Disorders in the puerperium

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 10/03/2015

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Chapter 23 Disorders in the puerperium

CHAPTER CONTENTS

Postpartum haemorrhage 183

Primary postpartum haemorrhage (PPH) 183
Secondary postpartum haemorrhage 185
Puerperal infection 185

Site and spread of the infection 186
Diagnosis 186
Treatment 186
Thromboembolism 186

Diagnosis of deep vein thrombosis (DVT) 186
Diagnosis of pulmonary embolism 186
Treatment 187
Long-term consequences of DVT 187
Postpartum psychiatric problems 187

Third-day blues 187
Postnatal non-psychotic depression 187
Postnatal psychotic depression 188

POSTPARTUM HAEMORRHAGE

Primary postpartum haemorrhage is a blood loss per vaginam of more than 500 mL in the first 24 hours after birth. Secondary postpartum haemorrhage is defined as abnormal bleeding from 24 hours after birth until 6 weeks postpartum.

Primary postpartum haemorrhage (PPH)

Recently many centres are reporting an increase in the rates of postpartum haemorrhage. The reasons for this are not resolved but factors such as increased operative deliveries, multiple pregnancies, obesity and changes in obstetric practice including longer duration of labour and delays in administering prophylactic oxytocics have been postulated as possible contributors.

Aetiology

In normal labour, following the birth of the baby a blood loss of 200–600 mL occurs before myometrial retraction, supplemented by strong uterine contractions. This causes shortening and kinking of the uterine blood vessels and a retraction of the placental bed. These changes prevent further blood loss (Fig. 23.1). Some discussion arises as to whether this traditional quantity of blood loss is an underestimate, when blood loss is measured accurately. Provided the blood loss is less than 800 mL, the woman should have no problems.

image

Fig. 23.1 ‘Living tourniquet’ of contracted uterine muscle. (A) Uterine muscle fibres relaxed. (B) Contraction of muscle fibres restricts blood flow through the uterine vessels.

If the uterus does not contract effectively (atonic uterus) or if placental remnants prevent good placental site retraction, haemorrhage may occur (‘an empty contracted uterus does not bleed!’). These two causes account for 80% of cases of PPH.

In 20% of cases the cause of bleeding is a laceration of the genital tract, usually of the vagina or cervix, but rarely following uterine rupture (see p. 180). In a few instances PPH follows a blood coagulation defect, such as may occur following abruptio placentae.

PPH is more likely to occur following a prolonged labour; overdistension of the uterus (multiple pregnancy or polyhydramnios); antepartum haemorrhage; with operative deliveries, and deep general anaesthesia. In these cases action is taken to prevent PPH: either prophylactic oxytocics are given following the birth or, if the third stage is managed traditionally, ‘fundal fiddling’ is avoided. If an oxytocic is not routinely administered, the PPH rate is quadrupled to 16%.

Diagnosis

The diagnosis is usually obvious, excessive blood loss occurring before the placenta has been delivered (third-stage bleeding) or following its expulsion. After delivery of the placenta, blood may clot inside the uterus and not be expelled, causing the fundus to rise in the abdomen; if a contraction is rubbed up, the uterus contracts and the clots are expelled. The bleeding tends to be intermittent, as the uterus contracts periodically.

Management

PPH must be dealt with expeditiously, as it is a cause of maternal death. The management differs depending on whether the placenta is still in the uterus or if it has been expelled.

Third-stage bleeding (placenta in the uterus)

Two stages are involved:

• A contraction is rubbed up and fundal pressure combined with controlled cord traction is generated with the aim of delivering the placenta. If bleeding continues in spite of a contracted uterus, the lower vaginal tract should be inspected to see if there is any damage.
• If the placenta cannot be delivered or if, when it is delivered, inspection shows that it is incomplete, the uterine cavity must be explored. Unless the patient already has an epidural anaesthetic, a general anaesthetic is given and manual removal of the placenta is effected by inserting a gloved hand into the uterine cavity and controlling its actions with the other hand placed on the fundus (Fig. 23.2). The umbilical cord is followed to its insertion and the lower placental edge is identified. With the palm of the intra-uterine hand facing the uterine cavity, the obstetrician separates the placenta from its attachments with a sawing motion. When the placenta has been completely detached, the remainder of the uterine cavity is explored for further placental remnants and damage. This completed, the placenta is grasped by the hand in the uterus and the membranes are pulled out of the birth canal while the external hand massages the fundus. The placenta is inspected carefully to ensure that it is complete. Ergometrine 0.5 mg is then injected intravenously and 0.5 mg is given intramuscularly.
image

Fig. 23.2 Manual removal of the placenta.

True postpartum haemorrhage (placenta expelled)

Several stages are involved:

• Check the placenta to determine if it is complete.
• Massage the uterus with a slow, rotary movement.
• Set up an infusion of Hartmann’s solution and give 0.25 mg of ergometrine intravenously or Syntocinon by continuous infusion (10 IU in 500 mL Hartmann’s solution). Alternatives are Syntometrine or misoprostol 800 μg given rectally. As Syntometrine is contraindicated if the mother has hypertension, misoprostol may be preferred. In cases of severe PPH (a loss estimated at over 1000 mL) due to a hypotonic uterus, carboprost (15-methyl-PGF2α

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