High Risk Pregnancy

Maribee T. Espiritu, RN, MD


Hypertension-related problems in pregnancy are classified in four ways:
Chronic hypertension (HTN) Pregnancy-induced HTN Preeclampsia Eclampsia


The hypertension in each of these diagnoses is classified as:
Mild: Systolic • 140 mm Hg and/or diastolic • 90 mm Hg Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg

Hypertension Pathophysiology of Hypertension in Pregnancy y Normal y Arachadonic acid triggers two pathways: 1. Prostacycline: Decreases blood pressure via: x Decreased vasoconstriction x Increased uteroplacental blood flow .

Thromboxane: Increases blood pressure via: y x Increased vasoconstriction x Decreased uteroplacental blood flow .Hypertension Pathophysiology of Hypertension in Pregnancy y Normal 2.

Hypertension y In Pregnancy-Hypertensive States The balance is thought to be tipped toward the thromboxane pathway. .

CHRONIC HYPERTENSION (HTN) AND PREGNANCY Defined as hypertension that antecedes pregnancy: y Mild: y Systolic • 140 mm Hg and/or diastolic • 90 mm Hg y Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg .

. it is pregnancy induced hypertension superimposed on chronic hypertension.CHRONIC HYPERTENSION (HTN) AND PREGNANCY y If during pregnancy a chronic hypertensive patient·s systolic blood pressure (BP) rises by 30 mm Hg or diastolic rises by 15 mm Hg.


Management y y Mild: Early and serial ultrasounds. biophysicals Severe: Serial ultrasounds and biophysicals Antihypertensives (methyldopa or nifedipine) .

PREGNANCY-INDUCED PREGNANCYHYPERTENSION (PIH) y hypertension during pregnancy in a previously normotensive woman the patient had normal blood pressure prior to 20 weeks· gestation y Mild: Systolic • 140 mm Hg and/or diastolic • 90 mm Hg y Severe: Systolic > 160 mm Hg and/or diastolic > 110 mm Hg (same as chronic HTN) .

y . HELLP syndrome: The clinical picture is dominated by hematologic and hepatic manifestations.PREGNANCY-INDUCED PREGNANCYHYPERTENSION (PIH) Subsets of PIH 1. 4. Eclampsia: Central nervous system involvement leads to seizures. PIH (simple) 2. 3. Preeclampsia: Renal involvement leads to proteinuria.

PREGNANCY-INDUCED PREGNANCYHYPERTENSION (PIH) Complications y Heart failure y Cerebral hemorrhage y Placental abruption y Fetal growth restriction y Fetal death .

PREGNANCY-INDUCED PREGNANCYHYPERTENSION (PIH) Management y Mild: Observe. bed rest y Severe: Always hospitalize + antihypertensive pharmacotherapy x hydralazine or labetalol short term x nifedipine or methyldopa long term .

PREGNANCY-INDUCED PREGNANCYHYPERTENSION (PIH) Management y Generally. If < 34 weeks/fetal lung immaturity: x Steroids plus expectant management If fetal or maternal deterioration at any gestational age. induce labor . for all pregnancyhypertensive states: y Plus the following: If > 36 weeks/fetal lung maturity: x Induce labor.

y Preeclampsia rarely develops before 20 weeks and usually occurs in a first pregnancy y .PREECLAMPSIA Preeclampsia is pregnancy-induced hypertension with proteinuria +/í pathological edema y It is classified as mild or severe.

y < 150 mg/24 hrs in nonpregnant state .PREECLAMPSIA Criteria for Mild Preeclampsia y BP: • 140 systolic or • 90 diastolic y Proteinuria: 300 mg to 5 g/24 hrs (norm: < 300 mg/24 hrs in pregnancy.

PREECLAMPSIA Manifestations of Severe Disease y BP: > 160 systolic or > 110 diastolic y Proteinuria: > 5 g/24 hrs y Elevated serum creatinine y Oliguria (< 500 mL/24 hrs) .

PREECLAMPSIA Manifestations of Severe Disease y Symptoms suggesting end organ involvement: Headache Visual disturbances Epigastric/right upper quadrant pain Pulmonary edema Hepatocellular dysfunction x elevated aspartatetransaminase [AST] x alaninetransaminase [ALT]) .

PREECLAMPSIA Manifestations of Severe Disease Thrombocytopenia IUGR or oligohydramnios Microangiopathichemolysis Grand mal seizures (eclampsia) .

PREECLAMPSIA Predisposing Factors y Nulliparity y Family history of preeclampsia²eclampsia y Multiple fetuses y Diabetes y Chronic vascular disease y Renal disease y Hydatidiform mole .

HELLP SYNDROME HELLP syndrome is a manifestation of preeclampsia with y Hemolysis y Elevated liver enzymes y low platelets y .

it is associated with: High morbidity Multiparous mothers Mothers older than 25 Less than 36 weeks· gestation .HELLP SYNDROME y In contrast to typical presentations of preeclampsia.

Diagnosis of Preeclampsia y Once preeclampsia is suspected. the following tests should be done: Blood: x x x x x x x Electrolytes blood urea nitrogen (BUN) Creatinine liver function tests (LFTs) (ALT. AST) complete blood count (CBC) uric acid platelet count .

Diagnosis of Preeclampsia Once preeclampsia is suspected. the following tests should be done: y Urine: y Sediment 24-hour protein 24-hour creatinine y Fetal: Ultrasound nonstress test biophysical profile .

bed rest. low-salt diet. bed rest. nifedipine or methyldopa long term y Anticonvulsive therapy: Magnesium sulfate .Management Varies depending on severity of disease and gestational age of fetus: y Mild Preeclampsia y Hospitalize. observe. low calories y Antihypertensive pharmacotherapy: Hydralazine or labetalol short term. monitor labs closely y Severe Preeclampsia Hospitalize. low salt.

Management y Plus the following: If > 36 weeks/fetal lung maturity: x Induce labor. The only cure is delivery . If < 34 weeks/fetal lung immaturity: x Steroids plus expectant management If fetal or maternal deterioration at any gestational age: x Induce labor.

ECLAMPSIA y Criteria Mild or severe preeclampsia Generalized seizures .

ECLAMPSIA Management y 1. BP control y hydralazine or labetalol y 4. Correction of hypoxia and acidosis y 3. Control of the convulsions Magnesium sulfate IV and IM 2. Delivery after control of convulsions .

palpitations Labetalol:IV or PO. headache. nonselective beta-1 and alpha-1 blocker Side effects: x Headache and tremor . ANTIHYPERTENSIVE AGENTS USED IN PREGNANCY y Short-Term Control Hydralazine: IV or PO.ECLAMPSIA Management 1. direct vasodilator Side effects: x Systemic lupus erythematosus (SLE)-like syndrome.

selective beta-1 blocker x Side effect: breathlessness . dizziness Atenolol: x PO. calcium channel blocker Side effects: x Edema. false neurotransmitter x Side effects: x Postural hypotension. fluid retention Nifedipine: x PO. drowsiness.ECLAMPSIA Management y Long-Term Control Methyldopa: x PO.

PRETERM LABOR Criteria y Gestational age (GA) < 37 weeks with regular uterine contractions and: Progressive cervical change or A cervix that is 2 cm dilated or A cervix 80% effaced or Ruptured membranes .

PRETERM LABOR Epidemiology y Preterm labor has been associated with the following findings: 1. Infection: Systemic Pyelonephritis urinary tract infection (UTI)/sexually transmitted disease (STD) Chorioamnionitis .

Maternal factors: Low socioeconomic status Coitus Long work hours Youth Grand multiparity smoking/narcotics Previous preterm labor Previous abortion Preeclampsia/eclampsia/HTN .PRETERM LABOR 2.

fibroids) Cervical incompetence Multifetal pregnancy Polyhydramnios Fetal anomalies Placenta previa/abruptio . Anomalies: Uterine (septated uterus.PRETERM LABOR 3.

PRETERM LABOR Assessment Frequency of uterine contractions Possible causes such as infection Confirm GA of fetus (i. . by ultrasound). Assess fetal well-being with a biophysical profile..e.

and ADH mimics oxytocin . y Dehydration causes antidiuretic hormone (ADH) secretion. y It often stops contractions.PRETERM LABOR Management of Preterm Labor y HYDRATION y Always hydrate first in preterm labor.

PRETERM LABOR Management of Preterm Labor y TOCOLYTIC THERAPY y Tocolysis is used if < 34 weeks. y Tocolytic Agents IV magnesium sulfate³suppresses uterine contractions Oral calcium channel blocker (nifedipine) .

PRETERM LABOR Management of Preterm Labor y TOCOLYTIC THERAPY y Beta mimetics (ritodrine. terbutaline)³ stimulate beta-2 receptors on myometrial cells increase cyclic adenosine monophosphate (cAMP) decrease intracellular Ca decrease contractions .

tachycardia.PRETERM LABOR Management of Preterm Labor y TOCOLYTIC THERAPY Beta mimetics x Side effects: x Pulmonary edema. and interventricular hemorrhage . headaches Prostaglandin inhibitors (indomethacin) x Side effects: x Premature constriction of ductusarteriosus. pulmonary HTN.

PRETERM LABOR Contraindications to Tocolysis y Severe Bleeding from any cause y Severe Abruptioplacentae y Fetal Death/life-incompatible anomaly y Chorioamnionitis y Severe pregnancy-induced Hypertension y Unstable maternal hemodynamics .

thus decreasing contractions.PRETERM LABOR y ABOUT MAGNESIUM SULFATE Magnesium sulfate antagonizes Ca and decreases intracellular Ca. . Side effects: x x x x Depressed reflexes pulmonary edema fatigue. It is 70 to 90% effective in achieving 2 to 3 days of tocolysis. Toxicity is treated with calcium gluconate.

dry mouth. hypocalcemia . warmth.PRETERM LABOR Action y Acts as Ca2+ antagonist and reduces actin²myosin interaction (at 7 mg/100 mL) Side Effects y Decreases deep tendon reflexes (at 8 to 10 mg/100 mL) y Respiratory/cardiac depression (at > 12 mg/100 mL) y Flushing. dizziness. nystagmus. headaches.

PRETERM LABOR y Mg Level Side Effect 4²7 mg Uterine contractions decreased 8²12 mg Depressed deep tendon reflexes > 12 mg Respiratory/cardiac depression .

PRETERM LABOR y CORTICOSTEROIDS Given to patients in preterm labor from 24 to 35 weeks unless they have chorioamnionitis Reduce fetal mortality: x Accelerate fetal lung maturity (decreases respiratory distress syndrome [RDS]) x reduce intraventricular hemorrhage x reduce necrotizing enterocolitis .

PRETERM LABOR y LECITHIN²SPHINGOMYELIN RATIO An amniocentesis may be performed to assess fetal lungs for risk of RDS. Fetal lungs are mature if: x Phosphatidylglycerol is present in amniotic fluid x Lecithin²sphingomyelin ratio is > 2 .

PROM Premature rupture denotes spontaneous rupture of fetal membranes before the onset of labor. y This can occur at term (PROM) or preterm (PPROM). y .

PROM Etiology y Unknown but hypothesized: Vaginal and cervical infections Incompetent cervix abnormal membranes nutritional deficiencies .

PROM y Risks Prolonged rupture of membranes: x > 18 to 24 hours before labor. x Patients who do not go into labor immediately will have prolonged rupture of membranes and are at increasing risk of infection as the duration of rupture increases: .

PROM Risks Chorioamnionitis Neonatal infection Umbilical cord prolapse .

PROM Risks y Only if preterm PROM: Prematurity: x If PROM occurs at < 37 weeks. the fetus is at risk of being born prematurely. .

PROM Risks y Oligohydramnios: If PROM occurs at < 24 weeks. y Survival at this age is low. there is a risk of oligohydramnios may cause pulmonary hypoplasia. .

as it increases the risk of infection: Sterile speculum examination: x Visualize extent of cervical effacement and dilation. and exclude prolapsed cord or protruding fetal extremity.PROM y Diagnosis of Rupture of Membranes (ROM) A digital exam should not be performed. . Pool test: x Identify fluid coming from the cervix or pooled in the posterior fornix of the vagina supports diagnosis of PROM.

Ferning test: x A swab from the posterior fornix is smeared on a slide. which turns blue if fluid is alkaline. .PROM y Diagnosis of Rupture of Membranes (ROM) Nitrazine test: x Put fluid on nitrazine paper. allowed to dry. and examined under a microscope for ´ferningµ + for amniotic fluid. x Alkaline pH indicates fluid is amniotic.

PROM Management of All PROM Patients Evaluate patient for chorioamnionitis (common etiology of PROM): Fever > 38°C Leukocytosis maternal/fetal tachycardia uterine tenderness malodorous vaginal discharge .

. gentamicin).PROM Management of All PROM Patients Gram stain and culture of amniotic fluid to assess for chorioamnionitis If positive for chorioamnionitis x delivery is performed despite GA x antibiotics are initiated (ampicillin.

it should be induced or cesarean delivery should be performed. If labor is not spontaneous. gentamicin .PROM Specific Management for PROM at Term y Ninety percent of term patients go into spontaneous labor within 24 hours after rupture: Patients in active labor should be allowed to progress.

PROM Specific Management of PPROM y Fifty percent of preterm patients go into labor within 24 hours after rupture. one needs to balance the risks of premature birth against the risk of infection increases with the time that membranes are which ruptured before birth . y Generally.

PROM Specific Management of PPROM Gram stain and culture of amniotic fluid to assess for chorioamnionitis If chorioamnionitis is suspected x begin ampicillin and/or erythromycin Prophylaxis Amniotic fluid assessment of lecithin² sphingomyelin ratio for lung maturity Perform ultrasound to assess gestational age. . position of baby. and level of fluid.

give steroids to decrease incidence of RDS. Expectant management .PROM y Specific Management of PPROM If < 34 weeks.

Terms: y y ROM: Rupture of membranes PROM: Premature rupture of membranes (ROM before the onset of labor) y PPROM: Preterm (< 37 weeks) premature rupture of membranes y Prolonged rupture of membranes: Rupture of membranes that lasts .

THIRD TRIMESTER BLEEDING y INCIDENCE Occurs in 2 to 5% of pregnancies WORKUP x History and physical x Vitals x Labs: x x x x CBC coagulation profile type and cross urine analysis .

THIRD TRIMESTER BLEEDING y Determine whether blood is maternal or fetal or both: Apt test: Put blood from vagina in tube with KOH: x Turns brown for maternal x Turns pink for fetus .

THIRD TRIMESTER BLEEDING y Determine whether blood is maternal or fetal or both: Kleihauer²Betke test: x Take blood from mother·s arm and determine percentage of fetal RBCs in maternal circulation: x > 1% = fetal bleeding. Wright·s stain: x Vaginal blood x nucleated RBCs indicate fetal bleed .


THIRD TRIMESTER BLEEDING DIFFERENTIAL y Obstetric Causes Placental abruption Placenta previa Vasaprevia/velamentous insertion Uterine rupture Circumvillate placenta Extrusion of cervical mucus (´bloody showµ) .

THIRD TRIMESTER BLEEDING y Nonobstetric Causes Cervicitis Polyp Neoplasm .

5 to 4% y MORTALITY Maternal: 1 to 5% Fetal: 50 to 80% .Placental Abruption (AbruptioPlacentae) AbruptioPlacentae) Premature separation of placenta from uterine wall before the delivery of baby y INCIDENCE y 0.

Placental Abruption (AbruptioPlacentae) AbruptioPlacentae) .

such as a car accident) preeclampsia (and maternal HTN) Smoking cocaine abuse high parity previous history of abruption .y RISK FACTORS Trauma (usually shearing.

and typically hypertonic uterus Evidence of fetal distress Maternal shock .y CLINICAL PRESENTATION Vaginal bleeding (maternal and fetal blood present) Constant and severe back pain or uterine tenderness Irritable. tender.

ABRUPTIO PLACENTA DEGREE OF SEPARATION GRADE CRITERIA 0 ² no symptoms of separation. There is evidence of fetal distress and the uterus is tense and painful on palpation 3. Maternal shock or fetal death will result . no fetal distress and hemorrhagic shock 2.extreme separation. Recent adherent clot 1 ² minimal separation enough to cause bleeding and changes in VS. Slight separation occur after birth.moderate separation.

Clinical and pathological findings .y DIAGNOSIS Ultrasound will show retroplacental hematoma only part of the time.

Expectant management: x Close observation of mother and fetus with ability to intervene immediately If there is fetal distress. perform C-section. platelets).y MANAGEMENT Correct shock (packed RBCs. fresh frozen plasma. cryoprecipitate. .

Placenta Previa three types: y Complete placenta previa: y The placenta covers the entire internal cervical os. Partial placenta previa: x The placenta partially covers the internal cervical os. . Marginal placenta previa: x One edge of the placenta extends to the edge of the internal cervical os.


Placenta Previa y y INCIDENCE 0.5 to 1% ETIOLOGY Unknown. but associated with: Increased parity Older mothers Previous abortions Previous history of placenta previa Fetal anomalies .

profuse bleeding in T3 Postcoital bleeding Spotting during T1 and T2 Cramping (10% of cases) .Placenta Previa y CLINICAL PRESENTATION Painless.

x The double set-up exam is performed only on the rare occasion that the ultrasound is inconclusive.Placenta Previa y DIAGNOSIS Transabdominal ultrasound (95% accurate) Double set-up exam: x Take the patient to the operating room and prep for a C-section. . x Do speculum exam: x If there is local bleeding. palpate fornices to determine if placenta is covering the os. do a C-section x if not.

The specific management is geared toward different situations.Placenta Previa y MANAGEMENT Cesarean section is always the delivery method of choice for placenta previa. .

Transfusions to replace blood loss tocolytics to prolong labor to 36 weeks if necessary .Placenta Previa MANAGEMENT y For Preterm If there is no pressing need for delivery. monitor in hospital or send home after bleeding has ceased.

Placenta Previa MANAGEMENT y Even after the bleeding has stopped. y For Mature Fetus C-section y For a Patient in Labor C-section . repeated small hemorrhages may cause IUGR.

Placenta Previa .

Comparison of Placenta Previa&Abruptio Placenta Previa& Condition Bleeding Abdomen Pain BP Previa Bright red No rigidity None Depend on the amount of bleeding Abruptio Central Marginal complete None Dark red Profuse Rigid No rigidity rigid Acute Uterine tenderness Acute Decreased Decreased shock .

.Fetal Vessel Rupture y Two conditions cause third-trimester bleeding resulting from fetal vessel rupture: (1) Vasaprevia (2) velamentous cord insertion.

Fetal Vessel Rupture

A condition in which the fetal cord vessels unprotectedly pass over the internal os, making them susceptible to rupture and bleeding

y y

0.03 to 0.05%

Rapid vaginal bleeding fetal distress
x Meconium stain, fetal thrashing, brady/tachycardia

Fetal Vessel Rupture
VASA PREVIA y Management

Correction of shock and immediate C-section Vaginal bleeding + sinusoidal variation of fetal heart rate = fetal vessel rupture.

Fetal Vessel Rupture

the fetal vessels insert between amnion and chorion. This leaves them susceptible to ripping when the amniotic sac ruptures.

Fetal Vessel Rupture

1% of single pregnancies 10% of twins 50% of triplets

Clinical Presentation
Vaginal bleeding fetal distress

Fetal Vessel Rupture VELAMENTOUS CORD INSERTION y Management y Correction of shock immediate C-section .

5% .Uterine Rupture The ripping of the uterine musculature through all of its layers. usually with part of the fetus protruding through the opening y Incidence y 0.

5% risk .Uterine Rupture y Risk Factors Prior uterine scar is associated with 40% of cases: x Vertical scar: 5% risk x Transverse scar: 0.

Uterine Rupture y Presentation and Diagnosis Sudden cessation of uterine contractions with a ´tearingµ sensation Recession of the fetal presenting part Increased suprapubic pain and tenderness with labor x may not be readily apparent if analgesia/narcotics are administered .

Uterine Rupture y Presentation and Diagnosis Vaginal bleeding (or bloody urine) Sudden. severe fetal heart rate decelerations Sudden disappearance of fetal heart tones Maternal hypovolemia from concealed hemorrhage .

Uterine Rupture y Management Total abdominal hysterectomy is treatment of choice (after delivery). If childbearing is important to the patient. rupture repair is possible but risky. .

Immediate Postpartum Hemorrhage y Postpartum hemorrhage denotes excessive bleeding > 500 mL in vaginal delivery > 1.000 for C-section y y Blood loss during first 24 hours: ´Earlyµ postpartum hemorrhage Blood loss between 24 hours and 6 weeks after delivery: ´Lateµ postpartum hemorrhage .

Immediate Postpartum Hemorrhage y CAUSES Coagulation defects Uterine atony (myometrium cannot contract postpartum) Ruptured uterus Degrees of retained placental tissue Bleeding from the placental implantation site Trauma to the genital tract and adjacent structures .

.Immediate Postpartum Hemorrhage y CAUSES Most common cause is uterine atony. compressing blood vessels and preventing bleeding. Normally the uterus contracts.

Immediate Postpartum Hemorrhage y RISK FACTORS Blood transfusion/hemorrhage during a previous pregnancy Coagulopathy Vaginal birth after cesarean (VBAC) High parity Large infant Midforceps delivery .

3. 2. Obtain assistance. Manually compress and massage the uterus³controls virtually all cases of hemorrhage due to atony. . Give y oxytocin (20 units in 1 L of lactated Ringer·s) methergonovine prostaglandins if oxytocin is ineffective.Immediate Postpartum Hemorrhage management 1.

5. y . 6. Place Foley and monitor urine output.Immediate Postpartum Hemorrhage If not previously done. 7. Inspect the cervix and vagina. obtain blood for typing and crossmatching y begin fluid or blood replacement. Carefully explore the uterine cavity to ensure that all placental parts have been delivered and that the uterus is intact.

Immediate Postpartum Hemorrhage y If all this fails: Hysterectomy or Uterine artery ligation or hypogastric artery ligation .

Abnormal Placentation The abnormal implantation of the placenta in the uterus: y These conditions can cause retention of the placenta after birth y .

Abnormal Placentation Types of Abnormal Placentation y Placenta accreta: An abnormally adherent implantation of the placenta in which the placental villi attach directly to the myometrium rather than to the deciduabasalis .

Abnormal Placentation
Types of Abnormal Placentation y Placenta increta:
An abnormally adherent implantation in which the placental villi invade the myometrium

Placenta percreta:
An abnormally adherent implantation in which the placental villi penetrate through the myometrium

Abnormal Placentation
ETIOLOGY y These conditions are associated with:
Placenta previa Previous C-section Previous dilation and curettage (D&C) Grand multiparity

Abnormal Placentation
MANAGEMENT y All of these conditions often result in postpartum hemorrhage (third stage of labor hemorrhage) and require hysterectomy.

bacteria responsible for pelvic infections are those that normally reside in the bowel and colonize the perineum. vagina. and cervix.POST PARTUM INFECTION y In the majority of instances. .

Proteus species . Listeriamonocytogenes Aerobic gram-negative bacilli: Escherichia coli. B. Klebsiella. and D streptococci y y Gram-positive bacilli: Clostridium species.POST PARTUM INFECTION Causes y Gram-positive cocci: Group A.

fragilis.POST PARTUM INFECTION Causes y Anaerobic gram-negative bacilli: Bacteroidesbivius. disiens y Other: Mycoplasmahominis Chlamydia trachomatis . B. B.

hominis. group B streptococci.e.. M. trachomatis. and Gardnerellavaginalis Premature labor Frequent vaginal exams .POST PARTUM INFECTION y Risk Factors Prolonged rupture of membranes C-section Colonization of the lower genital tract with certain microorganisms x (i. C.

000/ìL) Malaise .4°F (38°C) Soft.POST PARTUM INFECTION y Diagnosis Fever > 100. tender uterus Lochia has a foul odor. Leukocytosis (WBC > 10.

.. culture the lochia).e.e.POST PARTUM INFECTION y Management Identify source of infection (i. Treat (i. Identify the cause of infection (i. with antibiotics). Assess the severity of the infection.e. perform urinalysis)...

myometrium.Types of Postpartum Infections ENDOMETRITIS y A postpartum uterine infection involving the decidua. and parametrial tissue y Also called metritis with pelvic cellulitis Endomyometritis endoparametritis .

Types of Postpartum Infections ENDOMETRITIS y Typically develops postpartum day 2 to 3 y Treat with IV antibiotics gentamicin and clindamycin until patient is afebrile for 24 to 48 hours. .

Types of Postpartum Infections URINARY TRACT INFECTION y Causes: Catheterization birth trauma conduction anesthesia frequent pelvic examinations y Presents with: dysuria Frequency Urgency low-grade fever .

Types of Postpartum Infections URINARY TRACT INFECTION y Rule out pyelonephritis costovertebral angle tenderness Pyuria hematuria Obtain a urinalysis and urinary culture (E. y Treat with appropriate antibiotics. coli is isolated in 75% of postpartum women). y .

Antibiotics should be given if extensive infection . irrigated. and debrided. Wound should be drained. Wound erythema and tenderness several days after surgery Obtain Gram stain and cultures from wound material.Types of Postpartum Infections CESAREAN SECTION WOUND INFECTION Fever that persists to the fourth or fifth postoperative day suggests wound infection.

. y Rule out the presence of a rectovaginal fistula with a careful rectovaginal exam.Types of Postpartum Infections EPISIOTOMY INFECTION y Look for pain at the episiotomy site disruption of the wound a necrotic membrane over the wound.

. clean.Types of Postpartum Infections EPISIOTOMY INFECTION y Open. y Sitz baths are recommended. y Reassess for possible closure after granulation tissue has appeared. and debride the wound to promote granulation tissue formation.

Types of Postpartum Infections MASTITIS y Affects 1 to 2% of postpartum women y Two types: Epidemic (nosocomial) nonepidemic .

Treat with penicillin isolate from other patients. Mother presents on day 2 to 4 with fever and breast tenderness. .Types of Postpartum Infections MASTITIS y Epidemic mastitis is caused by infant acquiring Staphylococcus aureusin his nasopharynx from the hospital.

y Continue breast feeding. Treat with penicillin or dicloxacillin.Types of Postpartum Infections MASTITIS y Endemic (nonepidemic) mastitis presents weeks or months after delivery. . usually during period of weaning. Mother presents with x x x x Fever systemic illness breast tenderness.

124 .

yIf you are animal. what would you be? 125 .

yRABBIT or SNAIL 126 .

yRabbits are the most sexually active animals and can have sex as many as 40-50x in a day. 127 .

ySnails live 80 years & will have sex only once in their lifetime. but its orgasm lasts for 18 hours. 128 .

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