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Y4: O&G > cOGText: Postpartum > Flashcards

cOGText: Postpartum Flashcards

1
Q

What is the puerperium?

How long does it last?

A

A period of repair and recovery after birth where tissues return to their nonpregnant state, lasting 6 weeks post-partum on average.

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2
Q

Within the first 3 weeks of the puerperium, the mother’s vaginal discharge undergoes a series of changes:

  1. 3-4 days: appearance? Name given?
  2. 4-14 days: appearance? Name given?
  3. 10-20 days: appearance? Name given?
A
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3
Q

The uterine changes during puerperium are collectively called “___ ____”

A

Uterine Involution

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4
Q

Uterine Involution

  1. Endometrial lining rapidly regenerates by day __ post-partum.
  2. The fundus of the uterus, which usually sits around the ____ level during pregnancy, returns to its physiological location within the pelvis by around __ weeks.
  3. Furthermore, uterine weight decreases to around __% of what it was immediately after birth by the end of puerperium.
  4. T/F: whilst the lower reproductive tract structures (cervix, vagina and perineum) regress after pregnancy, they will never return to their prepregnancy state.
  5. T/F: diuresis is completely normal a couple of days after birth.

Uterine Involution

A
  1. 7
  2. Umbilical, 2
  3. 5
  4. True
  5. True
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5
Q

Lactation

  1. By the ___ month of pregnancy the breasts will have become fully adapted to produce milk.
  2. What is colostrum
  3. What initiates lactation?
  4. What inhibit milk production during pregnancy?
  5. Prolactin release triggers milk production by ____ in mammary_____.
  6. Prolactin release is maintained via what mechanism?
  7. What is ‘the let-down reflex’?
A
  1. 5th/ 6th
  2. the first milk a breastfed baby receives - is more protein and vitamin rich than later milk produced by the mother. Is essential for early immunological protection
  3. expulsion of the placenta in stage 3 of labour as well as a decrease in oestrogen and progesterone levels.
  4. High levels of oestrogen and progesterone block the RELEASE of prolactin from the anterior pituitary gland (still be produced, but is prevented from carrying out its function of milk production)
  5. Lactocytes, alveoli
  6. a positive feedback mechanism, whereby suckling by the infant promotes prolactin production by stimulating nipple mechanoreceptors.
  7. The mechanism of milk release from the breast during feeding: suckling stimulates production of oxytocin from posterior pituitary gland (also pain, alcohol and the sight/ cry of an infant) > myoepithelial cells surrounding the breast alveoli are stimulated to contract > squeeze milk out of the breast alveoli and nipple.
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6
Q
  1. WHO recommends “exclusive breastfeeding for the first ___ months of an infant’s life.
  2. T/F: it is not recommended breastfeeding should continue beyond six months
  3. T/F: It is important that doctors advocate breastfeeding as the best method of feeding a baby
  4. Most common reason women stop breastfeeding?
  5. What should you do if a women presents with this problem?
A
  1. Six
  2. False – it is recommended, alongside the introduction of appropriate solid foods, for up to two years of age or for as long as the mother chooses
  3. True – also good knowledge on breastfeeding technique
  4. “insufficient milk”, despite all women having the capability of providing sufficient breast milk, no matter the size of the breast. The main reasons why milk won’t eject as effectively: ineffective attachment and infrequent feeding
  5. any pain while breastfeeding/ nipple skin changes (cracks/dryness/bleeding). If nipples damaged from ineffective attachment, milk won’t be removed as effectively and will pool in the breast. Ask about baby’s reaction during and after feeds. Are they irritable? Do they refuse to suckle? This is a result of ineffective milk release as the baby isn’t getting enough to satisfy them and therefore may lose weight. - Assess the mother’s breastfeeding technique as this is most likely to be the cause of the problem.
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7
Q
  1. What is mastitis?
  2. Can be due to infectious and non-infectious causes, which is most common?
  3. Causes of both?
  4. Mastitis can happen to the breast at any point, however the risk is highest when?
  5. The cause of lactational mastitis is most commonly linked to improper what?
  6. Consequences of poorly treated mastitis?
A
  1. Inflammation of the breast
  2. Non-infectious
  3. Infectious: mainly staph aureus, followed by coagulase positive staphylococci. Non-infectious: mainly duct ectasia (blocked lactiferous duct) or a foreign body e.g. breast implant or nipple piercing.
  4. During breastfeeding.
  5. Breastfeeding technique - trauma to the breast and subsequent milk stasis and ineffective milk release make the breast more likely to harbour bacteria and therefore be more prone to infection.
  6. Can lead to an abscess, mainly in the peripheral breast (abscesses unrelated to breastfeeding tend to be sub-areolar)
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8
Q

What points should be covered in a focused history of a breastfeeding mother with mastitis? (MAIDS)

A
  • Milk stasis (decreased milk output)
  • Possible abscess (tender lump)
  • Symptoms related to possible breast inflammation (e.g., warmth, pain, swelling, firmness, erythema)
  • Nipple discharge, which may be present with mastitis and occurs more often with duct ectasia (dilated ducts with inflammation); however, purulent discharge is usually indicative of breast infection
  • Systemic symptoms of infection (fever, malaise, myalgia)”
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9
Q

Mastitis

  1. Diagnosis?
  2. Treatment
  3. Should breastfeeding continue?
  4. Ix if the pt is showing signs of an abscess (bulging mass central to the area of mastitis)?
A
  1. Clinical
  2. Abx effective for staph aureus as soon as signs appear (e.g. flucloxaxillin)
  3. Yes, imp to continue breastfeeding; pt can use a breast pump for the infected breast if they would prefer
  4. Breast USS to view the abscess and aspiration with an 18-guage needle for culture to confirm the diagnosis
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10
Q

PPH

  1. What ees eet?
  2. Primary vs secondary?
  3. Minor vs major?
  4. Bloss has effects every woman differently due to varying overall blood volume (e.g. small woman may suffer severe PPH from small volume lost). Describe a method of understanding how severe the blood loss of your individual is?

PPH

  1. What ees eet?
  2. Primary vs secondary?
  3. Minor vs major?
  4. Bloss has effects every woman differently due to varying overall blood volume (e.g. small woman may suffer severe PPH from small volume lost). Describe a method of understanding how severe the blood loss of your individual is?
A
  1. Blood loss ≥ 500ml after the birth of the baby
  2. Primary: occurs within 24 hours. Secondary: 24hr – 6 weeks
  3. Minor: 500-1000ml blood loss. Major: >1000ml OR Signs of cardiovascular collapse OR ongoing bleeding
  4. Take blood volume as equivalent to 100mls per kg – e.g. for a 65kg patient, total blood volume would be estimated at 6500mls or 6.5 litres.
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11
Q

Causes of PPH? (from most to least common)

A

‘The 4 Ts’

  1. Tone (70%): Uterine atony
  2. Trauma (20%): Vaginal tear, cervical laceration, rupture
  3. Tissue (10%): Retained Products of Conception
  4. Thrombin (<1%): coagulopathy
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12
Q
  1. Antenatal risk factors for PPH?
  2. Postnatal?
  3. Management (overall)?
A
  1. Placental Problems (e.g. Placenta Praevia/Accreta/ Percreta); Past Hx of: Retained Placenta, C-section, PPH; multiple pregnancy; polyhydramnios; obesity; macrosomia (placental issues, PMH, too big)
  2. Operative Vaginal Delivery; Perineal tear/Episiotomy during delivery; C-section; Syntocinon/Syntometrine Use (Induced labour); labour >12 hours; retained placenta
  3. Call for help - Assess, stop the bleeding, fluid replacement
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13
Q

What should your initial assessment in PPH include?

A

ABCDE

  • Oxygen via non-rebreather mask 15l/min
  • IV access with a grey/orange bore cannula
  • Retrieve blood for G&S, FBC, coagulation screen, fibrinogen, U&Es, LFTs, lactate
  • Cross-match 6 units red packed cells
  • Check vital signs every 15 minutes
  • Determine cause of bleeding using the 4 T’s
  • Consider utilising the Tayside Massive Haemorrhage Protocol
  • Early blood transfusion
  • Tranexamic acid 0.5-1g IV to stop bleeding, regardless of the cause
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14
Q

What

  1. Non-surgical
  2. Surgical

Methods can be used to stop the bleeding in PPH?

A

1. Non surgical

  • TONE/TISSUE: Uterine massage using bimanual compression. Administer 5 units IV Syntocinon
  • TONE: Insert urinary catheter to minimise bladder pressure on the uterus
  • THROMBIN: Expel clots manually

* N.B Most cases resolve by this point *

  • TONE/TISSUE: 500mcg IV Ergometrine if no response to Syntocinon. Carboprost 250 mcg IM every 15 minutes. Give Misoprostol 800mcg PR
  • TRAUMA Exclude/repair trauma

2. Surgical

  • Examine under anaesthetic (EUA) in theatre to look for trauma, RPOC, rupture etc
  • Balloon insertion to put pressure on bleeding blood vessels
  • Arterial Embolisation via Interventional Radiology
  • Uterine artery ligation
  • Internal Iliac ligation
  • “B-Lynch” sutures
  • Hysterectomy as a last resort
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15
Q

What is the purpose of the foramen ovale in the foetal circulation?

(small hole in atrial septum)

A

exists to relieve pressure on the right side of the heart caused by increased pulmonary resistance (allows the left atrium to take some of the pressure instead)

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16
Q

Describe why the foetal circulation has increased pulmonary resistance compared to the newborn?

A
  • The alveoli in fetal lungs contain fluid rather than air, which makes them lack oxygen.
  • As a result, nearby arterioles vasoconstrict in response to the alveoli’s hypoxic state, increasing the pulmonary circulation’s resistance.
17
Q

The fetal circulation has adapted another method of relieving this pressure through a structure called the ductus arteriosus. This vessel connects the pulmonary arteries to the aorta, which is already carrying the blood shunted from the right side of the heart. In doing this, overall pulmonary resistance is further relieved as blood will escape from an area of high pressure (in this case, the pulmonary arteries) to an area of low pressure (the aorta) via the ductus arteriosus. This blood travels down the aorta and drains into the internal iliac arteries where it finds its route back to the placenta via branches called the umbilical arteries

A

Y4: O&G (14 decks)

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