33. Postpartum Problems Flashcards
How long is the puerperium.
What are the main risks/problems associated with the postnatal period?
What is the most common cause of maternal death?
What does SBAR stand for?
Time from delivery to 6w (time taken for uterus to involute, most physiological changes of pregnancy returned to normal). Lactation and psychological strains continue >6w.
Postpartum haemorrhage (PPH), thromboembolic disease (TED), psychiatric disorders, pre-eclampsia, sepsis, cardiac disease (leading cause of direct death e.g. cardiomyopathy, aortic dissection, acute coronary syndrome, sudden adult death syndrome).
Medical and mental health problems in pregnancy (2/3). Only 1/3 from direct complications of pregnancy. Main cause in UK: cardiac disesae due to immigration.
Situation, Background, Assessment, Recommendation.
What is PPH and the 2 types?
What are the causes of primary PPH? (4 T’s)
What are some predisposing factors to PPH.
Excessive bleeding following delivery. Primary: >500ml loss from genital tract within 24h of delivery. Secondary: abnormal bleeding from genital tract from 24h after delivery to 6w. Normally presents in community.
Tone (70%, uterus doesn’t contract back), Trauma (20%), Tissue (9%, retained placenta), Thrombin (1%, if e.g. antepartum haemorrhage, all clotting factors used up).
Antepartum haemorrhage, placenta praevia, multiple pregnancy, pre-eclampsia, nulliparity, previous PPH, maternal obesity/age, multiparity >4.
What are some intrapartum risk factors?
What is the most comon cause of PPH? What are the steps to take if this occurs?
What are some uterotonics?
What is a Bakri balloon and B-lynch?
Emergency C-section, elective CS, retained placenta, episiotomy, operative vaginal delivery, labour >12hrs, >4kg baby, maternal pyrexia in labour.
Uterine atony (uterus fails to contract after the delivery). Initial step: bimanual uterine massage and compression, oxytocic agents (syntometrine, syntocinon, prostaglandins).
Induce contraction or greater tonicity of the uterus: syntometrine, IVI syntocinon, PGE1, PGF2alpha, IV ergometrine (causes vasoconstriction).
Bakri balloon: used for temporary control/reduction of postpartum hemorrhage. [Pic] B-lynch: compression suture to keep uterus squeezed and tonic.
What is uterine artery embolisation? What else could be done?
What are the causes of secondary PPH?
How would you investigate and treat?
(If Bakri balloon and suture ineffective) radiologist passes pellet through femoral artery to try and semi-block it to reduce bleeding. Could also have vascular approach: bilateral ligation of uterine arteries/internal iliac. Resort to HYSTERECTOMY sooner than later.
Infection (endometritis), tissue (retained products of conception - most common).
FBC, CRP, blood cultures, high/low vaginal swab, MSU, USS if RPOC suspected. Tx: broad spectrum IV abx, if RPOC evacuate afer 24hrs of abx.
What is thromboembolic disease and how is it related to PPH?
What are some pre-existing risk factors for TED?
What are some pregnancy-related risk factors for TED?
A hypercoaguable state. Main protective physiological change against PPH is increasing clotting factors and reducing anticoagulants, but this predisposes to TED! Leading direct cause of maternal death.
Previous VTE, thrombophilia congenital/acquired, age >35, obesity BMI >30, parity >4, gross varicose veins, paraplegia, sickle cell, inflammatory disorders. Risk assessent scoring chart.
Surgical proceedure, dehydration, sepsis, pre-eclampsia, excessive blood loss, prolonged labour, immobility after delivery.
What are some symptoms of VTE?
How would VTW be investigated and managed?
Which postpartum psychiatric disorders might a woman present with?
DVT (painful, swollen, red leg). PE (sudden chest pain and breathlessness, dizziness, hypoxia), central vein thrombosis (headache, seizures).
Investigations: history, exam, ABG, USS, CXR, ECG. Mx: risk assessment, early mobilisation, good hydration, TEDs, LMW heparin, avoid COCP. Warfarin after delivery.
Postpartum blues/depression/psychosis.
Describe postpartum blues.
Describe perinatal depression. How is it treated?
Describe puerperal psychosis, its symptoms and treatment.
Tearfulness, lability, reactivity, peaks 3-5d after delivery, in 50-80% women, unrelated to environmental stress and psychiatric history. May be hormonal.
Low mood common among women during pregnancy and first postparum year, offer meds and counselling. Tx: largely the same for clinical depression, unless cause identified.
Acute mental ilness. Symptoms: loss of contact with reality, hallucinations, severe thought disturbance, abnormal behaviour, often no insight, sudden onset usually in first 10d after birth. Mania, depressive or atypical psychosis. Tx: same as general psychosis.Treat in same unit so mum has access to baby!
When should you admit a patient to a mother and baby unit?
What are the 3 types of pregnancy induced hypertension?
Rapidly changing mental state, suicidal ideation, pervasive guilt/hopelessness, estrangement from child, beliefs of inadequacy as mum, psychosis.
Gestational hypertension (no proteinuria), Pre-eclampsia, Eclampsia (PE + fits). Treat with antenatal hypertensives e.g. beta blocker labetalol or 2nd line nifedipine (Ca channel blocker). Cotrol fits with MgSO4. If previous PE advise women to tkae asprin to help with vasodilation of placental bed.
