Liver disorders in pregnancy, abnormal uterine bleeding, puerperium, abnormal puerperium, uterine inversions, partogram, and contraceptives

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Here is a comprehensive review of all seven topics, drawn from Creasy & Resnik's Maternal-Fetal Medicine, Katzung's Basic and Clinical Pharmacology, Robbins Basic Pathology, Sabiston Textbook of Surgery, Rosen's Emergency Medicine, Tintinalli's Emergency Medicine, and Textbook of Family Medicine.

1. Liver Disorders in Pregnancy

Source: Creasy & Resnik's Maternal-Fetal Medicine, pp. 1582-1590

Liver disease in pregnancy is divided into conditions unique to pregnancy and those that coincide with pregnancy. Liver function test reference ranges change in pregnancy - alkaline phosphatase rises markedly in the third trimester (130-418 IU/L vs. 30-130 IU/L non-pregnant), while AST, ALT, and bilirubin remain similar or slightly lower.

A. Intrahepatic Cholestasis of Pregnancy (ICP)

Epidemiology: Affects ~0.7% of White women, ~5% of Chilean women; more common with multiple gestations, age >35, and in winter months. Recurrence rate is 60-90%.

Pathogenesis:

Genetic mutations in biliary transporters: ABCB4, ATP8B1, ABCB11 genes
Elevated reproductive hormones impair bile acid transport (particularly the farnesoid X receptor)
Women with hepatitis C infection are more susceptible

Clinical Features:

Intense, generalized pruritus (especially palms and soles) - the hallmark
No primary rash (excoriations from scratching may be seen)
Jaundice in severe cases

Diagnosis:

Serum bile acids >10 μmol/L = diagnostic
Serum bile acids >40 μmol/L = severe disease
Elevated AST and ALT may precede bile acid rise by weeks

Fetal Complications (with bile acids >40 μmol/L):

Preterm labor
Fetal asphyxial events
Meconium-stained amniotic fluid
Sudden intrauterine death (arrhythmia mediated)

Management:

Ursodeoxycholic acid (UDCA): 10-15 mg/kg/day (500 mg BD, max 2000 mg/day) - reduces pruritus and biochemical abnormalities
Second-line: dexamethasone, S-adenosylmethionine, cholestyramine
Delivery timing is guided by severity of bile acid elevation; early delivery often recommended for severe disease

B. Acute Fatty Liver of Pregnancy (AFLP)

A rare but life-threatening disorder of microvesicular fat deposition in hepatocytes.

Swansea Diagnostic Criteria (6 or more required, in absence of another cause):

Criterion	Threshold
Vomiting	Present
Abdominal pain	Present
Polydipsia/polyuria	Present
Encephalopathy	Present
Elevated bilirubin	≥14 μmol/L
Hypoglycemia	<4 mmol/L
Elevated urea	>340 μmol/L
Leukocytosis	≥11 × 10⁹/L
Ascites or bright liver on US	Present
Elevated AST or ALT	>42 IU/L
Elevated ammonia	>4 μmol/L
Renal impairment (creatinine)	>150 μmol/L
Coagulopathy (PT/aPTT)	PT >14 s or aPTT >34 s
Microvesicular steatosis (biopsy)	Present (oil red O or EM)

Imaging: CT is best for showing fat infiltration (successful in ~50% of cases).

Management:

Multidisciplinary team: MFM, hepatology, ICU, neonatology
Delivery is definitive treatment
Correct coagulopathy (monitor PT, aPTT)
If placenta is still in situ, do not remove it before repositioning in uterine inversion (applies to combined scenarios)
Differential diagnosis: acetaminophen overdose can mimic AFLP; check levels

C. HELLP Syndrome

Hemolysis, Elevated Liver enzymes, Low Platelets - a severe variant of preeclampsia occurring in the third trimester or peripartum.

Features:

Microangiopathic hemolytic anemia
AST/ALT elevation (often 2-10x normal)
Platelets <100,000/μL
Right upper quadrant or epigastric pain (hepatic capsule distension)
May develop hepatic hematoma or rupture

Management: Delivery is the only definitive treatment; corticosteroids may be used to mature the fetus and temporarily improve platelet counts.

2. Abnormal Uterine Bleeding (AUB)

Sources: Robbins Basic Pathology p. 587; Sabiston Textbook of Surgery p. 2929

Definition: Bleeding that occurs in excess of or in addition to normal menstrual cycle bleeding. Normal menstrual cycle: every 24-38 days, duration 4-8 days.

The older terminology (menorrhagia, metrorrhagia, dysfunctional uterine bleeding) has been replaced by the PALM-COEIN classification system (established by FIGO, 2011):

Group	Acronym	Entities
Structural (PALM)	P	Polyp
	A	Adenomyosis
	L	Leiomyoma
	M	Malignancy and hyperplasia
Non-structural (COEIN)	C	Coagulopathy
	O	Ovulatory dysfunction
	E	Endometrial causes
	I	Iatrogenic (medications)
	N	Not otherwise classified

Causes by age group:

Age Group	Cause
Prepuberty	Precocious puberty (hypothalamic/pituitary/ovarian origin)
Adolescence	Anovulatory cycle, coagulation disorders
Reproductive age	Pregnancy complications (abortion, ectopic, trophoblastic disease), leiomyomas, polyps, endometritis, coagulopathy, PCOS
Perimenopausal	Anovulatory cycles, endometrial hyperplasia/carcinoma
Postmenopausal	Atrophy (most common), endometrial carcinoma

Dysfunctional Uterine Bleeding (DUB):

Uterine bleeding without structural abnormality - most commonly due to anovulation
Anovulatory causes: hypothalamic/pituitary imbalance (at menarche and perimenopause), prolactinoma, PCOS, obesity, malnutrition
Can also result from luteal phase defect (insufficient progesterone from corpus luteum)

Workup:

Detailed history + pelvic exam
Pregnancy test
CBC, thyroid function, prolactin, cervical cancer screening
STI screening
Pelvic ultrasound
Coagulation screen (if heavy bleeding since menarche, family history, on anticoagulants)
Endometrial biopsy for:
- All women ≥45 years with AUB
- Women <45 with obesity/ovulatory dysfunction, persistent/refractory AUB, or familial cancer risk

Postmenopausal Bleeding:

Always abnormal; most common cause is endometrial atrophy
Major concern: endometrial carcinoma (must be excluded)
Evaluate with transvaginal ultrasound + endometrial biopsy

Management Options:

Medical: hormonal (progestins, OCPs, levonorgestrel IUD, GnRH agonists), NSAIDs, tranexamic acid
Surgical: endometrial ablation, hysteroscopic polypectomy/myomectomy, hysterectomy (for refractory cases)

3. Puerperium

Source: Textbook of Family Medicine 9e, pp. 518-520

The puerperium is the time during which the mother's anatomy, physiology, and biochemistry return to the non-pregnant state. It begins at the third stage of labor and is complete at 6 weeks postpartum.

Normal Physiologic Changes

Immediate (first 24 hours):

Pulse rate drops
Temperature may be slightly elevated
Leukocytosis up to 20,000/μL (normal finding)
Lochia rubra: grossly bloody vaginal discharge

Days 3-10:

Lochia serosa: serous, pinkish-brown
Diuresis begins (urinary output increases, may contain protein and sugar)
Hematocrit artificially elevated (due to decreased intravascular volume)

Week 2 onward:

Lochia alba: pale yellow-white
Uterus: after 5-7 days, firm, nontender, midway between symphysis and umbilicus; not palpable abdominally by 2 weeks

Uterine involution management:

Manual massage for 1 hour after third stage
Breastfeeding promotes uterine contraction via oxytocin release
If uterus not contracting: oxytocin 10 units IM or IV infusion (10-30 U/1000 mL at 125-200 mL/hr)
Active management of third stage (oxytocin before placental delivery) decreases uterine atony and PPH

Other considerations:

Regular diet can be offered as soon as patient requests it (after normal vaginal delivery)
Early ambulation encouraged
No vaginal douching in early postpartum period
Bladder care: prevent retention and overdistention (particularly when oxytocin discontinued - rapid diuresis occurs)
Analgesics: avoid meperidine in breastfeeding mothers (long half-life metabolite toxic to neonates)
Most drugs are secreted in breast milk

4. Abnormal Puerperium

Complications of the puerperium requiring medical attention:

A. Postpartum Hemorrhage (PPH)

Primary PPH: >500 mL blood loss within 24 hours (>1000 mL after cesarean)

Risk factors (from Tintinalli's):

Primiparity or grand multiparity
Previous PPH
Preeclampsia
Prior cesarean section
Placenta previa or low-lying placenta
Macrosomia
Multiple gestation
Prolonged labor

The "4 T's" of PPH:

Tone (uterine atony - most common, 80%)
Tissue (retained placenta)
Trauma (lacerations, uterine rupture, inversion)
Thrombin (coagulopathy)

Management of uterine atony:

Bimanual uterine massage
Oxytocin (20-40 U in 1L NS at 200-500 mL/hr)
Methylergometrine (methergine) 0.2 mg IM (contraindicated in hypertension)
Misoprostol 800-1000 mcg rectally
Carboprost (15-methyl PGF2α) 0.25 mg IM q15-90 min (contraindicated in asthma)
Uterine packing / intrauterine balloon
Surgical options: B-Lynch suture, uterine artery ligation, hysterectomy

B. Postpartum Fever / Puerperal Sepsis

Temperature ≥38.5°C on any day, or ≥38°C on two consecutive days excluding the first 24 hours
Common causes: endometritis (most common), UTI, wound infection, mastitis, DVT
Endometritis risk increased after cesarean section
Treatment: broad-spectrum IV antibiotics (e.g., gentamicin + clindamycin)

C. Postpartum Depression (PPD)

Occurs in 10-15% of women
Onset within 4 weeks postpartum (DSM-5 definition)
"Baby blues" (transient, first 2 weeks) must be distinguished from true PPD
Treatment: CBT, SSRIs (sertraline preferred in breastfeeding)
Postpartum psychosis (rare, 1-2/1000): emergency, requires hospitalization

D. Mastitis

Painful, erythematous, firm area of breast, usually with fever
Common organism: Staphylococcus aureus
Continue breastfeeding; treat with dicloxacillin or cephalexin
If abscess forms: surgical drainage

E. Secondary PPH

Excessive bleeding 24 hours to 12 weeks postpartum
Causes: retained products of conception, endometritis, coagulopathy, subinvolution of the placental site
Management: ultrasound, uterine evacuation if retained products confirmed

5. Uterine Inversion

Sources: Rosen's Emergency Medicine p. 3421; Tintinalli's Emergency Medicine p. 686

Definition and Incidence

Uterine inversion is a serious obstetric emergency in which the uterine fundus collapses into and through the uterine cavity. It occurs during the 4th stage of labor and complicates approximately 1 in 2000 deliveries. Maternal mortality can reach 15% if not promptly managed.

Classification

Grade	Description
1st degree (Incomplete)	Fundus inverts but remains within uterine cavity
2nd degree	Fundus protrudes through cervix but within vagina
3rd degree (Complete)	Fundus protrudes beyond the introitus
4th degree (Total)	Both uterus and vagina are inverted

Risk Factors

Excessive fundal pressure during delivery
Forceful traction on the umbilical cord (especially with fundal placenta)
Placenta accreta
Congenital uterine anomalies
Connective tissue disorders
Magnesium sulfate use in antepartum period
Primiparity

Clinical Features

Sudden, severe lower abdominal pain
Profuse vaginal bleeding with hemodynamic instability
Absence of uterine corpus on abdominal palpation
Fundus visible at cervical os or protruding through introitus
Ultrasound can confirm the diagnosis

Management (Stepwise)

Simultaneous resuscitation: aggressive IV fluid resuscitation, call for help, cross-match blood
Withhold all uterotonics immediately (oxytocin, ergometrine, prostaglandins) - they cause cervical ring contraction that prevents replacement
Do NOT remove the placenta if still adherent - removal causes massive hemorrhage; replace the uterus first
Manual repositioning (Johnson's maneuver): push the fundus upward through the introitus toward the umbilicus with the palm of the hand
If cervical ring prevents repositioning:
- Terbutaline 0.25 mg IV or SC (tocolytic)
- Magnesium sulfate 4-6 g IV over 15-20 min
- A Rusch balloon catheter can be placed to maintain the corrected position
Once replaced: restart oxytocin + prostaglandins; maintain firm manual pressure until cervical ring contracts
If all fails: halogenated anesthetics (for uterine relaxation) ± surgical repair (Huntington's or Haultain's procedure)
Post-correction: assess for uterine perforation, retained placenta, vaginal lacerations

6. Partogram

A partogram (also called partograph) is a graphical record of the progress of labor and the condition of the mother and fetus plotted against time.

Purpose

Monitor labor progress objectively
Early identification of prolonged/obstructed labor
Guide decisions on augmentation or operative delivery
Reduce maternal and perinatal morbidity and mortality (particularly in low-resource settings)

Components of the WHO Partogram

Fetal condition:

Fetal heart rate (normal: 110-160 bpm)
Amniotic fluid (clear [C], meconium [M], blood [B], absent [A])
Molding of fetal skull

Labor progress:

Cervical dilatation plotted against time (central feature)
Alert line: a line drawn from 3 cm at the time of admission, rising at 1 cm/hour - marks normal progress
Action line: drawn 4 hours to the right of the alert line - crossing this line indicates need for intervention
Descent of the presenting part (fifths palpable abdominally)
Uterine contractions (frequency, duration, intensity per 10 minutes)

Maternal condition:

Pulse, blood pressure, temperature
Urine output, protein, acetone
Medications, IV fluids

Phases of Labor (on the partogram)

Phase	Cervical Dilatation
Latent phase	0-3 cm (prolonged if >8 hours primigravida, >6 hours multigravida)
Active phase	3-10 cm (minimum rate 1 cm/hour)

Interpretation

Cervical dilatation left of alert line: normal progress
Between alert and action lines: heightened monitoring, assess cause, consider transfer if in peripheral setting
Crossing action line: clinical reassessment, possible augmentation with oxytocin, or cesarean section if obstructed labor

WHO Simplified Partogram (2018)

The WHO revised its partogram in 2018, using a single threshold of 1 cm/hour across the active phase (previously 4 hours vs. 2 hours). This guides when to reassess rather than mandating automatic intervention.

7. Contraceptives

Source: Katzung's Basic and Clinical Pharmacology 16th Ed., pp. 1141-1145

Pharmacologic Effects of Combined OCs

System	Effect
Ovary	Suppressed follicular development; corpora lutea absent; ovaries may shrink; 97% resume ovulation by 3rd post-treatment cycle
Uterus	Thicker cervical mucus; endometrial atrophy with 19-nor progestins
Breast	May cause breast tenderness or mild enlargement
Liver	Increased αs-globulins, fibrinogen; increased thyroxine-binding globulin → elevated total T4 but normal free T4; delayed clearance of bile → increased cholelithiasis risk
Blood	Increase in Factors VII, VIII, IX, X; decrease in antithrombin III → VTE risk
Lipids	Estrogen raises TG, total cholesterol, HDL; progestins (especially 19-nor) antagonize this; HDL may decrease with androgenic progestins
Carbohydrates	Altered glucose tolerance; progestins increase basal insulin
Renin-angiotensin	Increased plasma renin activity, increased aldosterone

Adverse Effects

Mild:

Nausea, mastalgia, breakthrough bleeding, edema (estrogen-related; managed by reducing estrogen dose)
Headache (migraine may worsen - discontinue if new-onset migraine)
Missed withdrawal bleeding (may mimic pregnancy)

Moderate (may require discontinuation):

Breakthrough bleeding (most common with progestin-only pills - 25%)
Weight gain (with androgenic progestins)
Hyperpigmentation (melasma) - 5% at 1 year, 40% at 8 years
Acne/hirsutism (with 19-nortestosterone derivatives)
Vaginal infections (more common and harder to treat)
Amenorrhea post-pill (galactorrhea possible; check prolactin for prolactinoma)

Severe:

Thromboembolic disease: increased VTE risk (especially with Factors VII, VIII, IX, X rise; antithrombin III decrease) - exacerbated in smokers >35 years and women with inherited thrombophilias
Hypertension
Glucose intolerance / worsening diabetes
Hepatic adenoma (rare, associated with long-term use)
Cerebrovascular accidents (especially in women with migraine with aura)
Cholelithiasis

Non-Hormonal Contraceptives

Method	Mechanism	Notes
Copper IUD	Spermicidal (copper ions); alters tubal transport	Can be used as emergency contraception up to 5 days; lasts 10+ years
Condoms (male/female)	Barrier	Only method with STI protection
Diaphragm/cervical cap	Barrier + spermicide	Requires fitting
Spermicides	Chemical disruption of sperm	Low efficacy alone; best combined with barrier
Fertility awareness	Periodic abstinence	Requires regular cycles
Surgical (tubal ligation/vasectomy)	Permanent occlusion	Considered permanent

Emergency Contraception

Method	Timing	Mechanism
Levonorgestrel (Plan B)	Up to 72 hours (effective up to 120 hrs)	Delays/inhibits ovulation; does NOT disrupt established pregnancy
Ulipristal acetate (ella)	Up to 120 hours	Selective progesterone receptor modulator; inhibits ovulation
Copper IUD	Up to 5 days	Most effective; provides ongoing contraception

Contraindications to Combined OCs (WHO Category 4 - Absolute)

Breastfeeding <6 weeks postpartum
Current/history of VTE
Ischemic heart disease or stroke
Migraine with aura
Smoking age >35 years
Hypertension ≥160/100 mmHg
Active liver disease
Known thrombogenic mutations (Factor V Leiden, etc.)
Current breast cancer

Key references:

Creasy & Resnik's Maternal-Fetal Medicine, Chapter 64 (Liver Disorders Unique to Pregnancy)
Katzung's Basic and Clinical Pharmacology 16e, Chapter 40 (Hormonal Contraception)
Robbins & Kumar Basic Pathology (Abnormal Uterine Bleeding)
Sabiston Textbook of Surgery, Chapter 120 (AUB - PALM-COEIN)
Textbook of Family Medicine 9e (Puerperium)
Rosen's Emergency Medicine (Uterine Inversion)
Tintinalli's Emergency Medicine (Uterine Inversion and Rupture, PPH)

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1. Liver Disorders in Pregnancy

A. Intrahepatic Cholestasis of Pregnancy (ICP)

B. Acute Fatty Liver of Pregnancy (AFLP)

C. HELLP Syndrome

2. Abnormal Uterine Bleeding (AUB)

3. Puerperium

Normal Physiologic Changes

4. Abnormal Puerperium

A. Postpartum Hemorrhage (PPH)

B. Postpartum Fever / Puerperal Sepsis

C. Postpartum Depression (PPD)

D. Mastitis

E. Secondary PPH

5. Uterine Inversion

Definition and Incidence

Classification

Risk Factors

Clinical Features

Management (Stepwise)

6. Partogram

Purpose

Components of the WHO Partogram

Phases of Labor (on the partogram)

Interpretation

WHO Simplified Partogram (2018)

7. Contraceptives

Categories

A. Hormonal Contraceptives

Pharmacologic Effects of Combined OCs

Adverse Effects

Non-Hormonal Contraceptives

Emergency Contraception

Contraindications to Combined OCs (WHO Category 4 - Absolute)