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socioeconomic status. The rate of infection in this group of women
has been greatly reduced by the prophylactic use of antibiotics, Dr.
Gilmandyar noted. Treatment can include not only antibiotic regimens,
but also surgical debriding and packing, if needed. Generally the
treatment chosen will be guided by the severity of the infection and
the clinical response of the patient.
Postpartum hemorrhage
(PPH) is a major cause of maternal
morbidity, occurring in 1 percent to 5 percent of all deliveries, and is
one of the top causes of maternal mortality.
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Uterine blood flow
increases over the course of pregnancy, reaching roughly 600 ml/
minute by the time a woman is in her third trimester of pregnancy.
As a result, a patient can lose more than a quart of blood every
minute at term if there is a significant hemorrhage. And, since there
may be no maternal signs until up to 15 percent to 20 percent of the
blood volume is lost, a patient can lose a significant amount of blood
before exhibiting well-recognized PPH symptoms, Dr. Gilmandyar
warned. Symptoms include mild hypotension, peripheral vasoconstriction,
and tachycardia (100 to 120 bpm) at between 20 percent and 25
percent blood loss; hypotension (SPB 80 to 100 mmHg), restlessness,
oliguria, and tachycardia (>120 bpm) at 25 percent to 35 percent
blood loss; and hypotension (SBP <60 mmHg), altered consciousness,
and anuria, at blood loss greater than 35 percent.
Risk factors for PPH include retained placenta, labor dystocia (second
stage), placenta accreta (placenta abnormally attached to the inside
of the uterus), lacerations, hypertensive disorders, and a fetus who is
large, such as when the mother has gestational diabetes.
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Causes
may include such factors as uterine atony (when the uterine muscles
fail to contract normally after delivery), retained placenta, trauma
from birth, and a coagulopathy.
Postpartum hemorrhage that is caused by uterine atony may be the
result of an overdistended, fatigued uterus that cannot contract
normally, said Dr. Gilmandyar. The first step in this case is to alert the
entire obstetrical team in a stat manner and have them on standby
if further intervention is necessary. Another part of the initial
management approach, especially if the bleeding does not appear to
be slowing down, is to quickly transport the patient to the operating
room. Once in the operating room, the obstetrical team focuses on:
Ensuring adequate anesthesia for the patient.
Establishing appropriate IV access (a larger-gauge IV or two is
helpful here).
Performing a pelvic examination to attempt to identify
the source of bleeding.
Emptying the patient's bladder.
Checking uterine tone and massaging or administering uterotonics.
If the hemorrhage is caused by retained placenta, the uterus
should be manually explored and the retained placental fragments
removed. If manual extraction of the placental fragments is not
possible, then a suction and curettage must be performed to empty
the endometrial cavity. Because the postpartum uterus is much more
likely to perforate, ultrasound guidance is useful, Dr. Gilmandyar
advised.
Hemorrhages resulting from birth trauma can include lacerations
(perineal, vaginal, and cervical), hematomas, and hysterotomy/
uterine rupture, while those caused by coagulopathy can be related
to maternal conditions or pregnancy-related conditions.
Less-invasive therapies for treating postpartum hemorrhage include
uterine massage and uterotonic drugs, such as oxytocin, methyler-
gonovine, carboprost, dinoprostone and misoprostol. More invasive
therapies include arterial embolization, uterine compression sutures,
uterine artery ligation, and, ultimately, if all other measures fail,
hysterectomy.
As an intermediate intervention, a uterine tamponade may be used
to help control the hemorrhage. The tamponade may be created
using packs or balloons, Dr. Gilmandyar said. The balloon is inserted
into the uterus and filled, exerting pressure on the uterine wall
until the bleeding stops. Once the tamponade is in place (inflated),
it can be left in place for 12 to 24 hours. The balloon can be
deflated gradually over several hours, or all at once, depending
on the situation.
Uterine artery embolization also can be considered if the patient is
hemodynamically stable and interventional radiology is available.
The femoral artery is used for access, and gelfoam is used for
embolization. This procedure has a success rate of 89 percent to 97
percent, Dr. Gilmandyar said. The gelfoam used is typically reabsorbed
by the body within weeks; this procedure is not the same as Uterine
Artery Embolization (UAE) for fibroids, which is permanent, she
noted.
Cases of postpartum hemorrhage are instances in which a multi-
disciplinary team must be available for the most consistent and the
best outcomes, Dr. Gilmandyar said. This team usually includes the
obstetrician, nursing staff, anesthesiologists, surgical assistance,
and other health professionals or departments (e.g., blood bank).
Protocols and drills, as noted by Dr. Chervenak, have been shown to
improve outcomes, and to help reduce not only the time to diagnosis,
but also the response times of the health care team for acting on the
condition, she said.
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