postpartum complications
TRANSCRIPT
Postpartum ComplicationsPostpartum Complications
Nori Y. Buising MDNori Y. Buising MD
LTC, MCLTC, MC
ObjectivesObjectives
Recognize common and potentially life-Recognize common and potentially life-threatening postpartum complicationsthreatening postpartum complications– Postpartum hemorrhagePostpartum hemorrhage– Postpartum endometritisPostpartum endometritis– Peripartum cardiomyopathyPeripartum cardiomyopathy– Postpartum thyroiditisPostpartum thyroiditis– Postpartum depressionPostpartum depression
Direct the initial management of the ill Direct the initial management of the ill postpartum patientpostpartum patientKnow the appropriate threshold for consultation Know the appropriate threshold for consultation with specialistwith specialist
Postpartum HemorrhagePostpartum Hemorrhage
Obstetrical emergency that can follow vaginal or Obstetrical emergency that can follow vaginal or cesarean deliverycesarean delivery
Incidence – 3% of birthsIncidence – 3% of births
33rdrd most common cause of maternal death in US most common cause of maternal death in US
DefinitionDefinition– Excessive bleeding that makes the patient Excessive bleeding that makes the patient
symptomatic (lightheaded, syncope) and/or results in symptomatic (lightheaded, syncope) and/or results in signs of hypovolemia (hypotension, tachycardia, signs of hypovolemia (hypotension, tachycardia, oliguria)oliguria)
Board ReviewBoard Review
Which of the following is the most common Which of the following is the most common cause of postpartum hemorrhage?cause of postpartum hemorrhage?– A. primigravida birthA. primigravida birth– B. retained placentaB. retained placenta– C. uterine atonyC. uterine atony– D. uterine ruptureD. uterine rupture– E. lacerations of the cervixE. lacerations of the cervix
Causes of Postpartum HemorrhageCauses of Postpartum Hemorrhage
Four TsFour Ts CauseCause Approximate Approximate incidence (%)incidence (%)
ToneTone Atonic uterusAtonic uterus 7070
TraumaTraumaLacerations, Lacerations, hematomas, hematomas, inversion, ruptureinversion, rupture
2020
TissueTissue Retained tissue, Retained tissue, invasive placentainvasive placenta 1010
ThrombinThrombin CoagulopathiesCoagulopathies 11
Postpartum HemorrhagePostpartum Hemorrhage
Risk FactorsRisk Factors– Prolonged 3Prolonged 3rdrd stage of labor stage of labor– Fibroids, placenta previaFibroids, placenta previa– Previous PPHPrevious PPH– Overdistended uterusOverdistended uterus– EpisiotomyEpisiotomy– Use of magnesium sulfate, preeclampsiaUse of magnesium sulfate, preeclampsia– Induction or augmentation of laborInduction or augmentation of labor
PPH - ManagementPPH - Management
Swift execution of a sequence of interventions Swift execution of a sequence of interventions with prompt assessment of responsewith prompt assessment of responseInitial stepsInitial steps– Fundal massageFundal massage– ABCs, O2, IV access with 16g cathetersABCs, O2, IV access with 16g catheters
Infuse crystalloid; transfuse blood products as neededInfuse crystalloid; transfuse blood products as needed– Examine genital tract, inspect placenta, observe Examine genital tract, inspect placenta, observe
clottingclotting– Give uterotonic drugsGive uterotonic drugs
Oxytocin 20 IU per L of NSOxytocin 20 IU per L of NSCarboprost (Hemabate) 250mcg IM q15-90min up to 2mg Carboprost (Hemabate) 250mcg IM q15-90min up to 2mg Methylergonovine (Methergine) 0.2mg IM q2-4hMethylergonovine (Methergine) 0.2mg IM q2-4hMisoprostol 800 or 1000mg PRMisoprostol 800 or 1000mg PR
Uterotonic Agents for PPHUterotonic Agents for PPH
OxytocinOxytocin
(Pitocin)(Pitocin)
10 units/ml10 units/ml
Dilute 20-Dilute 20-40 units in 40 units in 1 L NS1 L NS
10 IU IM10 IU IM
IVIV
IMIM
ContinuousContinuous
Infusion, Infusion, 250 ml/hr250 ml/hr
Nausea, vomitingNausea, vomiting
Water intox with Water intox with prolonged IV useprolonged IV use
Hypersensitivity to Hypersensitivity to the drugthe drug
Room Room temptemp
CarboprostCarboprost
(Hemabate)(Hemabate)
15-methyl PG 15-methyl PG F2aF2a
0.25 mg/ml0.25 mg/ml
0.25 mg0.25 mg IMIM
IMMIMM
Q 15-90 min Q 15-90 min not to not to exceedexceed
8 doses8 doses
Nausea, vomitingNausea, vomiting
DiarrheaDiarrhea
Fever/ChillsFever/Chills
HAHA
HypertensionHypertension
BronchoconstrictionBronchoconstriction
Hypersensitivity to Hypersensitivity to the drugthe drug
Use with caution Use with caution in patients with in patients with HTN or asthmaHTN or asthma
RefrigRefrig
Methylergon-Methylergon-ovineovine
(Methergine)(Methergine)
0.2 mg/ml0.2 mg/ml
0.2 mg0.2 mg IMIM Q 10 min x Q 10 min x 22
Q 2 – 4 hrsQ 2 – 4 hrs
Nausea, vomitingNausea, vomiting
Hypertension, esp Hypertension, esp in pts with PIH or in pts with PIH or chronic HTNchronic HTN
HypotensionHypotension
HypertensionHypertension
PreeclampsiaPreeclampsia
Hypersensitivity to Hypersensitivity to the drugthe drug
RefrigRefrig
Protect Protect from lightfrom light
MisoprostolMisoprostol
(Cytotec)(Cytotec)
100 and 200 100 and 200 mcg tabsmcg tabs
600-1000 600-1000 mcgmcg
PRPR Single doseSingle dose Nausea, vomitingNausea, vomiting
ShiveringShivering
FeverFever
DiarrheaDiarrhea
Hypersensitivity to Hypersensitivity to the drugthe drug
Room Room temptemp
Drug Dose Route Freq Side Effects Contraind. StoreDrug Dose Route Freq Side Effects Contraind. Store
ManagementManagement
Secondary stepsSecondary steps– Will likely require regional or general anesthesiaWill likely require regional or general anesthesia– Evaluate vagina and cervix for lacerationsEvaluate vagina and cervix for lacerations– Manually explore uterusManually explore uterus
Treatment optionsTreatment options– Repair lacerations with running locked #0 absorbable sutureRepair lacerations with running locked #0 absorbable suture– TamponadeTamponade– Arterial embolizationArterial embolization– LaparotomyLaparotomy
uterine vessel ligationuterine vessel ligationB-Lynch sutureB-Lynch suture
– HysterectomyHysterectomy
PPH – Preventive MeasuresPPH – Preventive Measures
correcting anemia prior to deliverycorrecting anemia prior to delivery
episiotomies only if necessaryepisiotomies only if necessary
active management of third stageactive management of third stageNNT to prevent 1 case of PPH = 12NNT to prevent 1 case of PPH = 12
assess patient after completion of assess patient after completion of paperwork to detect slow steady bleedspaperwork to detect slow steady bleeds
Postpartum EndometritisPostpartum Endometritis
Infection of the decidua (pregnancy Infection of the decidua (pregnancy endometrium)endometrium)IncidenceIncidence– <3% after vaginal delivery<3% after vaginal delivery– 10-50% after cesarean delivery10-50% after cesarean delivery
5-15% after scheduled elective cesareans5-15% after scheduled elective cesareans
Risk FactorsRisk Factors– Prolonged labor, prolonged ROM, multiple vaginal Prolonged labor, prolonged ROM, multiple vaginal
exams, internal monitors, maternal DM, meconium, exams, internal monitors, maternal DM, meconium, manual removal of placenta, low socioeconomic manual removal of placenta, low socioeconomic statusstatus
PP EndometritisPP Endometritis
Polymicrobial, ascending infectionPolymicrobial, ascending infection– Mixture of aerobes and anaerobes from genital tractMixture of aerobes and anaerobes from genital tract– BV and colonization with GBS increase likelihood of BV and colonization with GBS increase likelihood of
infectioninfection
Clinical manifestations (occur within 5 days pp)Clinical manifestations (occur within 5 days pp)– Fever – most common signFever – most common sign– Uterine tendernessUterine tenderness– Foul lochiaFoul lochia– LeukocytosisLeukocytosis– Bacteremia – in 10-20%, usually a single organismBacteremia – in 10-20%, usually a single organism
PP EndometritisPP Endometritis
WorkupWorkup– CBCCBC– Blood culturesBlood cultures– Urine cultureUrine culture– DNA probe for GC/chlamydiaDNA probe for GC/chlamydia– Imaging studies if no response to adequate Imaging studies if no response to adequate
abx in 48-72habx in 48-72hCT scan abd/pelvisCT scan abd/pelvis
US abd/pelvisUS abd/pelvis
PP EndometritisPP Endometritis
TreatmentTreatment– Broad spectrum IV abx Broad spectrum IV abx
Clindamycin 900mg IV q8h and Clindamycin 900mg IV q8h and Gentamicin 1.5mg/kg IV q8hGentamicin 1.5mg/kg IV q8h
– Treat until afebrile for 24-48h and clinically improved; Treat until afebrile for 24-48h and clinically improved; oral therapy not necessaryoral therapy not necessary
– Add ampicillin 2g IV q4h to regimen when not Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococciimproving to cover resistant enterococci
PreventionPrevention– Abx prophylaxis for women undergoing C-sectionAbx prophylaxis for women undergoing C-section
Cefazolin 1-2g IV as single doseCefazolin 1-2g IV as single dose
Peripartum CardiomyopathyPeripartum Cardiomyopathy
Rare cause of heart failure in late pregnancy or Rare cause of heart failure in late pregnancy or early puerperiumearly puerperium
DefinitionDefinition– Development of heart failure in last month of Development of heart failure in last month of
pregnancy or within 5 mos of deliverypregnancy or within 5 mos of delivery– No identifiable cause for the failureNo identifiable cause for the failure– No history of heart disease prior to the last month of No history of heart disease prior to the last month of
pregnancypregnancy– Left ventricular systolic dysfunctionLeft ventricular systolic dysfunction
LVEF <45%LVEF <45%
Peripartum CardiomyopathyPeripartum Cardiomyopathy
Incidence – 1:3000 to 1:4000Incidence – 1:3000 to 1:4000
Unknown etiologyUnknown etiology– Potential contributors:Potential contributors:
HormonesHormones
Inflammatory cytokines (TNF-alpha and IL-6)Inflammatory cytokines (TNF-alpha and IL-6)
MyocarditisMyocarditis
Abnormal immune responseAbnormal immune response
Genetic and/or environmental factorsGenetic and/or environmental factors
PPCM – Risk FactorsPPCM – Risk Factors
Age > 30Age > 30MultiparityMultiparityMultiple fetusesMultiple fetusesWomen of African descentWomen of African descentHistory of PIHHistory of PIHMaternal cocaine abuseMaternal cocaine abuseOral tocolytics with beta adrenergic Oral tocolytics with beta adrenergic agonists > 4 weeksagonists > 4 weeks
PPCM - DiagnosisPPCM - Diagnosis
ECGECG
CXRCXR
EchocardiogramEchocardiogram
Viral and bacterial culturesViral and bacterial cultures
Cardiology referralCardiology referral– Cardiac catheterizationCardiac catheterization– Endomyocardial biopsyEndomyocardial biopsy
PPCM - TreatmentPPCM - Treatment
Similar to treating other types of HFSimilar to treating other types of HFDigoxinDigoxinDiureticsDiureticsVasodilator – hydralazineVasodilator – hydralazineBeta blockers – beta-1 selectiveBeta blockers – beta-1 selectiveClass III antiarrhythmicsClass III antiarrhythmicsAnticoagulationAnticoagulation– heparin if pre-delivery (due to short half-life & heparin if pre-delivery (due to short half-life &
reversibility), but may use Coumadin during 3reversibility), but may use Coumadin during 3 rdrd trimester & postpartum, w/ INR goal of 2.0 to 2.5trimester & postpartum, w/ INR goal of 2.0 to 2.5
PPCM - TreatmentPPCM - Treatment
IVIG showed increase in LVEF in small IVIG showed increase in LVEF in small studystudy
Heart transplantationHeart transplantation– If conventional therapy not successfulIf conventional therapy not successful– Should avoid future pregnancyShould avoid future pregnancy
Postpartum ThyroiditisPostpartum Thyroiditis
A variant form of Hashimoto’s thyroiditis A variant form of Hashimoto’s thyroiditis occurring within 1 year after parturitionoccurring within 1 year after parturitionIncidence – 3-16% of postpartum womenIncidence – 3-16% of postpartum women– Up to 25% in women with Type 1 DMUp to 25% in women with Type 1 DM
Most have high serum levels of anti-Most have high serum levels of anti-peroxidase Abperoxidase AbThyroid inflammation damages follicles Thyroid inflammation damages follicles proteolysis of thyroglobulin proteolysis of thyroglobulin release of release of T3 + T4 T3 + T4 TSH suppression TSH suppression
Postpartum ThyroiditisPostpartum Thyroiditis
Clinical manifestationsClinical manifestations– 20-30%20-30%
Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, Hyperthyroidism 2-4 mos pp, lasting 2-8 wks, followed by hypothyroidism, lasting 2-8 wks, then followed by hypothyroidism, lasting 2-8 wks, then recoveryrecovery
– 20-40%20-40%Hyperthyroidism onlyHyperthyroidism only
– 40-50%40-50%Hypothyroidism only, beginning 2-6 mos ppHypothyroidism only, beginning 2-6 mos pp
Postpartum ThyroiditisPostpartum Thyroiditis
Symptoms and signs, when present, are Symptoms and signs, when present, are mildmild– Hyperthyroidism Hyperthyroidism
Anxiety, weakness, irritability, palpitations, Anxiety, weakness, irritability, palpitations, tachycardia, tremortachycardia, tremor
– HypothyroidismHypothyroidismLack of energy, sluggishness, dry skinLack of energy, sluggishness, dry skin
DiagnosisDiagnosis– Small, diffuse, nontender goiter or normal Small, diffuse, nontender goiter or normal
examexam
PP ThyroiditisPP Thyroiditis
Diagnosis contd.Diagnosis contd.– No ophthalmopathyNo ophthalmopathy– High or high normal T3 + T4, low TSH, low High or high normal T3 + T4, low TSH, low
radioiodine uptake (hyper phase)radioiodine uptake (hyper phase)– Low or low normal T4, high TSH (hypo phase)Low or low normal T4, high TSH (hypo phase)
65-85% have high antithyroid Abs65-85% have high antithyroid Abs
PP ThyroiditisPP Thyroiditis
TreatmentTreatment– Most need no treatment unless have Most need no treatment unless have
bothersome sxbothersome sxHyper: atenolol or propanololHyper: atenolol or propanolol
– Avoid in nursing womenAvoid in nursing women
Hypo: levothyroxine 50-100 mcg qd for 8-12 wks, Hypo: levothyroxine 50-100 mcg qd for 8-12 wks, discontinue, re-eval in 4-6 wksdiscontinue, re-eval in 4-6 wks
Educate patient on sx, increased risk of developing Educate patient on sx, increased risk of developing hypothyroidism or goiter, likely recurrence with hypothyroidism or goiter, likely recurrence with subsequent pregnanciessubsequent pregnancies
Board ReviewBoard Review
Which of the following statements about Which of the following statements about postpartum depression is true?postpartum depression is true?– A. Postpartum depression usually occurs 9 to 12 A. Postpartum depression usually occurs 9 to 12
months after delivery.months after delivery.– B. Social support has little impact on the development B. Social support has little impact on the development
of postpartum depression.of postpartum depression.– C. Those with obstetric complications are at increased C. Those with obstetric complications are at increased
risk.risk.– D. Those affected are at increased risk for postpartum D. Those affected are at increased risk for postpartum
depression with subsequent pregnanciesdepression with subsequent pregnancies– E. Patients who have postpartum depression have no E. Patients who have postpartum depression have no
higher risk of developing depression in later years higher risk of developing depression in later years when compared to the general population.when compared to the general population.
Postpartum DepressionPostpartum Depression
Most common complicationMost common complication– Occurs in 13% (1 in 8) of women after pregnancyOccurs in 13% (1 in 8) of women after pregnancy– Recurs in 1 in 4 with prior depressionRecurs in 1 in 4 with prior depression– Begins within 4 weeks after deliveryBegins within 4 weeks after delivery
Multifactorial etiologyMultifactorial etiology– Rapid decline in hormones, genetic susceptibility, life Rapid decline in hormones, genetic susceptibility, life
stressorsstressors
Risk FactorsRisk Factors– Prior h/o depression, family h/o mood disorders, Prior h/o depression, family h/o mood disorders,
stressful life eventsstressful life events
Postpartum DepressionPostpartum Depression
Pattern of sx are similar to other episodes of Pattern of sx are similar to other episodes of depressiondepression– Depressed mood, anxiety, loss of appetite, sleep Depressed mood, anxiety, loss of appetite, sleep
disturbance, fatigue, guilt, decreased concentrationdisturbance, fatigue, guilt, decreased concentration– Must be present most of the day nearly every day for Must be present most of the day nearly every day for
2 wks2 wksNot a separate dx from depression in DSM-IV; “postpartum Not a separate dx from depression in DSM-IV; “postpartum onset specifier” is used for mood d/o within 4 wks pp onset specifier” is used for mood d/o within 4 wks pp
ScreeningScreening– Edinburgh Postnatal Depression ScaleEdinburgh Postnatal Depression Scale– + screen with score >/= 10+ screen with score >/= 10– r/o anemia and thyroid diseaser/o anemia and thyroid disease
PP DepressionPP Depression
Differential DiagnosisDifferential Diagnosis– Baby Blues – common, transient mood disturbanceBaby Blues – common, transient mood disturbance
Sadness, weeping, irritability, anxiety, and confusionSadness, weeping, irritability, anxiety, and confusion
Occurs in 40 - 80% of postpartum womenOccurs in 40 - 80% of postpartum women
Sx peak 4Sx peak 4thth – 5 – 5thth day pp and resolve by 10 – 14 days day pp and resolve by 10 – 14 days
– Postpartum psychosisPostpartum psychosisPsychiatric emergency due to risk of infanticide or suicidePsychiatric emergency due to risk of infanticide or suicide
Bizarre behavior, disorganization of thought, hallucinations, Bizarre behavior, disorganization of thought, hallucinations, delusionsdelusions
usually occurs in first 2 weeks ppusually occurs in first 2 weeks pp
PP DepressionPP Depression
TreatmentTreatment– SSRIs are first-line drugsSSRIs are first-line drugs
Initiate at half the usual starting doseInitiate at half the usual starting doseTreat for at least 6 – 12 months after full remission to prevent Treat for at least 6 – 12 months after full remission to prevent relapserelapseSertraline or paroxetine for breast-feeding mothersSertraline or paroxetine for breast-feeding mothers
– May also respond to psychotherapyMay also respond to psychotherapy– Hormonal therapy??Hormonal therapy??
Patient resourcesPatient resources– National Women’s Health Info Center (National Women’s Health Info Center (
www.4woman.govwww.4woman.gov))– www.depressionafterdelivery.comwww.depressionafterdelivery.com