Obstetrics 13

  1. What are physiological changes in Puerperium?
    • Urinary tract - Bladder wall becomes edematous and hyperemic  and often shows evidence of submucous extravasation of blood.
    • Stagnation of  urine along with a devitalized bladder wall contribute to UTI in puerperium

    GIT - slight intestinal paresis leads to constipation.

    Blood values - Decrease in blood volume; RBC and hematocrit values returns to normal by the end of first week, Platelet count decreases soon after the separation of the placenta, Fibrinogen level remains high upto the second week of puerperium. 

    Involution  of uterus is stimulated by vasospasm. [IOM 00]
  2. How do you clinically assess the involution of uterus?
    • Following delivery, the fundus lies about 13.5 cm  above the symphysis pubis. 
    • During first 24 hours, the level remains constant. 
    • Thereafter, there is a steady decrease in height by 1.25 cm in a day so that by the end of second week the uterus becomes pelvic organ. 
    • The rate of involution thereafter slows down until 6 weeks, the uterus becomes almost normal in size.

    In a woman in the 10th postpartum day, the uterus is felt just above symphysis pubis. [IOM 05]

    Image Upload 1
  3. How long does it take for the uterus to involute completely? [AI 95, IOM 11]
    6 weeks
  4. What is Lochia?
    • Lochia is the discharge from the uterus of blood, mucus, and tissue during the puerperal period. [AI 97] 
    • Lochia rubra - for first 6 days, blood tinged 
    • Lochia serosa - next 3-4 days,  brown 
    • Lochia alba - after loachia serosa, white
  5. What is early  and late postpartum hemorrhage?
    • Early - blood loss of >500ml during first 24 hours after delivery. 
    • Late - blood loss after 24 hours has passed.
  6. What  is the most common cause of Postpartum hemorrhage?
    • 4Ts:
    • 1. Tone - Uterine atony (50%) - most common cause [UP 98,IOM 09] 
    • 2. Trauma - Genital lacerations (20%) 
    • 3. Tissue - Retained placenta (10%) 
    • 4. Thrombin - DIC
    • Other rare causes - Uterine inversion

    Image Upload 2
  7. What are the causes of Uterine atony? [AI 06]
    • 1. Overworked uterus – Rapid labor, Prolonged labor, 
    • 2. Infected uterus – Chorioamnionitis 
    • 3. Relaxed uterus -  MgSO4, Beta-adrenergic agonists (Ritodrine, Terbutaline), Halothane 
    • 4. Overdistended uterus – Multiple pregnancy, Polyhydraminos, Macrosomia
  8. What is the most common clinical finding of Uterine atony?
    Doughy soft uterus above the umbilicus
  9. What is the management of Uterine atony?
    • Bimanual uterine massage should be done before any medications are used. 
    • Image Upload 3

    Uterotonics – Oxytocin, Methergine, PGF2α
  10. Which of the following drugs is not useful in the management of PPH? [AI 08]

    B) Mifepristone

    Mifeprostone is an anti-progesterone, used in early pregnancy to induce abortion.
  11. What is B-Lynch suture?
    • Is done if the uterus doesnot contract after C/S
    • - It helps to preserve the uterus sometimes if otherwise needs to be removed.  

    Image Upload 4
  12. What are the risk factors for Retained placenta?
    • - Accessory lobe (common),
    • - Placenta accreta
  13. What is most common cause of retained placenta? [IOM 2059]
    Uterine atony
  14. What is  the clinical finding of DIC leading to PPH?
    • - Generalized oozing of blood
    • – Bleeding even from sites of  suture needle prick  
    • - Petechiae
    • – Contracted uterus
  15. In PPH, you cannot  palpate the uterus, what is  your diagnosis?
    • Inverted uterus – normally it should be palpable  upto the umbilicus.
    • BEEFY BLEEDING MASS IS seen – the beefy color is of  the endometrium seen that is inverted.
  16. What is the management of Inverted  Uterus?
    • Management  is to elevate the uterus  and replace the uterus in its anatomic position and give IV oxytocins to contract.
    • It should be done before cervix closes because after cervix closes, it is almost impossible to  replace the uterus back.

    Image Upload 5
  17. What is Sheehan's syndrome?
    Sheehan syndrome  is  hypopituitarism  caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.

    • Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply.
    • Secondly, the anterior pituitary is supplied by a low pressure portal venous system.
    • These vulnerabilities, when affected by major hemorrhage or hypotension during the peripartum period, can result in ischaemia of the affected pituitary regions leading to necrosis.
    • The posterior pituitary is usually not affected due to its direct arterial supply.
  18. What  is the  first symptom of Sheehan syndrome?
    Failure of lactation due to lack of  prolactin hormone
  19. What is the management of Sheehan's syndrome?
    • Maintainence regimen of:
    • - Thyroxin,
    • - Adrenal cortical hormones [AI 95]
    • - and possibly gonadotropin
  20. What is the management of Unexplained bleeding?
    • Ligation of uterine arteries or
    • TAH(Total Abdominal Hysterectomy)
  21. What are the causes of Pospartum Fever by Postpartum days?
    • Day 0  - Wind (Atelectasis)
    • Day 1-2 - Water (UTI) 
    • Day 2—3 - Womb (endometritis) 
    • Day 4-5 - Wound (Wound infection) 
    • Day 5-6 - Walk (Septic pelvic thrombophlebitis)
  22. Fever on Post partum day 0, emergency C/S with general anesthesia, rales on lungs on auscultation, Diagnosis?

    • - Atelectasis is more common on general anesthesia use.
    • - Management is pulmonary exercise.
  23. Fever on PP day 1-2, Multiple labor catheters, costovertebral angle tenderness, Diagnosis?
    UTI with pyelonephritis.

    • Multiple vaginal examination and multiple catheterization due to prolonged labor is the cause of UTI.
    • Management is with IV antibiotics.
  24. What is your diagnosis in PP fever and exquisite tender uterus?
    • Endometritis 
    • Image Upload 6
  25. Post partum day - 5-6, triple antibiotics patient not responding, Diagnosis?  Management?
    Septic thrombophlebitis

    • – There is picket fence type of fever.  
    • - Managemennt   is IV  heparin -  for 7-10 days 
    • Image Upload 7
  26. What is infectious mastitis?
    • Infectious mastitis develops on day 7-21 because of Lactational Nipple trauma.
    • Most common organism for infection is Staphylococcus aureus. [UP 97]
    • The immediate source of organism that cause mastitis is almost always the infants nose and throat.
    • Fissures, abrasions or cracks predispose to infections.
  27. What is the management of Infectious mastitis? [AI 08]
    • The drug of choice for mastitis is Flucloxacillin.
    • If patient is allergic, use erythromycin. 
    • Breast feeding should be continued even with infected breasts
    • Breast should be incised and drained if the infection does not resolve within 48 hours. [UP 94]
  28. Fever on Post partum 14, unilateral breast swollen, red, tender. Diagnosis?
    Infectious mastitis.
  29. Fever on postpartum day 3, Bilateral breast findings, entire breast swollen, red and tender, Diagnosis?
    • Congestive mastitis or Breast engorgement.
    • Some breast engorgement is found in almost every women.
    • Encourage emptying the breast either by feeding or by breast pump.
  30. Which hormone is responsible for milk ejection  reflex or Let down reflex? [UP 97, IOM 08]
  31. Is  is easier for the baby to suck the milk from the  breast or from the  bottle?
    • It is much easier to suck the milk from the  bottle – so once  it finds that it is easier from the bottle,  the baby forgets the  breast.
    • So, you should  exclusively breast feed and not bottle feed at least for 6 weeks.
  32. What is the most common cause of Post partum fever?
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Obstetrics 13