group A or group B strep suspected.
  • Recurrent mastitis - culture and treat as appropriate for 14-30 days
  • Rarely, persistent unresolved mastitis may be an early sign of inflammatory carcinoma
28
Q

What is a breast abscess?

A

Localized collection of pus in the breast. Infecting organism is most often S. aureus, MRSA is increasingly common

29
Q

Dx and Tx

A

Dx: by phys exam & US

Treatment:
- MD referral, may be collaboratively managed by midwife
- Surgical drainage or needed aspiration
- Antibiotics may be recommended (same tx as mastitis)
- Dicloxacillin (dynapen): 500mg PO 4x/day for 10-14 days
Or Cephalexin (keflex): 500mg PO 4x/day for 10-14 days

30
Q

S/S postpartum UTI

A

May present with classic symptoms, but postpartum women w/ upper or lower UTIs often present with fever and generalized s/s, w/o dysuria, frequency or urgency.
therefore any woman w/ fever postpartum should be eval’d for UTI

31
Q

Tx postpartum UTI

A
  • Nitrofurantoin (Macrobid) 50-100mg PO q6h x 5d
    Ok for lactating mothers of infants > 8d old, but consider other drugs if G6PD
  • Sulfa-trimethoprim (Bactrim) 800/160mg PO BID x 3d
    Ok to use in lactating mothers w/FT, healthy infants, consider other alternatives if infant is jaundiced or premature, or w/G6PD
  • Fosfomycin (Monurol) 3g PO x 1
    Low levels in milk, ok for lactating mother
32
Q

Define subinvolution

A

Uterus does not return to its pre-pregnant size and position within expected time frame

  • 2 wks PP: uterus should no longer be palpated abdominally
  • 6 wks PP: involution should be complete
33
Q

predisposing factors of subinvolution

A

Retained placental fragments, leiomyomas, infection

May occur from excessive maternal activity

34
Q

S/S of subinvolution

A
  • New onset bleeding or hemorrhage, often occurs during 2nd wk PP. Can present as increase or return of lochia rubra, or frank hemorrhage * for abnormal PP bleeding US may be useful to detect retained tissue or clot
  • During bimanual exam uterus is larger and softer than expected
35
Q

Management of subinvolution

A

If abnormal postpartum bleeding, perform US to assess if retained tissue or clot

  • ->
  • if retained tissue/clot – uterine evacuation and curettage
  • if empty uterine cavity – oxytocin or methergine therapy
36
Q

Puerperal hematoma

A

localized collection of extravasated blood that is usually clotted; arises following spontaneous or traumatic rupture of a blood vessel

37
Q

Etiologies hematomas

A

Unrepaired torn blood vessels, trauma from instrumental birth, episiotomy

38
Q

Predisposing factors to puerperal hematomas

A

Primiparity, multiple gestation, LGA, PEC, coagulopathies, vulvar varicosities, prolonged second stage

39
Q

S/S vulvar & vaginal hematomas

A
  • Perineal, vaginal, urethral, bladder, or rectal pressure and severe pain; Tense, fluctuant swelling
  • Bluish or blue-black discoloration of tissue
  • Extreme pain out of proportion to the expected amount of discomfort for that time period
  • Usually sudden onset within 2-6 hours of delivery
40
Q

S/S broad ligament hematomas

A
  • Lateral, uterine pain sensitive to palpation
  • Extension of pain to flank
  • Painful swelling identified on high rectal examination
  • A ridge of tissue just above the pelvic brim extending laterally
  • Possible abdominal distension
41
Q

Subperitoneal Hematoma

A

Very rare; likely diagnosed when patient begins experiencing hypovolemic shock from unrestricted bleeding

42
Q

Management for Hematoma

A
  • Frequent VS to monitor for increase in pulse rate and RR, drop in BP, and increase in temperature

If small, likely will absorb → manage expectantly

  • Trace borders with pen to observe any change in size
  • Pain medication as needed

If large (or growing)…CONSULT a physician

  • Consider CBC and IV access if not already in place
  • Frequent VS monitoring to observe for signs of shock
  • Pain medication as needed

Possibly…

  • Vaginal packing for counter pressure (12-24 hours)
  • Incision to evacuate blood and blood clots/ensure closure of the cavity
  • Involve interventional radiology, blood replacement, or antibiotics
  • Require arterial embolization as a first or second line intervention to achieve hemostasis
  • Be careful with cold therapy. Use intermittently (10 minutes per hour) and not directly on skin for best practice
43
Q

Subsequent risks of puerperal hematomas

A

Subsequent risks include - Hemorrhage, Anemia, Infection, Hypovolemic shock

44
Q

Why assess for puerperal hematoma w/ perineal/vulva exam during PP rounds?

A

Some hematomas will act inconspicuously so thorough examination of the vagina and the perineum/vulva (and possibly a rectal exam) may allow for earlier detection of hematomas and decrease risk of subsequent issues

45
Q

Predisposing factors for VTE

A
  • Pregnancy itself
  • previous VTE
  • family hx of VTE
  • inherited thrombophilia
  • diabetes
  • autoimmune inflammatory disorders
  • age greater than 35
  • BMI >30
  • varicose veins
  • multifetal gestation
  • hospitalization
46
Q

Dx of VTE

A

venous doppler US

47
Q

Describe pelvic venous thrombosis & management

A
  • Blood clot in a pelvic vein.
  • Often asymptomatic, incidence upwards of 30% in NSVD, and 47% in C/S
  • Asymptomatic pelvic venous thrombosis is almost always not an issue, but in rare cases can be life threatening.
  • if a thrombus is found incidentally, should be treated with some sort of thromboprophylaxis
  • May need MRI to confirm if suspected; difficult to see with U/S during pregnancy
48
Q

Management of PP venous thrombosis

A
  • IV heparin and oral warfarin simultaneously; larger doses are often necessary in the PP period to achieve target INR of 2-3; will need 6 months of anticoagulation
  • Will often need to wear graduated compression stockings for 2 years post treatment to avoid postthrombotic syndrome (chronic leg paresthesias or pain, intractable edema, skin changes, and leg ulcers)
  • Therapeutic mgmt that we can encourage:
    rest, elastic support, elevation of LE to improve venous return, warm packs, BR then ambulate once s/sx disappear, avoid standing for long periods of time, wear TEDS hose
    Avoid pillow behind knees (causes pooling)
49
Q

Management of PP venous thrombosis

A
  • IV heparin + oral warfarin simultaneously
  • Will often need to wear graduated compression stockings for 2 years post tx to avoid postthrombotic syndrome (chronic leg paresthesias or pain, intractable edema, skin changes, and leg ulcers)
  • Therapeutic mgmt that we can encourage:
    rest, elastic support, elevation of LE to improve venous return, warm packs, BR then ambulate once s/sx disappear, avoid standing for long periods of time, wear TEDS hose
    Avoid pillow behind knees (causes pooling)
50
Q

Risks for septic pelvic thrombophlebitis

A
  • c/s
  • chorioamnionitis
  • endometritis
  • wound complications
51
Q

Tx and prevention

A
  • Tx: abx

- Prevention: fewer C/S, DVT prophylaxis, abx prophylaxis

52
Q

Define pulmonary embolism

A

Blockage of artery in lung by clot that has been dislodged from elsewhere in the body (complication of DVT)

53
Q

S/S pulmonary embolism

A

Dyspnea, sudden/sharp chest pain, tachycardia, syncope, tachypnea, pulmonary rales, cough, hemoptysis, low O2 sats, CXR shows atelectasis and pleural effusion

54
Q

Tx pulmonary embolism

A

EMERGENCY. Go to ER!
- O2 by tight face mask to decrease hypoxia
- Bed rest w/HOB elevated to reduce dyspnea
- Analgesics for pain
(there were more on her slide….)
- Thrombolytic therapy (IV heparin)

55
Q

PP thyroiditis (incidence, risk factors, s/s)

A

Incidence: 1.1-16.7%

Risk factors: 
GDM 
Autoimmune disorders (ie. T1DM, previous thyroid dysfunction, hx of thyroid disorders) 
Family hx of thyroid disease 
Presence of goiter

S/S:
Can present as
1. Transient hypothyroidism
(4-8 months PP)
Constipation, depression, dry skin, fatigue, goiter, impaired concentration
*similar to normal PP changes and those with PP mood disorders.
2. Transient hyperthyroidism
(occurs 1-4 months PP)
Anxiety, fatigue, goiter, heat intolerance/sweats, insomnia, irritability, weight loss
3. Hyperthyroidism followed by hypothyroidism, and then recovery.

Associated with PP depression

56
Q

Postpartum thyroiditis Dx

A

Dx:
- Can occur anytime during the 1st year PP
Labs:
Hyperthyroidism: low TSH, positive for TPO, neg TSHRAb (TSH receptor antibodies)
Hypothyroidism: high TSH, positive for antithyroid peroxidase antibodies

57
Q

Postpartum thyroiditis TX

A

Tx:

  • If s/s mild - no treatment needed
  • Hyperthyroidism s/s if bothersome – beta blockers
  • Hypothyroidism if s/s - synthroid
  • MD consult
  • Long term follow up strongly advised – up to 50% of pts will develop permanent hypothyroidism in 5-10 years
58
Q

Describe Graves disease and course in the postpartum period

A
  • autoimmune disorder, most common cause of hyperthyroidism
  • most common cause of thyrotoxicosis in pregnancy
  • Graves hyperthyroidism may recur after delivery with an exacerbation in the 1st 3 months or between 6-12 months PP. S/s in grave’s disease more severe than pt’s with postpartum thyroiditis.
  • The late postpartum period is associated with risk of developing graves disease de novo
59
Q

Graves disease risk factors

A

Hx of or active grave’s disease during pregnancy or a thyrotoxic phase in early pregnancy at inc’d risk

60
Q

Graves disease s/s & clinical course

A

Exacerbation of hyperthyroidism
Opthalmopathy
Visible goiter
Bruit

61
Q

Graves disease dx

A
  • Undetected TSH, high T4, TRAb positive
  • 4 or 24hr thyroid radioactive iodine uptake (RAIU) (contraindicated w/ breastfeeding) – will be high normal or elevated with recurrent hyperthyroidism d/t Graves disease
62
Q

Graves disease Tx

A

MD consult
Anti-thyroid medications– PTU, methimazole
Beta blockers help w/ symptoms
May advise ablation therapy

63
Q

Sheehan’s syndrome

A
  • pituitary ischemia and necrosis associated with obstetrical blood loss → hypopituitarism
  • rare
  • s/s: Persistent hypotension, tachycardia, hypoglycemia, lactation failure, amenorrhea or oligomenorrhea
  • dx: check pituitary hormone labs. check for adrenal insufficiency as well, life threatening complication of Sheehan’s
  • tx: glucocorticoid replacement tx, lifelong hormone replacement tx

IP Exam 3 (3 decks)

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