Disorders of the puerperium

Question 1

What is the puerperium?

Answer 1

Time between delivery of the placenta to 6wks following the birth

Question 2

What are some major problems of the puerperium?

Answer 2

Sepsis 
Severe post partum haemorrhage (PPH)
Preeclampsia-eclampsia 
Thrombosis 
Post dural puncture headache 
Mental health - depression/psychosis

Question 3

How do you assess new mothers for serious problems?

Answer 3

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

Question 4

What are some risk factors for and likely causes of sepsis in new mothers?

Answer 4

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

Question 5

What is a good screening mnemonic for maternal sepsis?

Answer 5

3Ts with White Sugar:

Temp - <36 or >38
Tachyc. - >90bpm
Tachyp. - >20RR

WCC - >12 or <4x10/L
Hyperglycaemia - >7.7mmol

(Also hypotension, oliguria)

Question 6

What is primary post partum haemorrhage? (PPH)

Answer 6

> 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

Question 7

What is secondary PPH? What are some causes?

Answer 7

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

Question 8

How do you investigate secondary PPH?

Answer 8

Assess blood loss, haemodynamic status, clotting status

Bacteriology - high vaginal and endocervical swabs

Pelvic USS?

Question 9

How do you manage PPH?

Answer 9

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

Question 10

What are post dural pucture headaches?

Answer 10

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)

Question 11

What is postpartum urinary retention?

Answer 11

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

Question 12

What is the ‘baby blues’?

Answer 12

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

Question 13

What are some challenges with mental health in the puerperium?

Answer 13

Difficult to detect:
Fear of treatment or children being removed
Stigma
Lack of recognition - doctors as well as in self

Question 14

What are some red flags for mental health disorders in the puerperium?

Answer 14

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

Question 15

What are some features of puerperium mental health problems?

Answer 15

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

Question 16

What is the definition of maternal death?

Answer 16

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

Question 17

How is maternal death classified ?

Answer 17

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

Question 18

What is Sheehan’s syndrome?

Answer 18

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)

Question 19

What is purpureal pyrexia? What are some causes? How do you manage?

Answer 19

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

Question 20

What are the 4 Ts of PPH?

Answer 20

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

Question 21

What are some risk factors for PPH?

Answer 21

Big baby 
Nulliparity and grand multiparity (>5)
Multiple pregnancy 
Prolonged labour 
Maternal pyrexia 
Operative delivery 
Shoulder dystocia 
Previous PPH 
Known bleeding disorders

Question 22

How do you manage maternal sepsis?

Answer 22

Recognise within 1hr

O2 for SpO2 >94% 
Blood cultures 
IV Abx - cefuroxime + metronidazole ?
IV fluids 
Bloods - acetate, Hb, glucose