Rosen & Barkin's 5-Minute Emergency Medicine Consult (568 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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MEDICATION
  • Uterotonics—stimulate uterine contraction to control bleeding:
    • Ergonovine (Ergotrate): 0.2 mg IM; avoid if known hypertensive
    • Methylergonovine (Methergine): 0.2 mg IM; 0.2 mg PO q6h; avoid if known hypertensive
    • 15-methyl PGF
      2α
      (Hemabate): 0.25 mg IM; may repeat in 15–60 min
    • Oxytocin (Pitocin): 10 U IM or 20–40 U IV in 1 L normal saline; titrate to achieve uterine contractions
  • Cervical relaxation agents facilitate uterine inversion reduction:
    • Magnesium sulfate 20%: 2 g IM bolus over 10 min
    • Terbutaline: 0.25 mg IV; avoid if hypotensive
First Line
  • Uterotonics
  • Oxytocin
  • Methylergonovine
Second Line
  • Surgical intervention:
    • Hysterectomy is required in management of PPH in 1/1,000 deliveries
  • Radiologic embolization
FOLLOW-UP
DISPOSITION
Admission Criteria
  • All patients with immediate PPH require admission to a closely monitored setting
  • Early obstetrics consultation is recommended
  • Early surgical intervention is dependent on cause
  • ICU setting if DIC or evidence of hemodynamic compromise
  • Patients with endometritis should be admitted for parenteral antibiotics
Discharge Criteria
  • Delayed PPH that is easily controlled without excessive bleeding
  • Outpatient management with methylergonovine 0.2 mg PO every 6 hr may be considered in consultation and close follow-up with obstetrician
FOLLOW-UP RECOMMENDATIONS
  • Close follow-up with obstetrician
  • Seek immediate care if bleeding recurs
PEARLS AND PITFALLS
  • Active over expectant management
    • Most deaths are due to delayed diagnosis and/or inadequate resuscitation with blood products
  • Uterotonics are the first line of treatment
  • Aggressive use of fluid and blood products for resuscitation
  • Manual exam is the preferred diagnostic approach
  • Immediate obstetric consult
ADDITIONAL READING
  • Cabero Roura L, Keith LG. Post-partum haemorrhage: Diagnosis, prevention and management.
    J Matern Fetal Neonatal Med
    . 2009;22(suppl 2):38–45.
  • Hofmeyr GJ, Gülmezoglu AM. Misoprostol for the prevention and treatment of postpartum haemorrhage.
    Best Pract Res Clin Obstet Gynaecol
    . 2008;22:1025–1041.
  • Mercier FJ, Van de Velde M. Major obstetric hemorrhage.
    Anesthesiology Clin
    . 2008;26:53–66.
  • Mousa HA, Alfirevic Z. Treatment for primary postpartum haemorrhage.
    Cochrane Database Syst Rev
    . 2007;(1):CD003249.
  • Oyelese Y, Scorza WE, Mastrolia R, et al. Postpartum hemorrhage.
    Obstet Gynecol Clin North Am
    . 2007;34:421–441.
  • Rath WH. Postpartum hemorrhage—update on problems of definitions and diagnosis.
    Acta Obstet Gyencol Scand.
    2011;90:421–428.
  • Su CW. Postpartum hemorrhage.
    Prim Care
    . 2012;39:167–187.
  • Tunçalp Ö, Hofmeyr GJ, Gülmezoglu AM. Prostaglandins for preventing postpartum haemorrhage.
    Cochrane Database Syst Rev.
    2012;8:CD000494.
See Also (Topic, Algorithm, Electronic Media Element)
  • Vaginal Bleeding
  • Placenta Previa
  • Placental Abruption
  • Pregnancy, Trauma in
  • Pregnancy, Uncomplicated
  • Labor
  • Delivery, Uncomplicated
CODES
ICD9
  • 666.00 Third-stage postpartum hemorrhage, unspecified as to episode of care or not applicable
  • 666.10 Other immediate postpartum hemorrhage, unspecified as to episode of care
  • 666.20 Delayed and secondary postpartum hemorrhage, unspecified as to episode of care or not applicable
ICD10
  • O72.0 Third-stage hemorrhage
  • O72.1 Other immediate postpartum hemorrhage
  • O72.2 Delayed and secondary postpartum hemorrhage
POSTPARTUM INFECTION
Noah White
•
Yvonne C. Chow
•
Marco Coppola
BASICS
DESCRIPTION
  • Postpartum endometritis (PPE):
    • Early PPE
      • Develops within 48 hr
      • Most often complicating C-section
      • Occurs in 1–3% of uncomplicated vaginal deliveries
      • Classic triad: Fever, lower abdominal pain with uterine tenderness, foul-smelling lochia
    • Late PPE
      • Develops 3 days–6 wk after delivery
      • Usually follows vaginal delivery
    • Risk of PPE as high as 85–95% in high-risk nonelective C-section patient
  • Complications of PPE: All are more common after C-section:
    • Pelvic thrombophlebitis
    • Pelvic abscess
    • Bacteremia
  • Risk factors for PPE:
    • C-section
    • Prolonged labor
    • Prolonged rupture of membranes
    • Increased number of vaginal exams
    • Use of internal fetal monitoring
  • Septic pelvic thrombophlebitis is a diagnosis of exclusion with 2 distinct clinical presentations, either of which may present with postpartum pulmonary embolus:
    • Acute thrombosis:
      • Most common in right ovarian vein
      • Usually occurs in 1st 48 hr as acute, progressive lower abdominal pain
    • Enigmatic fever: “Picket fence” spiking fevers and tachycardia
  • Septic abortion:
    • Uncommon in developing countries
    • Usually an ascending infection through an open cervical os
    • Associated with:
      • Nonsterile techniques, instruments
      • Retained products of conception
  • Mastitis:
    • Ranges from mild breast redness to fever, systemic illness, and abscess
    • Common (1–30% of postpartum patients)
    • Occurs within the 1st 3 mo postpartum
    • Peaks at 2–3 wk
    • Recurs in 4–8%
  • UTI/pyelonephritis:
    • Along with mastitis accounts for 80% of postpartum infections
ETIOLOGY
  • PPE:
    • Polymicrobial infection result of ascending spread from lower genital tract
    • Anaerobic (up to 80%) and aerobic (∼70%):
    • Gram-positive aerobes:
      • Group A, B streptococci
      • Enterococci
      • Gardnerella vaginalis
    • Gram-negative aerobes:
      • Escherichia coli
      • Enterobacter
    • Anaerobes:
      • Bacteroides
      • Peptostreptococcus
    • Other genital mycoplasmas common in late PPE:
      • Ureaplasma urealyticum
      • Mycoplasma hominids
      • Chlamydia trachomatis
  • Septic abortion:
    • Usually polymicrobial
    • E. coli
    • Bacteroides
    • Anaerobic gram-negative rods
    • Group B streptococci
    • Staphylococcus
    • STD:
      • Gonorrhea
      • C. trachomatis
      • Trichomonas
  • Mastitis
    • Staphylococcus aureus
    • Group A and B hemolytic streptococci
    • E. coli
    • Bacteroides
DIAGNOSIS
SIGNS AND SYMPTOMS
History
  • Careful birth history:
    • C-section
    • Length of labor
    • Complications
    • Exposure to STDs
  • Pre-existing immunocompromise or disease
  • Endometritis:
    • Fever and chills
    • Abdominal pain
    • Foul-smelling lochia
  • Septic abortion:
    • Similar to endometritis
    • Fever
    • Abdominal pain
    • May present with symptoms of shock including:
      • Dyspnea (acute respiratory distress syndrome [ARDS], pulmonary edema)
      • Bruising, bleeding (disseminated intravascular coagulation [DIC])
  • Mastitis:
    • Fever
    • Breast pain, engorgement, redness
  • Other sources of infection:
    • Wound infection:
      • Redness, pain, swelling
    • UTI/pyelonephritis:
      • Fever, dysuria, frequency, flank pain

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