450 SBAs in Clinical Specialties - Post-partum Problems Flashcards
- Intraoperative complications
A 31-year-old undergoes a planned caesarean section for a breech presentation. After delivery of her healthy baby there is difficulty in delivering the placenta, as it is adhered to the uterus. She has lost 5 L of blood as a result of the placenta accreta. The placenta has been removed but she is still bleeding and is cardiovascularly unstable despite blood product replacement. What would be the most management to definitively arrest haemorrhage?
A. Syntocinon infusion
B. B-Lynch suture
C. Internal artery ligation
D. Hysterectomy
E. Intrauterine balloon
D. Hysterectomy
2 D This woman is in extremis. Primary post-partum haemorrhage in this case has been due to the retained placenta accreta. Once the placenta is removed (often they are left in situ) the aim is to help the uterus contract and compress any remaining bleeding uterine vessels. Syntocinon (A) may well be part of the initial management. The crucial part of this question is how unwell she is. No obstetrician wants to perform a hysterectomy (D) on a 30-year-old but this may be necessary. She has already lost 5 L of blood so this has been a complicated operation so far. A B-Lynch suture (B) is an external uterine suture that helps uterine contraction. A balloon (E) would provide internal uterine tamponade against any bleeding vessels. Internal iliac artery ligation (C) would prevent blood flow down the uterine artery reducing the blood volume reaching the uterus. All of the above could be part of her management but in this case she is so unwell that performing a caesarean hysterectomy would be the correct course of management.
- Post-partum complications (1)
A 39-year-old woman is 6 days post-partum and has come back to hospital with shortness of breath. She is struggling to breath at rest, has a respiratory rate of 28, pulse 115, BP 105/60 mmHg, temperature 37.4° C. On examination she has an audible wheeze and cough. Investigations reveal a PO2 of 9.5 kPa on arterial blood gas and a PCO2 3.7 kPa, pH 7.36, base excess -3.4. A chest x-ray shows some upper lobe diversion and bilateral diffuse shadowing with an enlarged heart. Her haemoglobin is 8.9 g/dL, white blood count 11.1 × 109/L and C-reactive protein 21 mg/L. What is the most likely cause of her symptoms?
A. Lower respiratory tract infection
B. Pulmonary embolism
C. Peri-partum cardiomyopathy
D. Systemic inflammatory response syndrome (SIRS)
E. Post-partum anaemia
C. Peri-partum cardiomyopathy
3 C This woman appears to be unwell. Her tachycardia, tachypnoea, low grade pyrexia and cough would give weight to the diagnosis of a lower respiratory tract infection (A). She is hypoxic, raising the suspicion of a pulmonary embolus (B) but she has no chest pain, does not have a respiratory alkalosis on her ABG and there are chest x-ray findings that could otherwise explain her hypoxia. She does not meet the diagnostic criteria for SIRS (D) and there is no proof of infection yet. Her haemoglobin is low (E) but we would not expect to see this level of symptomatic anaemia at 8.9 g/dL. The diagnosis is to exclude is peri-partum cardiomyopathy (C). Although it is rare it has a mortality rate of 9–15 per cent. It usually develops in the last month of pregnancy and up to 5 months post-partum. Risk factors include multiple pregnancies, hypertension in pregnancy and advanced maternal age. It presents as shortness of breath, tachycardia, tachypnoea and signs of congestive cardiac failure. In this case the x-ray findings of cardiomegaly and pulmonary oedema give weight to the diagnosis.
- Post-partum complications (2)
A 17-year-old girl is seen in accident and emergency 14 days after an emergency caesarean delivery of a healthy infant, her first. Her neighbours became concerned and called the police. She had been seen prostrate in the garden chanting verses from the Bible and shouted at them accusing them of being spies when they asked if she was ok. They say her problem has worsened over the past fortnight. What is the most likely diagnosis?
A. Post-partum depression
B. Bipolar affective disorder
C. Puerperal psychosis
D. Schizophrenia
E. Acute confusional state (delirium)
C. Puerperal psychosis
4 C Puerperal psychosis (C) affects around one in 1000 mothers and normally presents within the first 2 weeks after delivery. Caesarean section, emergency delivery and a primiparity are independent risk factors for puerperal psychosis. It commonly presents with delusional ideation and hallucinations, with a religious aspect to the delusions often being noticeable. It is clinically similar to bipolar affective disorder (B), though depressive episodes are much less common in puerperal psychosis, and depression (A) is not evident here. Schizophrenia (D) would normally be associated with third person hallucinations which are not present here. An acute confusional state is a clinical syndrome normally caused by a non-psychiatric process such as infection. Although hallucination may be present, as in this case, acute confusional state classically fluctuates and its onset is much quicker, usually over the course of hours or a few days. In this case, her behaviour has become more odd over the course of a fortnight, and there are features of frank psychosis. The time from delivery within which acute-onset psychosis has occurred, coupled with the risk factors, makes puerperal psychosis the most sensible diagnosis.
- fetal physiology
At birth, which of the following does not occur in the fetal circulation?
A. Right ventricular output increases
B. A decrease in venous return
C. Closure of the foramen ovale
D. Pulmonary artery vasoconstriction
E. Closure of the ductus arteriosus
D. Pulmonary artery vasoconstriction
5 D After birth the umbilical vessels are occluded. This subsequently reduces the venous return (B) back to the right side of the heart reducing the right atrial pressure and closing the patent foramen ovale (C). As the fetus starts to breath, the pressure in the pulmonary circulation lowers and right ventricular output increases (A). The pulmonary artery vasodilates, not constricts (D), to allow this new low-pressure system on the right side of the heart to develop. The increased flow through the pulmonary system leads to more venous return to the left side of the heart via the pulmonary veins, leading to an increase in the pressure on the left side. In turn, the ductus arteriosus (E) in response to the rising oxygen levels will close.
- Assessment of the newborn
A woman on the labour ward has just had a normal birth. At birth there was a lot of meconium present. The newborn did not respond initially but did after subsequent resuscitation. The midwife records the Apgar score as 5. Which of the following best describes the categories an Apgar score is created from?
A. Tone, colour, noise, pulse and blood pressure
B. Tone, colour, respiratory effort, heart rate and reflex irritability
C. Tone, colour, pulse, reflex irritability and blood pressure
D. Tone, colour, pulse, respiratory effort and blood pressure
E. Tone, colour, cry, blood pressure and heart rate
B. Tone, colour, respiratory effort, heart rate and reflex irritability
6 B Apgar scores were developed in the 1950s. They provide a unified way of assessing a newborn baby to determine the level of care they require and predict the risk of long-term morbidity. Apgars take account of the infant’s tone, colour, breathing, heart rate and reflex irritability (B). The scores are measured at 1, 5 and 10 minutes. Infants’ Apgar scores at 1 minute are often low but usually they improve with the simple resuscitative measures of stimulation and inflation breaths. Blood pressure (A, C, D, E) is not measured in newborn babies.
- Post-partum haemorrhage
An 18-year-old woman has been successfully delivered of a healthy female infant by elective caesarean section for maternal request. Estimated blood loss was 1120 mL. Forty minutes after return to the recovery area, she has a brisk vaginal bleed of around a litre. Her pulse rate is 120 bpm and blood pressure is 95/55 mmHg. What should the immediate management process be?
A. Rapid fluid resucitation, uterine massage, intravenous ergometrine
B. Rapid fluid resuscitation, intravenous ergometrine and bimanual compression of the uterus
C. Rapid fluid resuscitation, insertion of an intrauterine balloon catheter device
D. Rapid fluid resuscitation, uterine massage, oxytocin infusion and vaginal assessment
E. Rapid fluid resuscitation and administration of direct intramyometrial uterotonic agents
D. Rapid fluid resuscitation, uterine massage, oxytocin infusion and vaginal assessment
7 D Recognizing that this woman has a primary post-partum haemorrhage is of vital importance. All the options listed are recognized options in the management of post-partum haemorrhage, but of these, fluid resuscitation, oxytocin infusion and uterine massage (D) are the most commonly employed first line techniques to arrest haemorrhage. Intravenous ergometrine (A) and bimanual compression (B) of the uterus may be employed if initial measures have not controlled bleeding, while intrauterine balloons (C) and intramyometrial uterotonics (E) are employed if bleeding continues in spite of other measures.
- Post-partum problems
A 34-year-old woman develops a significant post-partum haemorrhage and hypotensive shock following vaginal delivery of a healthy infant at term. The labour was uncomplicated. She recovers well with volume replacement and oxytocin and returns to the post-natal ward. She is unable to breast feed on the ward and 2 months later has neither started breastfeeding nor resumed her periods and is increasingly fatigued. What is the most likely diagnosis?
A. Addison’s disease
B. Syndrome of inappropriate antidiuretic hormone hypersecretion (SIADH)
C. Sheehan’s syndrome
D. Panhyperpituitarism
E. Post-partum depression
C. Sheehan’s syndrome
8 C In a well-motivated mother, the inability to lactate so far after delivery is a cause for concern. This, coupled with an absence of periods requires ruling out hypopituitarism (C). This woman suffered a post-partum haemorrhage significant enough to cause hypovolaemia. Since the anterior pituitary is hyperplastic during pregnancy, it is acutely sensitive to acute falls in blood pressure. If hypotension is severe, necrosis or infarction of the anterior pituitary can occur, rendering it hypofunctional, i.e. Sheehan’s syndrome (C). This can commonly result in absence of lactation and periods, fatigue and, less commonly, diabetes insipidus. This is the opposite of panhyperpituitarism, which is neither a recognized post-partum condition nor a complication of post-partum haemorrhage. Post-partum depression (E) can occur soon after pregnancy or up to a year after delivery. Younger and unsupported mothers, women with previous depression or drug use and those with a strong family history are most at risk of post-partum depression. It can cause fatigue and difficulty in breastfeeding, but is unlikely to stop periods or completely prevent any lactation. SIADH (B) would present with features of hyponatraemia, and although this can happen after Sheehan’s syndrome has been long established, it does not account for this woman’s symptoms at present. Adrenal insufficiency/Addison’s disease (A) could account for this woman’s fatigue but not the other symptoms and more often would present with symptoms associated with glucocorticoid insufficiency.
- Infection in pregnancy
A 30-year-old French woman delivers a live female infant by spontaneous vaginal delivery at term. In the eleventh week of pregnancy she developed a flu-like illness which resolved spontaneously a week later. Her newborn child has severe hydrocephalus and chorioretinitis. Four days after birth, she develops severe convulsions and efforts to revive her are unsuccessful. Which pathogen is most likely to be responsible?
A. Cytomegalovirus (CMV)
B. Human immunodeficiency virus
C. Toxoplasma gondii
D. Group B Streptococcus
E. Listeria monocytogenes
C. Toxoplasma gondii
9 C Cytomegalovirus (CMV) infection is very common, with about 60% of the population having had a prior infection. If it is contracted in pregnancy about 40–50% of fetuses will become infected. The manifestations of such an infection can be very broad. Complications include visual and hearing loss, microcephaly and long-term neurodevelopmental disability. Babies do not have hydrocephalus (so (A) is incorrect). HIV (B) infection is screened for routinely at booking, so with full antenatal care you should detect those mothers at risk. Admittedly, the flu-like illness here could represent seroconversion but you would not expect chorioretinitis or hydrocephalus. Group B Streptococcus (D) is a pathogen that is present in the genital tract of 25% of women. It has the ability to cause infection in the baby in the puerperium but not hydrocephalus. Listeria monocytogenes (E) is a bacterium that is present in unpasteurized cheeses and pâtés. It can lead to miscarriage, stillbirth or preterm delivery. The correct answer is (C) – toxoplasmosis. This is caused by the protozoon Toxoplasma gondii and can be contracted form undercooked meat and cat faeces. It can lead to chorioretinitis, macro- or microcephaly, convulsions and long-term neurodevelopmental delay. Initial infection in the mother is usually mild, and often she is not aware of it.
