176 Postpartum Complications for the PANCE: Hemorrhage, Sheehan & Endometritis

Hello and welcome to the Physician Assistant exam review podcast. This is episode 176, postpartum complications. Today we’re going to cover postpartum hemorrhages, Sheehan syndrome, and endometritis. Let’s jump right into the priming questions. This has been something I’ve just transitioned to. The priming questions get you started and thinking about the topics, whether you know them or not. Let’s just get started, think it through, and I’ll explain in just a second. A soft, boggy uterus above the umbilicus with heavy bleeding after delivery points to what cause of postpartum hemorrhage. A soft, boggy uterus above the umbilicus with heavy bleeding after delivery points to what cause of postpartum hemorrhage.

Number two, failure to lactate after major delivery hemorrhage points to what diagnosis?

Failure to lactate after a major delivery hemorrhage points to what diagnosis?

What’s the antibiotic of choice for endometritis after a C-section? What antibiotic do you use for endometritis after a C-section?

And then the last one, which second-line uterotonic is off the table in preeclampsia? Which one do you not use? Which uterotonic do you not use in preeclampsia? Great. The priming questions get your brain moving in the right direction. They start to build scaffolding for what’s coming. I know sometimes it feels a little jarring, a little awkward, but I promise you it is proven system for learning. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And we, during this show, we try to teach the medicine, but in a way that it’s going to stick in a way that’s going to show up for you during your exams, whether that’s EORs, the PACKRAT, the EOC, any of that. That’s the design here, is we want the information to go over it, but I don’t just want it to pass over you. I don’t just want it to move through you. I want you to retain it. I want you to think about it. I want you to build out the neural pathways that are going to help you have it on test day. That’s the goal here. That’s what we’re doing. All right, so let’s jump right in. We’re going to talk about postpartum hemorrhage to begin with. Postpartum hemorrhage is a cumulative blood loss of a thousand milliliters or more, or any blood loss with signs of hypovolemia within 24 hours of delivery. This is really important. So it’s cumulative blood loss of a thousand milliliters or more.

And that’s a lot, like a lot, a thousand milliliters. When I think about surgically, I think your average C-section between four and six hundred milliliters of blood loss, and that’s a lot for a surgery. Usually our blood loss is under a hundred milliliters for most surgeries I do. Once in a while, you know, total joints might get a little higher here or there. But realistically, we’re pretty low under four or five hundred in most surgical cases, unless there’s some kind of a problem. I think is a very fair statement. So to say a thousand milliliters, that’s a good amount of blood loss. So a cumulative blood loss of a thousand milliliters or more. And this is the other caveat to that, though. Any blood loss with signs of hypovolemia, we’ll get to those signs in just a second within 24 hours of delivery. But you should be thinking in your head as I’m going through this and being engaged and active, you should be thinking, what are signs of hypovolemia? What’s he talking about there? What are we thinking?

Okay. So there were two sort of classifications for postpartum hemorrhage. One is primary. That’s in the first 24 hours. This is most of the time. Secondary is 24 hours to 12 weeks, usually from retained tissue or infection. In general, postpartum hemorrhage is the leading cause of maternal death worldwide. And it says worldwide, but this realistically happens. This is not, you know, I, someone in our community a few years ago, passed away after delivery from a postpartum hemorrhage that went, she went, I believe, I don’t know the whole story, went to the ER following her delivery was sent home, some other things transpired, but it’s a real, real problem. This is not just something that says worldwide and you kind of think, oh, this doesn’t happen in the United States. It absolutely happens here. So we want to keep an eye out. Risk factors, these get sorted out into four causes, the things. So I’m going to kind of go through these as the causes of postpartum hemorrhage, but we’re going to start with risk factors. So it’s going to be the things that present those risk factors. So you’ll see what I mean here. So one of the major causes is atony, right? So the tone of the uterus, if the uterus doesn’t clamp down, then it’s not going to cut off the bleeding. It needs to clamp down after delivery. That’s part of the whole design of the system we’ve been talking about. Now, what are the risk factors? Well, if you have an over distended uterus, it has trouble clamping down. The tone is trouble, right? So what would cause an over distended uterus? Stop and think for a second. Don’t just listen to the podcast. Actually think this through. What would cause an over distended uterus?

How about multiple gestations? How about twins? How about triplets? How about quadruplets, right? All of that’s going to make it harder for the uterus to clamp down. Macrosomia, even one big baby, going to be harder to clamp down afterwards. Polyhydramnios, that’s going to be another problem, right? So these are risk factors.

Exhausted or relaxed uterus. So a prolonged labor.

If we use oxytocin for induction, that can be a risk factor. Chorioamnionitis. So if you have an infected uterus, it’s not going to contract as well.

Let me just run through with you. So our four T’s for causes are tone, trauma, tissue, and thrombin, meaning clotting problems. So we’re kind of stepping through them. As the risk factors, but I need you to have that overall presentation first.

So next we have trauma. So if you have an operative vaginal delivery, you may cause some trauma, right? There may be some problems where you’re going to increase your blood loss because you have traumatized the tissue. Macrosomia would be a risk factor. Caesarean section would be a risk factor factor. Tissue is the third T. And this really what this is talking about is retained placenta, right? So if you have a placenta accreta, if you have a prior caesarean, all those things will increase your risk for retained placenta. Let’s pause here for a second. Cause I always struggle here. Placenta accreta is when the placenta grows too deep into the uterine wall.

Usually this is after a caesarean. So the uterus is scarred and it gives it a place that it grows into that scar tissue and gets really adherent. So it won’t separate after delivery. And this causes that retention.

And just to be a little bit careful here. Placenta previa is a term that gets mixed up here and I’m just bringing it up because I always mix up placenta previa and placenta accreta and a couple of the others. This is a placenta previa is where the placenta sits over or right next to the cervical os. So we have to do a C section. Placenta accreta is when it’s, the placenta is stuck too deeply into the uterine wall, into the uterine lining. Hopefully that makes sense. Next to our fourth T is thrombin. So a clotting problem, it’s sort of a general catch-all for clotting issues. Here we talk about preeclampsia with HELLP, placental abruption and anticoagulants. So if you remember, HELLP is hemolysis, elevated liver enzymes and low platelets. So this is a severe form of preeclampsia. This is kind of the edge case. They get right upper quadrant pain, epigastric pain and nausea.

The low platelets is where the bleeding comes in. And treatment there is delivery plus magnesium. Placental abruption is when the placenta separates from the uterine wall before the baby’s born. Remember, this is painful bleeding, tender, rigid uterus, fetal distress.

Placenta previa bleeds without pain because that’s just the placenta sitting over the os.

Placental abruption is the disconnection of the placenta, right? And the reason, the problem here is you can become a setup for DIC because the risks for that are hypertension, cocaine, smoking and trauma. So you can wind up with disseminated intravascular coagulation issues. So that’s kind of the four T’s and the risk factors. I would know those and I know we sort of went through them and it might’ve felt kind of awkward how I went through them. Go check them out on the website. You’ll get a better overview of what that looks like inside of the notes, physicianassistantexamreview.com/176. But I think that’s something I would absolutely know is the different risk factors for postpartum hemorrhage because this is a big deal.

All right, let’s move into clinical presentation here. So what are the, what’s the clinical presentation of a postpartum hemorrhage? So if you have someone who comes into the ER or into your clinic after having their baby or, you know, they delivered last night and now in the morning, what are some things you think they might look like? What are they going to present like?

Let’s start with signs of hypovolemia. What are some signs of hypovolemia? You could probably rattle off at least two or three. If you stop and think, even if you’re in didactic gear early on, you could think of two or three reasons, signs of hypovolemia. Well, one would be tachycardia. Two of my list would be dizziness. They’d look pale. They might be cool or clammy. Slow capillary refill is a good one. Low urine output is a good sign. Confusion is sure we’re getting towards the end of the road here.

And of course, hypotension.

The vital signs are going to lag a little bit. Tachycardia will come in. But here’s the problem when we’re talking about specifically postpartum hemorrhage, a young, healthy woman will maintain her blood pressure for a long time, for a long time, a young, healthy women, woman will maintain her blood pressure until she has lost a lot of blood. So you can’t only look at blood pressure as the indicator, right? A lot of times you’d like to use that and you can, it is an indicator, but in this population, it’s not as, it’s not as good. As far as the uterine tone fields, you can actually feel the boggy uterus at or above the umbilicus. You can, you can palpate that and you can by palpating it, you’re actually also kind of solving this problem. Bleeding will slow with fundal massage, but fundal massage will actually increase the amount that the uterus is clamping down. And we do this intraoperatively. And you do this post, even for a vaginal delivery to help the uterus clamp down. So what will it look like for trauma? Well, if it’s a traumatic issue, you’re probably going to see bright red blood, coming from the vagina. You might find lacerations, you might see a hematoma, all of those things. Right. If we’re talking about a C section, it may be internal. So you’re not going to see the bleeding. So you say like, Oh, of course I would notice that you might, if it were a vaginal delivery, but you won’t, if it’s a, cesarean and it happens, I think just last week or the week before, there was a patient who had to be brought back to the OR after a cesarean. It happens. It’s not entirely uncommon that there’s some bleeding after a surgery and they have to go back to the OR and find the bleeding and put it into it. Right. That’s one of the things we need to keep in mind. We’re keeping an eye on this.

Tissue is next. So the placenta comes out incomplete or won’t separate at all. That’s accreta. So you can notice that if there was issues getting the placenta out, something to keep an eye on a major one for clotting problems, right? Is oozing from the IV sites or an incision. Then you’re thinking DIC. So what’s our question going to look like here? How is this going to present? Well, excuse me. There’s going to be something like, so what’s our question going to be here? What’s it going to look like? Well, it’s going to be something like heavy bleeding, probably shortly after delivery with a soft uterus.

And the answer is going to be, you know, what do you do here? And maybe she has some signs of hypovolemia. We’re going to start with fundal massage and oxytocin, right? That’s going to be the idea. We’ll get to, we’ll get to the two treatments in just a second. I’m jumping the gun there a bit. So diagnostics, how do you determine this? We got the risks. We got the causes. We got the, what the patient looks like walking through the door or laying in their bed the next day. Maybe they got up to go to the bathroom and they got dizzy. That kind of thing.

Okay. Now let’s talk about diagnostics labs. So first is quantitative blood loss. So what this means is you weigh pads and Ray-Tec and sponges and drapes in an effort to quantify how much bleeding there was, how much blood loss there was, and we did this during surgery for sure. Not in most cases, but in C-sections, we do quantitative blood loss. They actually weigh everything to get an idea of what the blood loss is, because it’s been shown that just looking at it is a, not a really good way to estimate the amount of blood loss. You know how hard it is to tell how much blood a patient has lost by guessing,

By seeing how many lap pads we used. It’s really, really difficult. And I, and I haven’t actually dug into this, but I’ve heard people talk about that they do studies on surgeon’s ability or, or, you know, scrubbed X abilities to judge it. And it tends to not be very close. You know, we’re in the ballpark. I can tell if it’s over under a thousand probably. But the difference between 50 milliliters and 150 milliliters or 200 milliliters and 400 milliliters, probably really hard to tell by eye.

As far as diagnostics go, again, you’re going to examine the uterus by manual exam for tone and look for lacerations and check for the placenta for missing pieces, that kind of thing. You’re going to get a CBC with hemoglobin and platelets, type and crossmatch, coag panel with fibrinogen. Hemoglobin is going to lag a little bit and it may be funny if you’re doing, lots of IV fluids. So keep that in mind.

A fibrinogen below 200 predicts severe bleeding.

You can do an ultrasound to look for retained placenta.

What are we going to do for treatment? Well, number one is going to call for help, right? You’re going to need, you’re going to need some hands on deck here. Number two is two large-bore IV needles. Our IVs, because we’re going to need fluids by manual uterine massage and oxytocin. This is your first, first, first steps. This is everything that happens all at once. Then we moved to second line, uterotonics.

And from what I’ve seen in the L&D where I am, they usually use misoprostol.

But you can use a carboprost, but not in asthma patients and methylergonovine, this is not in hypertensive patients or preeclampsia. You can use tranexamic acid.

This stops the body from breaking down the clots. It’s already making, so the clots hold up best to use within three hours of birth.

This is a medication that’s been used much more frequently of late. We use it in a lot of different surgeries. We use it in, sorry, we use it in total joints, lots of different places in a lot of different hours.

What else do we do?

In order to deal with this situation. Well, another one we’re going to do is fix the cause. We’re going to repair any lacerations. We’re going to remove, retain tissue. We’re going to look for a, anything that we can see that’s bleeding and take care of that. If it’s still bleeding, we can’t find it. We can’t stop it. A balloon tamponade. So you can put a balloon up into the uterus and inflate it. That may help, right? Tamponade just means putting pressure on uterine artery embolization. If the patient is stable is a possibility.

And the definitive treatment is a hysterectomy. You go in and take the uterus out. This is not a good plan because obviously it ends the patient’s ability to bear children, but also it is not the safest move when the, uterus has the blood supply it has during pregnancy. So it just carries its own weights to it. But this is the final stage is the hysterectomy remove the uterus.

You’re going to want to have massive transfusion protocol for large losses.

Don’t forget. We’re going to use oxytocin. I mentioned that earlier.

So again, here, what would the question stem look like? What are we talking about? Well, we’re going to see a patient who comes in and has atony and continues to have weak tone after oxytocin.

And then we’re going to have to decide what we’re going to give her. Next might be one possibility, right? And we went through, misoprostol would be the one that I would pick, but we went through those. That might be another, that might be a question you could look at.

What are our exam keys for this section? A boggy uterus above the umbilicus.

This is atony, loss of tone. So massage and oxytocin are how we’re going to fix that. A firm uterus plus ongoing bleeding might be a laceration. So we got to look for that oozing IV sites. This is a coagulopathy issue.

So we need to be on the lookout for DIC and what’s going on there. I hope that makes sense. I hope that’s clear. All right. We still have a long way to go, but I just want to stop here for a second and let you know that I have a ton of things coming as far as physician assistant exam review goes in the end of the year. We’re finishing out this year really, really strong. We’re in the middle of the October cohort of 33 Days to Pass the PANCE. And, we’re having a ton of fun and it is going fantastic. I just released to them a brand new mock exam with a diagnostic report on the end that is unlike anything that you’ve seen anywhere else. It goes through the types of questions you got wrong, how you got them wrong, why you might’ve gotten them wrong. If you took too long on certain areas, if you took too short on certain areas, if you lost focus in certain areas and it walks you through not just the content you get wrong, but gives you some idea of places you can improve in your test taking in your performance, in the whole picture, it’s been a ton of fun to send those out and get those back. Now I’m also putting together, I just released to them 1500 questions are about to get the other 500 and rounding up to 2000 questions. And I, excuse me, in a, in a, in a brand new question bank. And they’ve been absolutely loving that. That’s going to come out in November for everyone. We’re also going to do the registration for the December cohort of 33 Days to Pass the PANCE in November. So November is going to be super busy. The question bank and the mock exam are going to be part of a black Friday package, but just before that, we’re going to have registration for the December cohort of 33 Days to Pass the PANCE. Then in December, I’m going to be releasing at long, long last, the Final Step 3.0, I’ve stopped offering the 2.0 version because 3.0 is coming right around the corner. Super excited to get that out there. If you are interested in finding out about this stuff and being made aware of this stuff, of these resources that are going to be available to you, and you’re not on the email list, that’s the place to go. Physicianassistantexamreview.com/daily will get you to the email list. That’s where I send out daily tips, tricks, information. And we’ll let you know about when this stuff goes live and you’ll get the first on the list to hear about all these different things. All right, cool. So you can go to physicianassistantexamreview.com/daily to find out more and to get the latest information. All right, let’s move on to Sheehan syndrome. We still have a ways to go. Sheehan syndrome. This is the anterior pituitary dies from lack of blood flow after a severe postpartum hemorrhage. I wish that this was kind of weird. Why would this happen? But what happens is during pregnancy, the pituitary grows, but the blood supply doesn’t change, so a big drop in blood pressure causes an infarct. That’s the connection I didn’t realize in PA school. I just thought it was a weird thing and I could remember it, but I didn’t get the background picture. Interestingly enough, the posterior pituitary is usually spared risk factors. So a risk factor for Sheehan syndrome is going to be postpartum hemorrhage, right? Massive postpartum hemorrhage is what’s going to cause this. What’s our clinical presentation look like? Well, the symptoms follow the hormones in the pituitary. So if we have prolactin, we’re not going to, if we have a drop in prolactin, we’re not going to lactate, right? That’s usually the first sign is difficulty with lactation. FSH and LH drop. The menstruation does not come back and you can get loss of pubic hair and axillary hair, TSH, goes down. You can get fatigue, cold intolerance and weight gain, right?

ACTH goes down, you get weakness, low blood pressure, low blood sugar, low sodium, all of those things. So those are, you’re going to want to know those in order to be able to see this coming, but I think the question should be relatively to me, that should be relatively obvious.

So our diagnostics here, all those hormones are going to be low and the pituitary hormones that should be high or low or normal. So the gland hormones are low. So we get low prolactin, we get low free T4 with a low or normal TSH. We get low morning cortisol with a low or normal ACTH. We get low estradiol with a lower normal FSH and LH.

And, again, this is going to be a place you’re going to want to go back and check the notes. I’m not sure that listening through that unless you are killing it in endocrine, is going to be a place for you to hold onto that. You’re going to get an MRI is the bottom line. If you suspect this, you get an MRI and you find a, what they call an empty sella, which the sella turcica is the bony cup at the base of the skull that holds the pituitary and after the pituitary dies, it shrinks and spinal fluid fills that space. So on the MRI, that cup looks empty. So the MRI is what you’re going to get to prove this, outright. How are we going to treat it? Well, we are going to start replacing the things that the pituitary needs. So first we’re going to start with cortisol. So hydrocortisone comes before levothyroxine. This is one important caveat. I would absolutely mark down thyroid hormone first speeds up cortisol use and can trigger, trigger adrenal crisis. So hydrocortisone comes first, then levothyroxine. And the levothyroxine is adjusted by free T four, not TSH. And then they’re probably going to need, or they will need estrogen and progestin until the age of menopause or maybe beyond.

All right. Our exam keys here, postpartum hemorrhage, plus failure to lactate. That’s what I would be looking for. Right. If I was going to write a question, I was going to think about a question here. I’d have a patient who came into the office who had severe bleeding postpartum and then is having issues with lactation. And I would take it from there.

That’s going to be Sheehan syndrome. And the other key is cortisol before, thyroid hormone. That’s going to, before levothyroxine. All right. Our last one for today is going to be postpartum endometritis. This is an infection of the uterine lining after delivery, often spreading into the muscle wall. The most common postpartum infection. This is the most common postpartum infection is endometritis. Right. And this is bacteria usually coming from the vagina and the cervix. So it tends to be polymicrobial risk factors. A cesarean delivery is the strongest risk factor highest after labor or ruptured membranes.

Chorioamnionitis. I always struggle with this and I can’t pronounce it and I struggle with it. And I spend some time looking into it and it looks to me like chorioamnionitis is at the infection before the baby comes out. The amniotic fluid and the membranes become infected. The placenta make become infected. This is during labor and before, right? This is our risk factor with ruptured membranes. We talked about this before.

So this is where we get concerned about that long labor after a prolonged rupture of membranes.

Endometritis is an infection of the endometrial wall. So that’s sort of like after the baby’s delivered and you still have the infection of the uterus, that’s our endometritis.

Another risk factor here is many cervical exams. So if, or manual removal of the placenta, those are, might be seeding the, bacteria into the endometrium. Clinical presentation, fever of a hundred point four or higher. Usually this is a couple of days after delivery. It’s not an instantaneous. So if you get a fever like immediately after delivery or after C-section, usually not going to be an infection from that, although it’s possible. Usually it comes a couple of days later. A tender uterus, foul smelling, lochia, tachycardia, lower abdominal pain is a good one. That’s kind of what we’re thinking here for endometritis. What’s your question going to look like? So this would be something like a woman two days after a cesarean. I said, a C-section comes in with a fever, tender uterus, and foul lochia. The answer here is going to be something like you’re going to give IV, clindamycin and gentamicin, not an oral antibiotic. That’s going to be the key.

Our diagnostics. So what are we going to do to diagnose this? Well, if you think it through, stop and think, what would you do if a patient came in who had just delivered two days ago or three days ago, comes into your office and has lower abdominal pain, significant fever, tender uterus,

Tachycardia, but we’d start with calling this endometritis and they’ll prove it otherwise. So a fever plus a tender uterus is going to kind of be enough to get the ball rolling, right? You’re going to be nervous about this patient. A CBC is going to be supportive. We’re going to want to get one.

If she looks like she’s in septic shock, we’re going to move to blood cultures. We’re going to, we can do an ultrasound to look for retained tissue. If we suspect that to be a problem. And we can go through and we can rule out other reasons for postpartum fever, but we’re going to assume endometritis because we’re going to assume the worst and kind of go from that point.

So this could be a urinary tract infection, right?

But you’d have dysuria. This could be a straight up wound infection. If it’s a C-section, if you have a fever after a C-section, in that case, you would expect to see that at the site of the wound, redness, drainage, that kind of thing.

What else can cause fever after delivery? Mastitis, one red, painful breast, right? That would be a link there.

So those are things you kind of want to pay attention to. So you’re going to be thinking endometritis. And if you have that lower abdominal pain and you have all those signs, that’s definitely where you’re going.

But you want to keep those other pieces in mind. I jumped ahead a little bit in our question again. I started dropping those in, into the question is, is not going to be not just the diagnosis, but also the treatments. The treatment for endometritis is IV clindamycin plus gentamicin.

This usually goes for 24 to 48 hours and you don’t need oral antibiotics afterwards.

You can add ampicillin if there’s no response in 48 to 72 hours to cover enterococcus. Breastfeeding continues through all of this.

All right. So what’s next? What happens if it still doesn’t go away in 48 to 72 hours?

What are we thinking? Stop and think for a second. If she has endometritis and we’re giving her the right antibiotics and it’s not getting better, what might be going on? Well, if she has an abscess, right, that would be difficult to get to. So a CT or ultrasound and then drainage.

We talked about this touch on this before, but retained tissue. So you might want to do a D&C and to look for that exam keys. So post-cesarean fever plus tender uterus plus foul lochia equals endometritis.

For endometritis, what’s the medication? Well, we give it IV clindamycin and gentamicin.

All right. Let’s do a quick, quick run through. This is going a little bit long, but I want to just wrap everything up with a bow, kind of like a little package here. So let’s talk about, we have hemorrhaging, right? At delivery, there’s bleeding. We’re first going to check the tone. If the, if the uterus is boggy, we’re going to use massage and oxytocin.

Right. That’s going to be the thing. If we have that person with a hemorrhage and weeks later, they’re not producing milk, they’re not lactating and they haven’t gotten their period yet.

We’re going to be concerned about Sheehan syndrome. All right. Before we go over the priming questions, let’s talk about our study tip for today. One major, major key that is super important and makes things so much easier. But it does take some extra time and nobody wants to do it is going back to the material, finding a way to touch things more than once.

A lot of people heard about, I’ve known about repetition. A lot of people know about spaced repetition, but it’s the implementation that’s the difficult part. So how do you go back and touch information?

So one of the things I’d like to do is go through questions from previous sections. Not all, I don’t have to go through everything I’ve studied before, but can you go through some of the things you’ve studied before? Can you touch on things from last week? Can you touch on things from a month ago? Can you touch on things from yesterday? So the easiest way for me to explain this is let’s say you make a stack of a hundred index cards on a certain topic and you study those for a quiz. And then the quiz comes and goes and you did fine. Don’t throw those cards out.

I’m going to want you to go back to those and take a look at them from time to time. And then people will say, well, I can’t look at all a hundred of those because I’ve got another class where there’s another hundred. I have this before that. So there’s another hundred. So I literally have thousands of flashcards. So what do I do?

What I would do in that sense is I’d pull out 10 from that pile and I’d go through them. I’d set aside a little bit of time each day or each week for review of everything. But I know you can’t get to everything. So don’t worry about getting to everything, everything, worry about touching some of the older things, flip through your review books. Maybe just turn the pages and stop and read one section on something you covered a month ago or two months ago. This is how you stop the forgetting curve. You interrupt it. That’s how you break that cycle. So our study tip is today is to go back and see material you’ve covered before. Touch it a little bit. It’s that iterative learning that keeps those neural networks strong and building out. That’s what we’re looking for.

All right, next week, we’re going to be covering postpartum depression and trauma in pregnancy. So that’ll be what we do there. And let’s wrap up with our priming questions for today.

A soft boggy uterus over the umbilicus with heavy bleeding after delivery points to what cause of postpartum hemorrhage, uterine atony, failure to lactate after a major delivery. Hemorrhage points to what diagnosis? Sheehan syndrome, the infarcted anterior pituitary stops making prolactin and you don’t get, lactation. What’s the antibiotic of choice for endometritis after a C-section? IV clindamycin plus gentamicin. Which second line uterotonic is off the table in preeclampsia?

Methylergonovine, it raises the blood pressure. So we’re not going to give it to preeclampsia patients. Fantastic. All right. Great work today. I look forward to talking to you guys next week. Remember think different, work different, score different. I’ll see you next week. Take care.