Disorders of the puerperium Flashcards
What is the puerperium?
Time between delivery of the placenta to 6wks following the birth
What are some major problems of the puerperium?
Sepsis Severe post partum haemorrhage (PPH) Preeclampsia-eclampsia Thrombosis Post dural puncture headache Mental health - depression/psychosis
How do you assess new mothers for serious problems?
Modified Early Obstetric Warning Score (MEOWS) whilst in hospital
RR, SpO2, oxygen source, HR, BP, urine output, temperature, consciousness
Scores between 0-3 for each:
1-2 low risk - repeat R/V 1hr +/- simple treatemnt
3-4 medium risk - repeat 30mins +/- simple intervention +/- medical review
>6 high risk - repeat 5-15mins + senior med R/V + treatment
What are some risk factors for and likely causes of sepsis in new mothers?
Risk factors:
Obesity, DM, anaemia, amniocentesis, PROM, vaginal trauma, GBS Hx
Likely causes:
Endometritis, Skin + soft tissue infection, Mastitis, UTI, Pneumonia, Gastroenteritis, infection related to epidural
What is a good screening mnemonic for maternal sepsis?
3Ts with White Sugar:
Temp - <36 or >38
Tachyc. - >90bpm
Tachyp. - >20RR
WCC - >12 or <4x10/L
Hyperglycaemia - >7.7mmol
(Also hypotension, oliguria)
What is primary post partum haemorrhage? (PPH)
> 500mls estimated blood loss after birth
Minor = <1500 + no signs of clinical shock Major = >1500ml + continuing to bleed OR clinically shocked
Total blood volume at term = c.100mls/kg
What is secondary PPH? What are some causes?
Abnormal or excessive bleeding from birth canal between 24hrs - 12wks postnatal
Endometritis
Retained produces of conception
Subinvolution of the placental implantation site (failure to close and slough modified spiral arteries)
Arteriovenous malformation
c. 1% of all pregnancies
How do you investigate secondary PPH?
Assess blood loss, haemodynamic status, clotting status
Bacteriology - high vaginal and endocervical swabs
Pelvic USS?
How do you manage PPH?
ABCD
Assess severity, locate source
If severe:
Keep warm using appropriate available measures
Transfuse blood as soon as possible if clinically required until blood is available, infuse up to 3.5 l of warmed clear fluids, initially 2 l of warmed isotonic crystalloid
Prepare syntocinon - to contract postpartum to seal off placental vessels
What are post dural pucture headaches?
Accidental puncture of the dura when performing epidural - 1/100 - 1/500 procedures
Leakage of CSF leading to reduced pressure in the cranium
Presentation:
Headache - worse on sitting/standing; starts 1-7 days after epidural
Neck stiffness
Photophobia
Management:
Lying flat
Analgesia
Fluids
Caffeine - increase cerebral artery vasoconstriction and increase ICP
Epidural blood patch - small injection of blood near the hole made by epidural - should clot and seal the hole in the dura, stop fluid leakage and increase ICP and resolve headache (60-70% success, may need repeat)
What is postpartum urinary retention?
The abrupt onset of aching or acheless inability to completely micturate, requiring urinary catheterization
over 12hrs after giving birth
OR
Not to void spontaneously within 6 h of vaginal delivery
Incidence: 0.05-37%
Risk factors: epidural, prolonged 2nd stage of labour, forceps delivery, perineal lacerations
What is the ‘baby blues’?
Brief period of feeling emotional and tearful around three to 10 days after giving birth
Affects about 60-70% of women, more in first time mothers
Due to: body change, sleeplessness, change in role etc
What are some challenges with mental health in the puerperium?
Difficult to detect:
Fear of treatment or children being removed
Stigma
Lack of recognition - doctors as well as in self
What are some red flags for mental health disorders in the puerperium?
Recent significant change in mental state or emergence of new symptoms
New thoughts or acts of violent self harm
New and persistent expression of incompetency as a mother or estrangement from the infant
What are some features of puerperium mental health problems?
Post natal depression:
10% of new mothers
Most start within 1m, peaking at 3m
Think typical depression symptoms + effects on infant bonding
Assessed with Edinburgh Postnatal Depression scale - >13/30 = depressive illness
Support and reassurance; CBT, ?paroxetine (as low conc. in milk)
Postpartum psychosis:
1-2/1000
Onset within the 2-3wks postpartum (sooner than the depression)
Severe swings in mood (like bipolar) + disordered perception
FHx of PPP, Dx bipolar (1/4 births)
Traumatic birth/pregnancy
Admission
20% of reoccurrence in future pregnancies
PTSD:
3.1% show full symptoms, 33% show some
Perceived lack of or unsafe care; poor communication; focus on outcome not as experiences of the mother
Also in fathers
What is the definition of maternal death?
ICD definition:
The death of a woman while pregnant or within 42days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes.
Occurs in c8/100,000
How is maternal death classified ?
Direct = as a result of complications of pregnancy/labour/puerperium - Thrombosis then haemorrhage then suicide
Indirect = preexisting disease/developing in pregnancy but not directly related to obstetric causes = cardiac and neurological disease (epilepsy)
Late deaths = after 6wks - suicide is most common
Most deaths - 75% - are postnatal
What is Sheehan’s syndrome?
Postpartum hypopituitarism
Ischemic damage to pituitary gland secondary to hypovolaemic shock following birth
Presents like hypothyroidism + amenorrhoea + problems with lactation + Hx of difficult/complicated birth (w/blood loss)
What is purpureal pyrexia? What are some causes? How do you manage?
Temp of >38 in first 14days following delivery
Causes:
Endometritis - most common - pink vaginal discharge that may smell, tachycardia, diffuse suprapubic tenderness
UTI - usual symptoms
Wound infection e.g. from tears or c-section - will see
Mastitis - breast tenderness
VTE - hot/red/swollen leg, chest pain/breathing problems
Manage cause:
Endometritis needs admission for monitoring + clindamycin and gentamicin IV until afebrile for >24hrs
What are the 4 Ts of PPH?
Tone:
Atonic uterus - most common - risk factors:
Tissue:
Ensure placenta is entirely removed - may need to do it manually by hand, may also make haemorrhage worse initially
Trauma:
Tears or episiotomy - may need repairs
Thrombin:
Check clotting - transfusion may be needed
What are some risk factors for PPH?
Big baby Nulliparity and grand multiparity (>5) Multiple pregnancy Prolonged labour Maternal pyrexia Operative delivery Shoulder dystocia Previous PPH Known bleeding disorders
How do you manage maternal sepsis?
Recognise within 1hr
O2 for SpO2 >94% Blood cultures IV Abx - cefuroxime + metronidazole ? IV fluids Bloods - acetate, Hb, glucose
