Facts

-Collapse of the uterine fundus into the endometrial cavity turning the uterus partially or completely inside out.

-A rare complication of vaginal delivery

-An obstetrical emergency.

-If not promptly recognized and treated, uterine inversion can lead to severe hemorrhage and shock

-The most common disorder in differential diagnosis: Prolapsed fibroid

-Diagnosis:

-Key finding: On abdominal examination, lack of palpation of a normally positioned fundus.

-Ultrasound, CT, MRI

-Treatment: Manage postpartum hemorrhage and shock, if present using volume resuscitation, blood transfusion, Discontinue uterotonic drugs (oxytocin), give uterine relaxants (nitroglycerin,Terbutaline, Sevoflurane, Desflurane, Isoflurane), do not remove the placenta, immediately attempt to manually replace the inverted uterus to its normal position, Place a hand inside the vagina and push the fundus along the long axis of the vagina toward the umbilicus (Johnson maneuver). If these measures fail, consider surgery (Huntington procedure, Haultain procedure)

-Postpartum hemorrhage is a condition in which a woman loses a very large amount of blood after childbirth.

-An obstetric emergency.

-Key features: (1) cumulative blood loss ≥1000 mL or (2) bleeding associated with signs/symptoms of hypovolemia within 24 hours of the birth process regardless of delivery route.

-The most common cause of PPH: Uterine atony

-Risk factors: trauma, retained placenta, membranes, failure to progress during the second stage of labor, lacerations, instrumental delivery, macrosomy, preeclampsia, eclampsia, HELLP syndrome, induction of labor, placental abruption, placenta previa, acquired or congenital coagulation defects.

-Prophylactic use of oxytocin during labor reduces the risk of PPH.

-Diagnosis:

Clinical: Tachypnea, tachycardia, hypotension, low oxygen saturation, and air hunger are signs of hypovolemia due to hemorrhage

Labs:Complete blood count, Prothrombin time, activated partial thromboplastin time, fibrinogen level, HCG, Thromboelastography (TEG) and rotational thromboelastometry (ROTEM), where available; Ultrasound, CT, MRI

-Treatment: Volume resuscitation, blood transfusion, Coagulopathy is treated medically, with transfusion of blood and blood products.

-Treat the cause of bleeding (manage atony, repair lacerations, remove any retained placental fragments, manually replace an inverted uterus if present, hysterectomy if there is uterine rupture.

Surgical: dilation and curettage, suction curettage, arterial embolization,Ligation of the uterine and utero-ovarian arteries. intrauterine balloon tamponade, pelvic packing, laparotomy,Hysterectomy in resistant cases

-Hyperfibrinolysis and fibrinogen depletion are common in the early stages of bleeding. Therefore, an early administration of tranexamic acid, an anti-fibrinolytic drug, can reduce death due to bleeding in women with postpartum hemorrhage related to atony or trauma.

-Tranexamic acid should not be mixed with blood or given through a line with blood, or mixed with solutions containing penicillin.

-Intra-amniotic infection (IAI, chorioamnionitis) is the infection of the amniotic fluid, membranes, placenta, umbilical cord, and/or decidua.

-The key criterion: Maternal fever

-The diagnosis of IAI is based on clinical findings: maternal fever, Baseline fetal heart rate >160 beats/min for ≥10 minutes, Maternal white cell count >15,000/mm³ , Purulent-appearing fluid coming from the cervical os visualized by speculum examination, positive Gram stain of amniotic fluid, Low glucose level in amniotic fluid, Positive amniotic fluid culture, High white cell (WBC) count in amniotic fluid, Histopathologic evidence of infection or inflammation or both in the placenta, fetal membranes, or the umbilical cord vessels

-Laboratory studies should be performed on amniotic fluid obtained by amniocentesis.

-Treatment: Antibiotics + Delivery. Treat with broad-spectrum antibiotics: ampicillin, gentamicin, ticarcillin-clavulanate, cefoxitin, cefotetan, piperacillin-tazobactam, ertapenem, vancomycin, clindamycin; Monitor fetus during delivery.

-Complications: perinatal death, asphyxia, early-onset neonatal sepsis, septic shock, pneumonia, meningitis, intraventricular hemorrhage, cerebral white matter damage, and long-term neurodevelopmental disability including cerebral palsy

-Endometritis is the inflammation and infection of the inner lining of the uterus.

-Postpartum endometritis is defined as an oral temperature of ≥38.0 °C [≥100.4 °F] or more on any 2 of the first 10 days postpartum, exclusive of the first 24 hours).

-The most common cause of infection after childbirth.

-The most important risk factor for development of postpartum endometritis: C-section

-Diagnosis depends on clinical criteria: postpartum woman with fever, uterine tenderness, foul lochia, chills, lower abdominal pain

-Labs may show a rising neutrophil count, elevated bands, but don’t rely on them.

-Treatment: Broad spectrum antibiotics: Clindamycin, gentamicin, ampicillin-sulbactam, vancomycin

Group B Streptococcal infection is a gram-positive coccus infection which is an important cause of illness in infants, pregnant women

-It is a frequent cause of asymptomatic bacteriuria, urinary tract infection, upper genital tract infection (ie, intraamniotic infection or chorioamnionitis), postpartum endometritis, pneumonia, puerperal sepsis, and bacteremia without a focus.

-Asymptomatic bacteriuria is identified by screening urine cultures that are obtained during prenatal visits. At least one screening urine culture should be obtained during early pregnancy.

-Invasive maternal infection with GBS is associated with pregnancy loss and preterm delivery.

-Colonization of pregnant women by GBS is a major risk factor for neonatal GBS infection.

-Sterile urine must be documented after treatment, and periodic screening cultures should be obtained throughout the pregnancy to identify recurrent bacteriuria.

-Women with documented GBS bacteriuria should not be screened for GBS rectal/vaginal colonization later in pregnancy but should be considered persistently GBS colonized and receive intrapartum chemoprophylaxis at the time of delivery.

-Perform universal screening at 35 to 37 weeks.

-Women with any GBS bacteriuria should receive intrapartum chemoprophylaxis at the time of delivery to prevent neonatal infection

-Treat with antibiotics: Amoxicillin, penicillin, cephalexin, clindamycin

-Gestational diabetes mellitus develops during pregnancy in women whose pancreatic function is insufficient to overcome the insulin resistance associated with the pregnant state.

-Identifying pregnant women with gestational diabetes mellitus followed by appropriate therapy can decrease fetal and maternal morbidity, particularly macrosomia, shoulder dystocia, and preeclampsia.

Two-step screening test: Screen everyone at 24 to 28 weeks; The first step is a 50-gram one-hour glucose challenge test (GCT). Positive patients go on to the second step, a 100-gram, three-hour oral glucose tolerance test (GTT), which is the diagnostic test for gestational diabetes mellitus.

-Adverse outcomes associated with gestational diabetes: Preeclampsia, gestational hypertension, hydramnios, macrosomia, maternal and infant birth trauma, operative delivery (cesarean, instrumental), perinatal mortality, Fetal/neonatal hypertrophic cardiomyopathy, neonatal respiratory problems and metabolic complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, polycythemia)

-Long-term, women with gestational diabetes mellitus are at increased risk of developing type 2 diabetes as well as type 1 diabetes and cardiovascular disease.

-A diagnosis of overt diabetes is made when A1C is ≥6.5 percent.

Treatment:

-Nutritional therapy, Glucose monitoring, target fasting blood glucose <95 mg/dl; insulin, selected oral antihyperglycemic agents (metformin, glyburide)

A single third trimester ultrasound to screen for macrosomia.

Scheduled cesarean delivery to avoid birth trauma is typically offered to women with GDM and estimated fetal weight ≥4500 grams.

-All women with GDM should have a two-hour, 75-gram oral glucose tolerance test between 6 and 12 weeks postpartum