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Toronto Notes 2019 Puerperal Complications Obstetrics OB45
Medical Therapy
• oxytocin10IUIMispreferredinlow-riskvaginaldeliveries,oxytocinIVinfusion(20-40IUin1000 mL crystalloid at 150 mL/h) is an acceptable alternative. Oxytocin 5-10 IU IV bolus (20-40 IU in 250 mL crystalloid) can be used after vaginal birth, but not with elective C/S
• carbetocin,along-actingoxytocin,100μgIVbolusover1minforelectiveC/Sor100ugIMforvaginal deliveries with 1 risk factor for PPH (instead of a continuous oxytocin infusion)
• methylergonavinemaleate(ergotamine)0.25mgIM/IMMq15minupto1.25mg;canbegivenasIV bolus of 0.125 mg (may exacerbate HTN)
• carboprost(Hemabate®),asyntheticPGF-1αanalog,250μgIM/IMMq15mintomax2mg(major prostaglandin side effects and contraindicated in cardiovascular, pulmonary, renal, and hepatic dysfunction)
• misoprostol600-800μgPO/SL(faster)orPR/PV(sideeffect:pyrexiaif>600μg)
• tranexamicacid(Cyklokapron®),anantifibrinolytic,1gIV
Local Control
• bimanualmassage:elevatetheuterusandmassagethroughpatient’sabdomen
• uterinepacking(meshwithantibiotictreatment)
• BakriBalloonfortamponade:mayslowhemorrhageenoughtoallowtimeforcorrectionof
coagulopathy or for preparation of an OR
Surgical Therapy (Intractable PPH)
• D&C(bewareofvigorousscrapingwhichcanleadtoAsherman’ssyndrome)
• embolizationofuterinearteryorinternaliliacarterybyinterventionalradiologist
• laparotomywithbilateralligationofuterineartery(maybeeffective),ovarianartery,orhypogastric
artery, compression sutures (B-Lynch or Cho sutures)
• hysterectomylastoption,withangiographicembolizationifpost-hysterectomybleeding
Retained Placenta
Definition
• placentaundeliveredafter30minpostpartum
Etiology
• placentaseparatedbutnotdelivered
• abnormalplacentalimplantation(placentaaccreta,placentaincreta,placentapercreta)
Risk Factors
• placentaprevia,priorC/S,post-pregnancycurettage,priormanualplacentalremoval,uterineinfection
Clinical Features
• riskofpostpartumhemorrhageandinfection
Investigations
• exploreuterus
• assessdegreeofbloodloss
Management
• 2largeboreIVs,typeandscreen
• Brantmaneuver(firmtractiononumbilicalcordwithonehandapplyingsuprapubicpressurecephalad
to avoid uterine inversion by holding uterus in place)
• oxytocin10IUin20mLNSintoumbilicalvein
• manualremovalifabovefails
• D&Cifrequired(U/Sguidanceifavailable)
• cefazolin2gIVifmanualremovalorD&C
Uterine Inversion
Definition
• inversionoftheuterusthroughcervix±vaginalintroitus
Etiology/Epidemiology
• ofteniatrogenic(excesscordtractionwithfundalplacenta)
• excessiveuseofuterinetocolytics
• morecommoningrandmultiparouswomen(laxuterineligaments) • 1/1,500-1/2,000deliveries
Clinical Features
• cancauseprofoundvasovagalresponsewithbradycardia,vasodilation,andhypovolemicshock • shockmaybedisproportionatetomaternalbloodloss