Postpartum Complications

Postpartum Complications

·        Maternal mortality used to be mainly due to PPH and puerperal fever, now PE is the biggest cause

Definitions of Perinatal and Maternal Mortality

·        Perinatal mortality = death of a fetus after 20^th week or > 500 gm through to the time of delivery + death in first week 

o   Born dead = late fetal death

o   Death in first week = early neonatal death 

o   Perinatal mortality rate (PMR) = (LFD + ENND)/1000 live births. In NZ is 6 – 8 per 1,000. Varies from region to region

·        Reasons for perinatal death:

o  Hypoxia (eg placenta separated, maternal hypertension)

o  Prematurity

o  Congenital abnormality (eg heart defect, spina bifida)

o  Trauma (eg difficult birth)

·        Maternal Death: 

o  Death associated with pregnancy or trophoblastic disease up to 3 months after the event (required to be reported to Medical Officer of Health)

o  Causes:

§  Obstetric causes – 70%.  Includes DVT/PE, hypertension, anaesthetic death, haemorrhage

§  Associated medical deaths (eg asthma, heart disease)

§  Associated malignancy (eg breast cancer)

§  Suicide/homicide

Postpartum haemorrhage (PPH)

·        Primary PPH:

o  = Loss of > 500 ml < 24 hours after delivery

o  Limitations: estimating loss is difficult and loss may be concealed

o  Causes:

§  Uterine atony (90%).  Eg in anything that causes large uterus – twins, polyhydramnios, etc

§  Genital tract trauma during delivery (7%)

§  Coagulation defect

o  Management:

§  Resuscitate mother.  Test bloods for coagulopathy

§  Rub up a contraction + IV oxytocics

§  Deliver placenta and inspect for completeness

§  Inspect genital tract for trauma.  Eg vaginal lacerations, ruptured uterus 

§  If bleeding continues Þ uterine atony. IM prostaglandins + other procedures

·        Secondary PPH:

o  = Loss of any volume of blood > 24 hours and < 6 weeks post delivery.  Usually 1 – 2 weeks after

o  Cause: retained placenta/clot, often infected

o  Risk factors: abnormal placentation or accessory lobes on placenta 

o  Diagnosis: Ultrasound +/- signs of infection: fever, tender uterus, offensive lochia (discharge after delivery)

o  Management: curettage with US guidance + antibiotics (Broad spectrum + anaerobic cover)

·        Pharmacology: 

o  Syntocinon: action lasts 20 – 30 minutes, causes hypotension, H2O retention, contraindicated in CV disease (eg pre-eclampsia). Used for labour induction or augmentation 

o  Ergot alkaloids (eg Ergometrine). For PPH. Causes hypertension and vomiting. Contraindicated in hypertension. 

o  Prostaglandin F2a.  IM for PPH.  Contraindicated in Asthma, CV disease

·        Sequalae: 

o  Massive bleed ® shock and death

o  Puerperal anaemia and morbidity 

o  Sheehan‟s syndrome: ischaemia of anterior lobe of pituitary ® pan-pituitary insufficiency

o  Fear of further pregnancies

·        Prophylaxis:

o  Active management of 3^rd stage

o  Elective C-section if placenta praevia

o  50% risk next time, reduces to 20% if active management

o  If at risk, then have active management of 3^rd stage labour, have wide bore cannula in place and specialist backup available

Puerperal Fever

·        Puerperium 

o  = Time in which reproductive organs return to their pre-pregnant state – usually 6 weeks after delivery 

o  Uterus involutes from 1 kg to 100 gm.  Pelvic organ by ~10 days

o  Lochia: red for day 1 – 3, yellow next 10 days, white until 6 weeks 

·        Puerperal Pyrexia = temperature of at least 38 C on any 2 of the first 14 days after abortion or delivery, exclusive of the first 24 hours

·        Incidence:

o   After vaginal delivery: 1 – 3 %

o   After Caesarean: ~10%

·        Pathogenesis: assume infection until proven otherwise. Can deteriorate quickly – need rapid assessment

·        Sources:

o   Clots, retained placenta, etc can facilitate growth

o   Generally an ascending infection

o   Lower genital tract (eg anaerobes).

o   Bowel: E. Coli and G –ive

o   Attendants: staph and haemolytic strep

o   Environment or partner

·        Severity is related to:

o   Bacterial factors: virulence, resistance, etc

o   Host: general health, immune status

o   Pregnancy related: duration of labour post-ROM, invasive examinations

·        Causes:

o   Endometritis (uterine infection):

§  Most common cause 

§  Fever, uterine tenderness on abdominal palpation, foul-smelling lochia (post-partum vaginal discharge)

§  Treat aggressively to avoid abscesses

§  Can proceed to peritonitis, septicaemia, etc 

o   Mastitis: Usually occurs 2 – 3 weeks postpartum and is associated with cellulites over the affected area. Staph Aureus is common 

o   UTI: ­risk from catheterisations, operative vaginal delivery 

o   Thrombophlebitis: 1% of women present with painful tender varicose veins. Look for DVT symptoms. ­Risk if obese, high parity, bed-bound, etc. Treat with NSAID

o   Wound and episiotomy infections

o   Respiratory tract infection, atelectasis

·        Investigations:  FBC, urine culture, high vaginal swabs

·        Management:

o   General: fluids, correct anaemia, pain relief 

o   Antibiotics: start empirical treatment immediately. CCHL protocol is IV Augmentin + Metronidazole