Postpartum Hemorrhage Complications

• Blood loss of 500mL during vaginal birth and 1000mL during cesarean birth is considered hemorrhage.

Types of Postpartum Hemorrhage

• Early postpartum hemorrhage occurs within the first 24 hours.
• Late postpartum hemorrhage occurs from 24 hours to 4 weeks postpartum.

Causes of Hemorrhage

• Tone: Failure of the uterine muscle to contract.
• Tissue: Presence of retained placental fragments.
• Trauma: Trauma to the genital tract accounts for 20% of cases.
• Thrombosis: Clot formation fibrin deposition.
• Uterine atony is when the uterus does not contract after delivery or 24 hours after.
• Laceration is a ragged wound.
• Hematoma is a collection of blood under the skin.

Types of Hematoma

• Genital hematoma is a collection of blood in the vulva, causing excruciating pain.
• Retroperitoneal hematoma is a collection of blood in the retroperitoneal space.

Retained Placental Fragments

• Retained placental fragments occur when part or all of the placenta remains in the uterus after birth.
• Accreta (75-78%) attaches firmly to the uterine wall and is the most common type.
• Increta (15-17%) is deeply embedded in the uterine wall.
• Percreta (5%) is the most severe, passing through the uterine wall.
• Subinvolution of the uterus refers to the uterus not returning to its normal size after birth.
• Endometritis is inflammation of the lining of the uterus, usually caused by an infection.
• Urinary Tract Infection (UTI) is inflammation of the bladder or urethra.
• A clean catch yielding more than 150 colony forming units or a catheter sample yielding 10,000 colony forming units confirm UTI.
• Common causes of UTI are Coliform bacteria coli, klebsiella pneumonia, and enterococci.
• Mastitis (2%) is an infection of breast tissue, typically occurring in the 2nd to 3rd week postpartum.

Postpartum Thromboembolic Disorders

• Blood clots (thrombi) occur after birth, leading to thromboembolic disorders.
• Thrombophlebitis is a swollen or inflamed vein due to a blood clot.
• Pulmonary embolism occurs when thrombi forms in the leg vein and travels to the lungs, obstructing blood flow.

Types of Thrombophlebitis

• Superficial thrombophlebitis affects veins near the surface.
• Deep vein thrombosis (DVT) affects veins deeper within the body.

Types of Thrombophlebitis (Location)

• Femoral thrombophlebitis is an infection of the veins in the legs, characterized by Homan’s sign, milk leg, swelling, and fever.
• Pelvic thrombophlebitis is an infection of the ovarian, uterine, and pelvic veins, causing fever/chills and pain in the abdomen.
• Postpartum blues are transient, appearing on the 2nd to 3rd day after delivery, peaking at the 5th, and ending by the 10th-14th day, due to hormonal changes.
• Postpartum depression is prolonged, occurring in the 1st month after delivery and lasting for weeks to months (3-6 months); it can be assessed with the Edinburgh Postnatal Depression Scale.
• Postpartum psychosis occurs 2 to 4 weeks after childbirth and is a severe but rare psychiatric problem.

Puerperium (Postpartum Phases)

• Puerperium is the 6-week period after birth.
• Taking In starts immediately after birth and lasts for 2 days; characterized by passive, dependent behavior, focus on own needs, and repeatedly reviewing the birth experience.
• Taking Hold occurs from the 3rd to 10th day after birth, with a focus on the infant and increasing independence.
• Letting Go occurs from the 10th to 6th week, involving redefining her new role and seeing herself as separate from the child.

Infertility

• Infertility is defined as the inability to get pregnant after one year of trying to conceive.

Types of Infertility

• Primary infertility is difficulty conceiving for the first time.
• Secondary infertility is difficulty conceiving after having at least one child.

Male Infertility Factors

• Inadequate sperm count: less than 20 million per milliliter of seminal fluid or less than 50 million per ejaculation.
• Increased body temperature.
• Cryptorchidism (missing testes).
• Sons of mothers that took DES (diethylstilbestrol).
• Varicocele (enlarged veins inside the scrotum).
• Other factors include testes trauma, surgery, endocrine imbalance, drug/alcohol abuse, and environmental factors.

Female Infertility Factors

• Anovulation (lack or absence of ovulation).
• Hormonal imbalance.
• Ovarian tumors.
• Radioactive exposure.
• Tubal Transport Problems (blocked or damaged fallopian tubes).
• Pelvic inflammatory disease (infection of pelvic organs).
• Uterine problems.
• DES (diethylstilbestrol) leading to T-shaped uterus.
• Poor secretion of estrogen or progesterone.
• Endometriosis (nodules grow outside the uterus).
• Diagnostic tests include pap smear, rubella titer, T3 and T4 uptake determination and TSH levels, blood assay for FSH, estrogen, LH and progesterone, serum prolactin level and pelvic sonogram.

Fertility Tests

• Fern Test: detects a fern-like pattern in vaginal secretions to determine if the membranes have ruptured.
• Spinnbarkeit Test: measures the stretchability of cervical mucus (13-15cm) to indicate when a woman is fertile.
• Postcoital Test: assesses how sperm interacts with cervical mucus after intercourse.
• Ultrasonography & X-Ray: Used to determine patency of fallopian tubes and assess the depth and consistency of the endometrial lining.
• Sonohysterography: inspects the uterus using ultrasound.
• Hysterography: examines the uterus and fallopian tubes using imaging.

Surgical Evaluation for Infertility

• Uterine Endometrial Biopsy: tests for ovulation or reveals an endometrial problem.
  • Corkscrew-like appearance suggests ovulation has occurred.
  • Done 2 to 3 days before an expected menstrual flow.
• Hysteroscopy: visual inspection of the uterus using a hysteroscope.
• Laparoscopy: examines the position and state of the fallopian tubes and ovaries, scheduled during the follicular phase and done under general anesthesia.

Management of Infertility

• Correction of underlying problems.
  • Increase sperm count and motility.
    • Clomiphene citrate (Clomid) is used to increase sperm count.
    • Testosterone and HCG may be used.
    • Reducing infection
    • Hormone therapy
    • Clomiphene citrate (Clomid, Serophene) acts as the drug of choice for ovulation.

Surgery and Assisted Reproductive Techniques

• Artificial Insemination: installation of sperm into the female reproductive tract (intracervical or intrauterine).
• In Vitro Fertilization and embryo transfer
  • IVF (Mature oocytes are removed then fertilized by exposure to sperm in the lab.)
  • ET (final step of IVF, which inserts of the lab grown ova 40 hrs. after fertilization.)
• Gamete Intrafallopian Transfer (GIFT): placing eggs and sperm directly into the fallopian tubes.
• Zygote Intrafallopian Transfer (ZIFT): Fertilized eggs are transferred to the fallopian tube.
• Surrogate Embryo Transfer (SET): Transferring an embryo into the uterus of a surrogate mother.
• Blastomere Analysis (BA): examines the genetic makeup of an embryo before implantation.
• Gender and Genetic Preselection (GGP): differentiate X-carrying and Y-carrying sperm have been identified.

Alternatives to Achieve Pregnancy

• Surrogate Mother: a woman who agrees to carry a pregnancy.
• Adoption:
  • Traditional: couple contacts agency.
  • International: adoption of children from other countries.
  • Private: pregnant woman place their children for adoption directly.
• Childfree Living: Choosing to have no children.

Children's Acute & Chronic Alterations

• Congenital Heart Disease (HD): Inherited at birth.
  • Idiopathic; assumed as inheritance
• Acquired HD: Developed after birth.
  • Lifestyle

Risk Factors for Cardiac Disorders

• Rheumatic Fever: Autoimmune response follows a group A beta-hemolytic streptococcal infection.
• Hypertension: Increase blood pressure.
• Hyperlipidemia:
  • Inherited
  • High cholesterol / many fats in the blood.
    • Infants/toddlers (no restriction for brain development), school aged/adolescents / adults (30% total calories)

Fetal Circulation

• Fetal circulation involves the placenta and three shunts.
• Foramen Ovale: Bypasses lungs blood from RA to LA
• Ductus Arteriosus: Moves blood from PA to Aorta
• Ductus Venosus: Bypasses liver
• High oxygenated blood bypass the liver to IVC to RA

Lab Tests for Cardiac Disorders

• Fetal Echocardiography: Reveal details about heart anomalies as early as 18 weeks.
• Chest X-ray: Provides understanding about heart size & orientation, blood flow, & lung disorders (e.g. effusion)
• Chemistry & Hematology Tests:
  • Child’s electrolyte balance, hematologic state, and acid-base balance
  • K (lost with most diuretics),
  • Ca (myocardial contractility),
  • Na (indicator of fluid status)
  • Hgb & Hct (determine the need for blood transfusion),
  • Coagulation studies (PT - prothrombin time, PTT - partial thromboplastin time, INRI - international normalized ratio) imperative before and after cardiac surgery to prevent bleeding,
  • CK (MB) & Troponin Levels (for myocardial injury or damage),
  • CRP & ESR (inflammation),
  • BNP (hormone found in ventricles, in response to changes in ventricular stretch),
  • Arterial Blood Gas Testing (info about arterial acid-base balance)
• Electrocardiogram: Electrical activity of the heart.
• Holter Event Monitor:
  • Worn for 24-74 hours (for 30 days)
  • Gives a complete account of every heartbeat experience.
• Transthoracic Echocardiogram: Non-invasive UTZ, that gives detailed info about the heart structure and function.
• Computed Tomography / Magnetic Resonance Imaging: Noninvasive, provide detailed images of the heart and chest, typically used to adjunct to echocardiography.
• Exercise Stress Testing: Evaluate a child's clinical condition during increased myocardial demand.
• Cardiac Catheterization: Invasive procedure, catheter inserted in a large vein and artery.
• Cardiac Output: Volume of blood pumped by the ventricles each min.
  • HR/PR x Stroke Vol.
    • Stroke Vol. is affected by:
      • Preload: Vol. before contraction
      • Contractility: Modulate the rate and force of fiber shortening.
      • Afterload: Resistance after ejection.

Cardiovascular Disorders

• Heart Failure: Heart unable to supply oxygenated blood.
• Congenital Heart Defects:
  • Increase, decrease, obstruction of pulmonary blood
  • HLHS (Single ventricle defects)

Heart Defects (Blood Flow)

• Cyanotic HD: venous blood from the right side of the heart mixes with blood on the left side, also known as “Right to Left” Shunt..
• Acyonotic HD: “Left to Right” Shunt, oxygenated blood from the left side mixes with blood in the right side of the heart and goes back to the lungs again.

Defects that Increase Blood Flow

• Patent Ductus Arteriosus: Fetal shunt fails to close for few days of life
  • ↑ Blood flow = diuretics (furosemide)
  • ↓ Weight = ↑ caloric intake
  • W/ heart dilation = PDA closure
  • (Premature) infants w/ HF due to PDA = Indomethacin (cardiac catheterization for older children)
• Atrial Septal Defect: Portions of atrial septal tissue do not form well.
  • Secundum type (Most common, center of the atrial septum)
  • Primum defect (Lower part of the atrial septum near IVC)
  • Sinus Venosus Defects (located high in the septum)
• Ventricular Septal Defect: Portion of the ventricular septum does not close
• Atrioventricular Septal Defect: Hole between both atrium and ventricles
• Transposition of the Great Arteries:
  • Reversal of the great arteries
  • 2nd most common defect
  • 2 separate circulation
  • Jatene procedure (cutting of pulmonary artery & aorta, switching both vessels)
• Anomalous Pulmonary Venous Return & Truncus Arteriosus:
  • 2 rare, uncommon cyanotic defects
  • APVR (Some pulmonary veins drain into the right atrium instead of the left, causing partial oxygenation issues)
  • TAPVR (All pulmonary veins drain into the right atrium, leading to severe cyanosis)
  • TA (A single large artery supplies both systemic and pulmonary circulation, causing mixed oxygenated and deoxygenated blood flow)

Defects that Decrease Blood Flow

• Tetralogy of Fallot:
  • Intervention first year of life
  • 4 components of cyanotic defect:
    • Pulmonary artery stenosis
    • Ventricular septal defect
    • Overriding aorta
    • Right ventricular hypertrophy
  • Unknown cause

Defects with Obstruction to Systemic Blood Flow

• Coarctation of the Aorta:
  • Common to males
  • Narrowing of the aorta
  • Increase blood pressure in the upper extremities & lower pressure in the lower extremities.
  • Surgery:
    • Balloon angioplasty and stenting:
      • Using a balloon-tipped catheter to widen the artery and a stent (a small mesh tube) to keep it open.
    • Resection with End-to-End Anastomosis:
      • Removing a diseased or damaged section of tissue (resection) and then reconnecting the remaining ends to restore continuity
    • Subclavian Flap Aortoplasty:
      • Widen the narrowed part of the aorta using a part of the left subclavian artery
    • Bypass Graft Repair:
      • changes the direction of blood in the area and the aorta affected by aortic coarctation by using a graft
    • Patch Aortoplasty:
      • Expand the affected area by cutting across the vessel to attach a synthetic material there
• Aortic Stenosis:
  • The valve between the lower left heart chamber and the body's main artery (aorta) is narrowed and doesn't open fully.
• Single Ventricle Defects:
  • It occurs when one of the two pumping chambers in the heart, called ventricles, isn’t large enough or strong enough to work correctly.
  • Congenital
    • Sometimes chamber is missing Types:
      • Tricuspid atresia
      • Hypoplastic left heart syndrome (HLHS)
      • Mitral valve atresia (usually associated with HLHS)
      • Single left ventricle
      • Double inlet left ventricle (DILV)
      • Double outlet right ventricle (DORV)
      • Pulmonary atresia with intact ventricular septum (PA/IVS)
      • Ebstein’s anomaly
      • Atrioventricular canal defect (AV Canal)

Surgical Procedures for Single Ventricle Defects

• Norwood Procedure:
  • One within a few days of birth once the child is hemodynamically stable.
  • Creating a new aorta using the pulmonary artery and placing a shunt for pulmonary blood flow.
• Bidirectional Glenn Shunt:
  • 4 to 6 months of age
  • Relieve the volume load on the single right ventricle
  • 2 Procedures:
    • Ligation of the previously placed BT or Sano shunt
    • Disconnection of the SVC at its insertion to the right atrium & attachment of the SVC directly to the branch pulmonary artery.
• Fontan Procedure:
  • A type of open-heart surgery.
  • Usually have it when they’re 18–36 months old.
  • Disconnects the inferior vena cava (IVC) from the heart and redirects it to the pulmonary artery using a conduit, allowing blood to reach the lungs without passing through the right ventricle. A small hole (fenestration) is often made between the conduit and the right atrium to relieve pressure and allow some blood to return to the heart.
• Cardiac Surgery involves pre-operative and post-operative care.
• Discharging a child after cardiac surgery.

Other Cardiac Procedures

• Cardiac Catheterization:
  • Is a procedure in which a thin, flexible tube (catheter) is guided through a blood vessel to the heart to diagnose or treat certain heart conditions, such as clogged arteries or irregular heartbeats.
• Cardiac Transplantation:
  • Remove a person's sick heart and replace it with a healthy donor heart.
• Dysrhythmias:
  • Abnormal/irregular heartbeat.
  • Sinus Arrhythmia:
    • Irregularity in the sinus rate.
  • Causes (Sinus Bradycardia):
    • Electrolyte Deficiency
    • Anorexia Nervosa
    • Inflammation
    • Infection
    • Chagas Disease (Kissing Bugs)
    • Rheumatic Fever & Heart Disease
    • Lyme Disease (Borreliosis, Tick bites)
    • Sick Sinus Syndrome (Sinoatrial node malfunctions)
    • Heart Block
    • Drugs