Postpartum Endometritis

Any postpartum women presenting with persistent fever of >38.0C should be assumed to have a genital tract infection until proven otherwise. Other common sources of fever include respiratory tract infection, UTIs, mastitis, and thrombophlebitis. However, Pelvic infection is the most common serious complication of the puerperium.

Risk factors of Postpartum Endometritis

• Cesarean Section
• Multiple Gestation
• Younger maternal age
• Prolonged labour and PROM
• Internal fetal monitoring
• Digital examination 
• Immunocompromised state

Common Bugs (reside in the bowel and colonize the perineum, vagina, and cervix) 

• Gram-positive and gram-negative aerobes, anaerobes
• Chlamydia trachomatis, and Neisseria gonorrhoea
• Gardnerella vaginalis is isolated more often in younger women. 
• MRSA

Many infections are polymicrobial

Clinical Presentation

• Fever 38.0C 
• Foul-smelling loch
• Leukocytosis
• Tachycardia
• Uterine tenderness

ED Management

• ABC
• General Sepsis Care (Fluids, Antibiotics, Cultures, Septic Screen). Combination of Ampicillin or Clindamycin plus gentamicin is sufficient for 90% of patients
• Drainage of abscesses and purulent material or debridement of necrotic tissue 
• OBGYN Consultation 

Complications of endometritis include parametrical spread of infection, pelvic abscesses; infected hematomas; septic pelvic thrombophlebitis; necrotizing fasciitis; and peritonitis. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

  

Post-Partum Haemorrhage

Postpartum hemorrhage that occurs within the first 24 hours of delivery is called as primary postpartum hemorrhage. The main causes of primary postpartum haemorrhage are:

• Uterine atony (TONE)
• Retained placental fragments (TISSUE)
• Lower genital tract lacerations (TRAUMA)
• Uterine rupture (Click here to read more)
• Uterine inversion (requires repair under general anesthesia)
• Hereditary coagulopathy (THROMBIN)

Secondary postpartum hemorrhage occurs after the first 24 hours and up to 6 weeks postpartum. Common causes of secondary postpartum haemorrhage are:

• Failure of the uterine lining to sub-involute at the former placental site
• Retained placental tissue
• Genital tract wounds
• Uterogenital infection

Causes can be remembered as TONE, TISSUE, TRAUMA, THROMBIN

Risk Factors fro PPH

• Primipara or Grandmultipara 
• Previous PPH
• Pre-eclampsia
• Prior CS
• Placenta Previa
• Cervical or Uterine trauma
• Fetal Wt >4.5Kgs
• Prolonged 3rd stage

Excessive blood loss in the postpartum period is defined as a 10% drop in the hematocrit, a need for transfusion of packed red blood cells, or volume loss that causes symptoms of hypovolemia. The hematologic changes of pregnancy can mask the typical symptoms of hemorrhage, and the first sign may be only a mild increase in pulse rate.

Resuscitation

• ABC
• IV Access x 2
• Fluid Resuscitation 
• Involve OBGYN ASAP
• Keep them warm (Prevent the deadly triad of hypothermia, coagulopathy and acidosis)
• Bimanual uterine massage - place a fist in the anterior fornix and compress the uterine fundus against the hand in a suprapubic location 
• Uterotonics 

Oxytocin: 10U IM or 20-40 units in NS over 1 hour 

Carboprost: 250mcg IM q30min (up to 2mg if needed), Avoid in HTN, Asthma

Misoprostol: 1000mcg PR

Methylergonovine: 0.2mg IM (up to 5 doses q2-4h), Contraindicated in HTN/Pre-eclampsia

• Consider Tranexamic Acid for critically ill 
• Look for evidence of trauma, uterine inversion and uterine rupture
• Inspect for missing placenta fragments 
• Arrange blood products (Packed Cells, FFP and Cryo if in DIC)
• Intrauterine balloon tamponade using Bakri balloon or Rusch catheter if uterine atony is the only or main cause of haemorrhage
• Move to OR for hysterectomy or Uterine Artery Ligation

Other advanced care methods:

• Interventional Radiology for Uterine Artery Embolisation
• REBOA as a temporary measure 

Take Home:

• Keep them warm (prevent Hypothermia, Coagulopathy and Acidosis)
• Remember the 4 causes - TONE, TISSUE, TRAUMA, THROMBIN
• Involve OBGYN ASAP

References and Further Reading:

1. Tintinai EM 8th edition
2. Shakur H, Elbourne D, Gülmezoglu M, Alfirevic Z, Ronsmans C, Allen E, Roberts I. The WOMAN Trial (World Maternal Antifibrinolytic Trial): tranexamic acid for the treatment of postpartum haemorrhage: an international randomised, double blind placebo controlled trial. Trials. 2010 Apr 16;11(1):40.
3. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg52/

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Hyperemesis Gravidarum

Nausea and vomiting of pregnancy is generally seen in the first trimester. EM Mindset always starts with the "ruling out the life threats first", therefore we need to think of other life-threatening pathologies as well before labelling someone as "Simple Nausea and Vomiting of Pregnancy". 

Severe nausea and vomiting of pregnancy is known as hyperemesis gravidarum and is defined as intractable vomiting with weight loss >5%, volume depletion, and laboratory values showing hypokalemia or ketonemia. Findings on physical examination in nausea and vomiting of pregnancy are usually normal except for signs of volume depletion. 

Physical exam is often normal in Nausea and Vomiting of pregnancy

The presence of abdominal pain in nausea and vomiting of pregnancy or hyperemesis gravidarum is very atypical and should prompt further work up.   

Etiology

The exact mechanism remains unknown. One theory is that nausea and vomiting are protective in pregnancy as it reduces exposures to teratogenic materials while others believe that elevated human chorionic gonadotropin (hCG) or estradiol levels could be the cause.

Potential mimics

• Ectopic Pregnancy, Molar Pregnancy
• Appendicitis
• Cholecystitis/Hepatitis
• UTI (Pyelonephritis)
• DKA
• Pancreatitis
• Ovarian Torsion
• Pre-eclampsia
• Gastroenteritis
• Bowel Obstruction
• HELLP Syndrome

Management

• IV fluids containing 5% dextrose to replete volume and reverse ketonuria
• Antiemetic drugs 
• Thiamine 100 mg (to avoid Wernicke’s encephalopathy)
• Oral fluids as and when possible

Serial measurements of urinary ketones can be used to determine success of therapy. With resolving ketonuria, correction of dyselectrolytemia and able to keep up with oral fluids, patients can usually be discharged with oral anti-emetics.There is no clear drug of choice. Options include Diphenhydramine, Ondansetron, Prochlorperazine, Phenothiazines, Doxylamine and pyridoxine, Metocloperamide. 

Steroids are used as last resort in patients who require parenteral nutrition due to weight loss. However, corticosteroids should be used with caution or possibly avoided before 10 weeks gestation as recent studies have linked oral clefts with methylprednisolone use in the first trimester.

Complications

• Wernicke’s encephalopathy
• Acute Renal Failure 
• Central pontine myelinolysis
• Mallory-Weiss tear
• Pneumomediastinum

Admission Criteria

• Uncertain Diagnosis
• Any complications 
• Unable to tolerate orally
• Persistent ketonuria or dyselectrolytemia
• Weight loss >10% prepregnancy weight. 

References:

1. Current Diagnosis and Treatment Emergency Medicine 7e, Chapter 38. Obstetric and Gynecological Emergencies and Rape. Ryan Tucker, MD; Melissa Platt, MD
2. Goodwin TM. Hyperemesis gravidarum. Obstet Gynecol Clin North Am 2008;35(3):401–417 [PubMed: 18760227].

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Uterine Rupture - An obstetric catastrophe

Introduction

Uterine rupture is defined as a non-surgical disruption or tear of the myometrium and serosa of the uterus with or without expulsion of the fetus. It is a life threatening condition for both the mother and the fetus. The overall incidence of uterine rupture is low but in India and other developing nations, it is 10 fold higher.

Etiology

• Scarred Uterus Rupture: Previous caesarean scar or myomectomy
• Unscarred Uterus Rupture: Obstructed labour, Trauma, Grand-multiparty, Uterine anomaly or injudicious use of oxytocin or prostaglandins

Clinical Features

• Severe haemorrhage, Tachycardia, Hypotension (Shock)
• Palpable fetal parts with loss of fetal station
• Recession of presenting fetal parts
• Prolonged, Persistent, Profound fetal bradycardia
• Loss of uterine contractility
• Hematuria
• Appearance of placenta at vulva 
• Prolapsed loops of gut into vagina 

Typically seen in patient with history of CS but also possible in Primigravida

USG: Fetus in peritoneal cavity, Free fluid seen

Differential Diagnosis

• Abruptio Placentae (Similar presentation)
• Hepatic Rupture in severe pre eclampsia (Look for other signs of pre-eclampsia)
• Chorioamnionitis (Look for fever, PROM, Tender uterus)

Management
ABC (Wide bore cannulas, fluids, O2, Blood Products)
Stop oxytocin if in progress
Type and Cross Match
Mobilising resources quickly is the key (OBGYN, Anaesthesia, Neonatology)
Immediate laparotomy is indicated 

• Vertical incision gives better access
• Fetus lies partially or completely in the abdominal cavity
• Rent repair or hysterectomy are the surgical options depending on the degree of rupture and damage

Several studies have shown that delivery of the fetus within 10-37 minutes of uterine rupture is necessary to prevent serious fetal morbidity and mortality.

Take Home

• When dealing with trauma in pregnancy, think Placental Abruption and Uterine Rupture (Both can co-exist)
• Establishing diagnosis early and mobilising the resources quickly and effectively results in favourable outcomes for the mother and fetus

For further reading:

1. Qudsia, Q. A. Z. I., et al. "Woman health; uterus rupture, its complications and management in teaching hospital bannu, pakistan." Maedica 7.1 (2012): 49.
2. Blanchette H, Blanchette M, McCabe J, Vincent S. Is vaginal birth after cesarean safe? Experience at a community hospital. Am J Obstet Gynecol. 2001 Jun. 184(7):1478-84; discussion 1484-7.
3. Leung AS, Leung EK, Paul RH. Uterine rupture after previous cesarean delivery: maternal and fetal consequences. Am J Obstet Gynecol. 1993 Oct. 169(4):945-50. 
4. Yap OW, Kim ES, Laros RK Jr. Maternal and neonatal outcomes after uterine rupture in labor. Am J Obstet Gynecol. 2001 Jun. 184(7):1576-81
5. Essentials of Obstetrics - Lakshmi Seshadri and Gita Arjun
6. Batra, Kanika, et al. "Determinants of rupture of the unscarred uterus and the related feto-maternal outcome: current scenario in a low-income country." Tropical doctor (2015): 0049475515598464.
7. A Massinde, E Ndaboine, A Kihunrwa. An unusual case of placenta abruption complicated with ruptured uterus: case report. The Internet Journal of Gynecology and Obstetrics. 2009 Volume 13 Number 1.

Author:

   Kritika Atrey 
   Intern
   Aarupadai Veedu Medical College
   Pondicherry
   Twitter: @atrey_kritika

   Edited by Lakshay Chanana @EMDidactic

HELLP Syndrome - Podcast

HELLP syndrome - Another great masquerader that requires a high suspicion for diagnosis. Check out the show notes and listen to the podcast.


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