20 - Perinatal Care Flashcards
Nutritional recommendations in pregnancy:
Calcium
1000 mg daily for those 19-50 yrs old (plus vitamin D 600 IU)
1300 mg daily for those < 19 years old (plus vitamin D 600 IU)
Nutritional recommendations in pregnancy:
Folic Acid
0.4 mg daily
Nutritional recommendations in pregnancy:
Iodine
220-250 micrograms daily
Nutritional recommendations in pregnancy:
Iron
27 mg daily
Why is folic acid supplementation important in pregnancy?
To prevent neural tube defects
What is the recommended caffeine intake during pregnancy?
< 300 mg/day
Does pregnancy increase or decrease the immune system?
decreases it
What is listeria present in?
unpasteurized milk, soft-ripened cheeses, deli meat
How do we prevent getting listeria?
Avoid unpasteurized milk, soft-ripened cheeses, deli meat, reheat until steaming hot, wash raw fruit/veggies well
What is salmonella present in?
raw seafood, raw eggs, sushi that hasn’t been properly handled/prepared
How do we prevent getting salmonella?
avoid raw or soft-cooked eggs, raw cookie dough, avoid sushi that hasn’t been prepared properly
What is methylmercury present in?
Fish (shark, swordfish, mackerel, albacore tuna)
How much fish is safe in pregnancy?
2 servings/week
How do we prevent methylmercury poisoning in pregnancy?
- Only 2 servings of fish/week
- Choose fish lower in mercury (shrimp, salmon, canned light tuna)
What is toxoplasma?
A parasite in raw meat, soil & dirty cat litter
How do we prevent toxoplasma in pregnancy?
Wear gloves if gardening, have someone else change the litter box, cook meat thoroughly
When is travel safe in pregnancy?
Generally safe up to 4 weeks before expected due date
What are the risks of air travel when pregnant?
Immobilization and pregnancy both increase the risk of venous thromboembolism:
-Maintain hydration, frequent walking, stretching & isometric leg exercises, compression stockings
Cabin hypoxemia:
-Concern in those with CV disease & compromised uterine blood flow (preeclampsia, growth restricted)
Cosmic radiation:
-ICRP recommends max exposure of 1 mSv over 40 week pregnancy (longest internal flight is <15% of this)
What things need to be considered before air travel?
- Increased risk of VT
- Comorbid conditions: respiratory & cardiac disease, pregnancy complications
- Air line policies
- Medical resources & insurance at destination
- Exposure to infectious diseases at destination (vaccination, malarial prophylaxis)
Are hot tubs/saunas safe in pregnancy?
- Avoid in 1st trimester
- Heat exposure in early pregnancy is associated with neural tube defects & miscarriage
Are hair treatments safe in pregnancy?
- Human studies showed very limited systemic absorption, quantities unlikely to reach fetus
- Personal use by pregnant women 3-4 times throughout pregnancy is not considered to be of concern
- Should be avoided if there are burns or open wounds on the area to be treated
- Occupational use (hairdresser): wear gloves, ensure adequate ventilation in workplace
What are some prenatal discomforts?
- Nausea & vomiting, heartburn, constipation, hemorrhoids
- Leukorrhea (increased vaginal discharge)
- Gingivitis
- Edema
- Varicose Veins
- Cutaneous changes: spider angioma’s, melasma, striae gravidarum
What is physiologic edema caused by?
- Hormone-induced Na retention (Increased plasma volume)
- Uterine compression of the interior vena cava
What are some differential diagnosis for edema in pregnancy?
- Preeclampsia
- DVT
- cellulitis
_____ ______ = symmetric, bilateral leg edema that lessens with recumbency (laying down)
physiologic edema
_____ = tender unilateral swelling of a leg or calf, erythema & warmth
DVT
_____ = hypertension and proteinuria
preeclampsia
_____ = tender unilateral swelling in a leg or calf, erythema (asymmetric), warmth and sometimes fever
Cellulitis
What are some symptoms that suggest preeclampsia?
- bilateral
- accompanied by HTN
- edema involves the hands, face & sacram
- blurry vision
- dyspnea
- nausea, vomiting, jaundice
- decreased urine output
- confusion, headache
- weight gain that is sudden and dramatic
- rash
What are some key questions that need to be asked when a pregnant patients comes to the pharmacy wondering about getting rid of swelling?
- Does the swelling get relieved when laying down/elevating them
- When did it start?
- Is it in both ankles?
- Any redness or warm to touch?
- Any fever?
- Maybe ask her to take BP reading
- Any swelling anywhere else in the body?
- Pitting edema? (leaves an impression in the leg which goes back to normal with time)
Are varicose veins itchy?
Yes - can be
Edema and varicose veins can cause such symptoms as ?
- numbness
- mild pain
- aching
- heavy feeling
- itching, throbbing, irritation around vein
Describe the etiology of varicose veins (same to edema)
- In addition hormones (progesterone) relax muscular walls of blood vessels
- Blood vessel valve weakens & blood stagnates in vein causing distension and ballooning
What are some self-management strategies for deem & varicose veins?
- Compression stockings
- Sleep in left side-laying position (allows IVC to open and more draining to happen over night)
- Maintain adequate fluid intake
- Avoid prolonged standing
- Rest with legs elevated often
- Do not sit with legs crossed
- Maintain physical activity
What is melasma/chloasma?
“Mask of Pregnancy”
- Dark skin discolouration occurs on sun exposed areas
- Generally affects the face, often symmetrical
- Caused by excess melanin in the skin
Why does melasma/chloasma happen in pregnancy?
Elevations in E and P levels in epidermal & dermal cells and melanocyte-stimulating hormone upon sun exposure may potentiate tyrosinase activity and thus stimulate melanogenesis
**Requires exposure to UV rays - SPF sunscreen is very important
Melasma/chloasma:
Risk factors
- genetic predisposition
- darker skin tones
Melasma/chloasma:
Does it stay after pregnancy is over?
Usually fades after delivery (within 1 year)
10-30% of cases persist
Describe spider angioma’s
- Central red pundit with radiating branches
- Usually appears in 2nd to 5th month of pregnancy
- Most common around eyes & areas drained by SVC (neck, face, upper chest, arms & hands)
- Vascular distention & proliferation of blood vessels during pregnancy increase risk
Who does spider angioma’s affect more?
Caucasians
Are spider angioma’s present after pregnancy?
90% regress by 3 months post partum
Striae gravidarum = ____ _____
stretch marks
Describe Striae gravidarum (stretch marks)
- Red or purple lines or streaks, fade to pale lines. Can be itchy.
- Commonly affect breasts, abdomen and thighs
Striae gravidarum (stretch marks): Risk factors
- degree of abdominal distension
- maternal weight gain
- genetic predisposition
- younger maternal age
Striae gravidarum (stretch marks): Mechanism ?
not well understood
-E, adrenocorticol hormone & relaxin: influence connective tissue formation (promotes separation of the collagen fibrils) leading to formation of striae when skin stretched
Striae gravidarum (stretch marks): Present after birth?
Usually persist postpartum, may fade over months to 1-2 years
Melasma:
_______ = key
prevention (broad-spectrum sunscreen)
Melasma:
Describe the pharmacological treatment options
- hydroquinone
- azelaic acid
- trentinoin (this is toxic during pregnancy so i’m assuming treatment is after birth)
Melasma:
Camouflage techniques?
mineral makeup containing titanium dioxide/zinc oxide
Do we treat angioma’s?
Treatment not required (resolve in 3 months)
Could treat with IPLS (intense pulsed light source)
List some common agents to treat striae gravidarum
- cocoa butter
- hyaluronic acid
- vitamin E
- cantella asiatica extract
- bitter almond oil
MOA of the agents to treat striae gravidarum?
- stimulation of fibroblastic activity leading to increased production of collagen
- increased blood perfusion through massaging of the area and potential anti-inflammatory
- increased skin hydration
_____ = only used post arum (toxic to babe)
tretinoin
What would you do if a person wants a skin lightening cream that is safe in pregnancy?
- Recommend broad-spectrum sunscreen
- Tell them that it will most likely go away after pregnancy
- Could recommend make up with titanium dioxide/zinc oxide
Prenatal Signs of Potential complications (prob signs for referral)
- Severe vomiting (risk of dehydration)
- Signs of infection (fever, diarrhea, pain on urination)
- Abdominal cramping
- Vaginal bleeding
- Sudden loss of fluid from vagina or continued leakage of fluid from the vagina (LOL THIS IS YOUR WATER BREAKING LMAO)
- decreased fetal activity
- signs of preterm labor (ex. low, dull backache, increased uterine activity compared to previous patterns; menstrual-like cramps; diarrhea, etc)
Describe normal nipple pain
- pain subsides within 30-60 seconds of initiation of feeding
- often peaks around 3-6 days postpartum
- usually resolves in about a week
Describe trauma nipple pain
- pain persists or increases throughout feeding
- lasts > 1 week
- cracks, fissures, bleeding
Describe bleb nipple pain
- shiny white bump at tip of nipple (blocked nipple pore)
- pinpoint pain on feeding
Describe eczema nipple pain
- bilateral
- Hx of eczema, assess for exposure to new irritant
- Red scaly rash usually not entered around nipple
Describe raynaud’s or vasospasm nipple pain
- Triphasic color change (red, white and blue)
- Intense pain, burning, numbness, prickling, stinging
- Pain on exposure to cold (may be during, following or b/w feedings)
Possible infections that can cause nipple pain?
mastitis
candidiasis
How can we manage nipple trauma?
Nipple care:
- Wash with warm water and mild soap when bathing
- Avoid excessive moisture
Cool or warm compresses
Acetaminophen or ibuprofen
Could use lanolin or hydro-gel dressings (avoid vitamin E oils or creams)
How do you manage a nipple bleb?
warm soaks
frequent feedings
How do you manage engorgement and plugged ducts?
- Optimize feeding technique & encourage frequent feeding
- Avoid tight or restrictive clothes (impede milk flow)
- Warm compress or shower may enhance letdown and facilitate milk removal (by expression or by baby)
- Cool compresses between feeding to decrease swelling/discomfort (ice 15 min on & 45 min off)
- Plugged ducts - massage breast from affected area toward nipple
List some risk factors for breast pain caused by mastitis (infection of breast tissue)
- previous mastitis
- engorgement
- poor milk drainage
- nipple damage
Mastitis:
Most common pathogen?
S. aureus
Mastitis:
Management?
- Supportive measures as for engorgement
- Antibiotics indicated if fever is present or if symptoms do not improve within 12-24 hours with supportive measures
- Cloxacillin or cephalexin 500 mg PO QID
- Clindamycin 300 mg QID if MRSA suspected or beta lactic allergy
- Treatment duration 10-14 days
*Symptoms should resolve within 48-72 hours of initiating antibiotics
Nipple Candidiasis:
Diagnosis?
- Pain out of proportion to physical finding (often sharp, shooting pain)
- Affected nipple appears pink/red & shiny or the skin may be flaky
- Exclusion of other causes of breast pain
Nipple Candidiasis:
Predisposing factors?
- history of infant oral or diaper candid infection
- history of maternal VVC
- previous antibiotic use
- nipple damage
Nipple Candidiasis:
Management?
- Non-pharms to prevent reinfection and cross contamination of candida
- Mother and child should be treated simultaneously
Nipple Candidiasis:
Treatment duration?
As with other fungal infections, continue 1 week AFTER patient is symptom free
Nipple Candidiasis:
What are the pharmacological treatment options?
- Topcial antifungals - miconazole or clotrimazole preferred over nystatin
- Applied after each feeding
-If fissures present, topical antibiotic often added
APNO = all purpose nipple ointment: 2% miconazole in mupirocin 2% ointment; betamethasone ointment 0.1% aa
- Possible add on therapy: Gentian violet 1% once daily for 3-4 days (used for a max of 1 week, should never be used alone)
- THIS STUFF IS SHIT - WHY IS IT IN OUR NOTES
-If treatment failure: consider Fluconazole 400 mg STAT then 200 mg daily for at least 2 weeks
What are common reasons to use a breast pump?
- To stimulate milk production
- To maintain milk supply
- To provide infant with breast milk
Tips for breast pumping
- Wash hands with soap and water before pumping
- Ensure that the pump pieces and milk collection containers are clean (wash with hot soapy water & rinse)
- Ensure flanges are the approbate size
- WTF is the flange man
How can you manage the difficulty with let-down (milk coming out?)
OMG USE NORMAL WORDS
- Gently massage the breasts before pumping
- Apply a warm wet cloth to breasts before pumping
- Pump in a quiet, darkened room to avoid distractions
- Look at a picture of the baby or smell of the baby’s blanket
List 3 ways to care for the vaginal area (perineum) after child birth
CTMA pg 1114
- Prevent constipation by drinking water and eating fibre
- Kegel exercises to strengthen the area
- Use a pillow when sitting
Signs for referral?
If you have severe pain, a foul-smelling discharge or a high fever
Lochia
uterine discharge after birth
Days 2-3 PP:
What type of Lochia?
Lochia = bright red, small clots
Days 3-10 PP:
What type of Lochia?
Lochia serosa = brown or pink
Days 10-up to 6 weeks PP:
What type of Lochia?
Lochia alba = white or pale yellow
Bleeding beyond 6 weeks, increasing bleeding or clots larger than a ____- size should be reffered
quarter/loonie
When does the period usually return?
within 1-6 months
List 3 post partum mood disorders
1) Postpartum “Blues” (max 2 weeks)
2) Postpartum Depression
3) Postpartum Psychosis
What are some postnatal red flags? (list 4)
- Abnormal vaginal bleeding
- Fever/chills
- Painful, difficult or frequent urination
- Breasts have signs of infection
