exam 2 - puerperium Flashcards
A 33 yo G1 P1001 postpartum day #39 s/p NSVD states, “I feel okay, but I am so tired all the time. I don’t know if I can stand to breastfeed for a whole year. And I want to have sex with my husband, but it hurts. And I am leaking urine sometimes, too.”
You examine your patient and find no lesions of the lower genital tract or anus and rectum. The perineum is well healed. You teach her about Kegel exercises and order a urine culture. You recommend that the patient speak to her partner about her concerns about sex, and that she consider using a water based lubricant. She leaves with a recommendation to return in 4 weeks if she isn’t feeling better.
the puerperium
-“the fourth trimester”
-This concept underscores the importance of providing care and support to the new patient
-Due to several factors, 40% of postpartum patients never attend a postpartum visit
-50% of all new patients are insured under Medicaid and lose insurance after 60 days postpartum, unless they live in a state in which Medicaid was expanded under the ACA
physiologic changes of the puerperium: edema
-shift of fluids due to diuresis -> diuresis
-causes dependent edema -> worst in 1st 48-96hrs
-risk of pulmonary edema in pts with pre-eclampsia
physiological changes of the puerperium: CNS
-“Baby blues”
-Emotional lability beginning in the first 10 days postpartum
-Occurs in 80% of postpartum patients
-Not the same as postpartum depression!
-Etiology is unknown
-May involve:
-Shifts in estrogen and progesterone
-Rapid decline of endorphins
-Stress of being responsible for an infant
Physiologic changes of the puerperium: breasts
-Breast engorgement
-Occurs hours to days after delivery
-May be painful
-Low-grade fever is common
-Discomfort relieved by breastfeeding
-If pt cant or doesnt want to breastfeed -> use cold compresses/ice packs and supportive bra
-May also use cabergoline inj
Physiologic changes of pregnancy and the puerperium: thrombophilia
-Postpartum patients continue to be in a hypercoagulable state in the puerperium
-important when considering contraceptive options during this time
-Avoid estrogen-containing contraceptives for the first 4-6 weeks
Physiologic changes of the puerperium: Uterus
-Immediately after an uncomplicated labor and delivery, the uterine fundus is located at about the umbilicus
-Involutes over 6 weeks -> At normal, nonpregnant size by 6 weeks postpartum
-Produces lochia (vaginal discharge) x 3-4 weeks
-Lochia rubra (lasts several days)
-Lochia serosa (appears in 1st week postpartum)
-Lochia alba (appears in 2nd week postpartum and may continue for a few weeks)
Physiologic changes of the puerperium: uterus and menstrual function
-90% of pts will menstruate within 13 weeks of delivery
Physiologic changes of the puerperium: Perineum and vagina
-Lacerations heal quickly
-Most sutures (if needed) absorb in 2-4 weeks
-Decreased estrogen and progesterone levels cause vaginal dryness and transient, relative atrophy
-May cause dyspareunia
postpartum process
-Rather than traditional postpartum visit at 6 wks -> today its patient-centered
-It may begin days after delivery and end with transition to well person care at 12 weeks
-hypertension -> 1 week
screening during the puerperium
-Anxiety
-Depression and perinatal depression screening
-Contraceptive counseling and methods
-Breastfeeding counseling, services and supplies
-Diabetes screening (in patients with history of GDM)
-Interpersonal violence
-Tobacco use (and cessation, if indicated)
postpartum visit: history
-Current signs or symptoms
-Screen for postpartum depression
-Life with baby
-Contraception
-Resumption of sex
-Resumption of other activities
-Breastfeeding (if indicated)
postpartum visit: screening for depression
-May use
-Edinburgh Postnatal Depression Scale, others
-These instruments ask about symptoms such as
-Anhedonia
-Guilt
-Fear
-Inability to cope with life
-Insomnia
-Sadness
-Crying
-Suicidal ideation
physical exam
-Vital signs
-Pay attention to blood pressure if the patient had hypertensive disorder of pregnancy
-Breasts
-Evaluate for nipple lesions, induration, erythema, tenderness, breast masses
-Abdomen
-Evaluate for tenderness, uterine involution
-Pelvic
-Inspect perineum for healing from lacerations
-Evaluate uterine involution; for adnexal masses and/or tenderness
-Repeat Pap, if indicated
-Screen for diabetes mellitus if patient had GDM
vaccinations
-Tetanus, diphtheria, and pertussis (Tdap)*
-Influenza, if not vaccinated during this flu season
-Measles, mumps, and rubella (MMR)#
-Varicella#
-!!If the patient has not been vaccinated previously
-!!If the patient had non-immune results during prenatal course
Rho(D) immune globulin
-Administer Rho(D) immune globulin (RhoGAM) 300 μg IM x 1 dose within 72 hours after delivery in those patients who meet all of the following criteria:
-Rh negative patient with no antibodies
-Rh positive baby
-Coombs negative cord blood
sexual function
-may have decreased libido due to sleep deprivation and/or distractions bc of baby
-normal -> reassure
-Libido generally returns to normal by 12 months postpartum
-Decreased lubrication and mild atrophic changes, as well as healing lacerations, may also cause dyspareunia
-If dyspareunia occurs, the patient may come to anticipate pain and to fear sexual relations
-Perform thorough pelvic and rectal examinations
-R/o vulvodynia- pain syndrome involving the external genitalia
-Use water-based lubricant
-Encourage the patient to discuss concerns with their partner
-Consider use of topical lidocaine jelly
-Consider sex therapy, if indicated
-Consider pelvic floor physical therapy, if indicated
breastfeeding
benefits
-Breastfeeding is best for babies
-Usually produces good weight gain
-Decreased risk of food allergies
-Increased immunity
-AAP: breastfeed exclusively x 6 mos
-WHO: breastfeed exclusively x 6 mos, then continue x 2 years and beyond, if desired
-Lactation consultants are present in all hospitals with L&D units in NYS
contraception
-Between 37-50% of pregnancies are unplanned
-Contraception should be discussed in the 2nd trimester
-significant risk of morbidity and mortality for pt and fetus when theres short interpregnancy interval (2 months)
contraceptive guidelines for breast- or chest- feeding pts
-No estrogen-containing products should be used for the first 4-6 weeks until feeding is established
-This restriction eliminates:
-transdermal patch (Ortho Evra)
-Combination OCP
-Contraceptive vaginal ring (NuvaRing, Annovera)
-May use long-acting reversible contraception (LARC)
-IUD- Paragard (hormone free IUD), Levonorgestrel IUDs, including Mirena, Skyla, Liletta and Kyleena
-Etonogestrel subdermal contraceptive implant (Nexplanon)
-May insert IUDs at time of C/S or immediately after NSVD
-May insert subdermal contraceptive implant (Nexplanon) before discharge to home
-Sterilization- Male and female sterilization (will be covered in subsequent lecture)
-Other types of contraception
-Progestin-only oral contraceptives
-Barrier methods:
-Diaphragms
-Cervical caps
-Female condoms
-Male condoms
-Vaginal contraceptive gel (Phexxi®)
Inserts
contraception: lactational amenorrhea method (LAM)
->99% effective
-Prevents ovulation
-Effective for up to 6 months
-When pt begins menstruating again -> no longer effective
-Menstruation demonstrates that ovulation has occurred
-must NOT pump breast (not high enough prolactin)
-Must breastfeed baby at least every 4 hrs during daytime and at least every 6 hrs at night
-may be used with confidence as a method of contraception
-becomes unreliable as pt increases time between breastfeeding, begins to pump, or breastfeeds for shorter periods of time
complications of the puerperium
-sexual dysfunction
-urinary incontinence
-endometritis
-retained products of conception
-mastitis
-DVT
-postpartum depression
-postpartum psychosis
urinary incontinence
-Affects up to 40% of postpartum patients
-After 12 months, 23% of patients are still affected
-Risk factors:
-NSVD
-Long second stage of labor
-Older age
-Higher parity
-Birth weight >4000 gm
-Incontinence during pregnancy
-Urine culture
-Kegel exercises:
-Squeeze the same muscles you use to stop urinating
-Hold the contraction of muscles x 3 seconds, then relax x 3 seconds
-Perform 10 contractions 3x/day, working up to 10 seconds per contraction
-Consider pelvic floor physical therapy after 3 months if symptoms do not improve
endometritis
-Affects <5% of patients s/p NSVD
-Increased risk with h/o:
-Chorioamnionitis
-h/o C/S
-Repeated, frequent vaginal exams in labor
-Prolonged labor
-H/O PROM or PPROM
-Symptoms:
-Abdominal pain
-Fever
-Heavy, malodorous lochia rubra
-Uterine subinvolution
-Management:
-Blood, urine, endometrial cultures
-CBC
-Administer clindamycin 900 mg IM Q8H and gentamicin 2 mg/kg IV x 1 dose, then 1.5 mg/kg IV Q8H; or may use ampicillin/sulbactam IV
-No need to continue antibiotics once the patient is afebrile x 24 hours
retained products of conception
-Abdominal pain
-Subinvolution
-Possible passage of POC
-Continued vaginal bleeding
-S&S of volume depletion
-Management
-US to determine presence of retained products
-Dilation and curettage, if indicated
mastitis
-10% of lactating patients
-Rare in non-lactating patients; consider inflammatory breast CA in such cases
-usually early on
-Usually inflammatory, not bacterial; thus antibiotics are not first line therapy
-Causative organisms: Staphylococcus, Streptococcus
-Signs and symptoms:
-Fever
-Induration
-Erythema
-Pain of affected breast
-dx- clinical
-management:
-NSAIDs
-Continue to breastfeed
-Avoid pumping breast to avoid hyperlactation
-Antibiotics with evidence of bacterial mastitis (worsening erythema, induration, persistent fever)
-Amoxicillin, cephalexin, cefadroxil
postpartum depression
-11-20% of all patients in the puerperium
-Not the same as postpartum blues, which are physiologic
-Postpartum depression is a pathologic process
-Disturbances of sleep (too much, too little)
-Disturbances of appetite (too much, too little)
-Feeling guilty, hopeless
-Anhedonia
-Thoughts of death, wishing they were dead
-Suicidal ideation/attempt
-May have decreased interest in the baby
dx criteria for postpartum depression
-At least 5 symptoms during the same 2 week period
-Must include either of the first two symptoms
-!!Depressed mood most of the day, nearly every day
-!!Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
-Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
-A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down)
-Fatigue or loss of energy nearly every day
-Feelings of worthlessness or excessive or inappropriate guild nearly every day
-Diminished ability to think or concentrate, or indecisiveness, nearly every day
-Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
management of postpartum depression
-Management
-Zuranolone
-A gamma-aminobutyric acid (GABA) A receptor positive modulator
-1st drug approved for tx of postpartum depression
-May cause driving impairment
Do not operate heavy machinery -while using agent until 12 hours after administration
-Peer counseling
-Psychotherapy
-Pharmacotherapy
-SSRIs are probably safe in lactating
-Electroconvulsive therapy (ECT) is treatment of choice for suicidal or profoundly depressed patients
do not use these during lactation
-doxy
-bactrim
-flouroquinolones
postpartum psychosis
-<1% of patients in puerperium
-May present within 72-96 hrs postpartum
-h/o previous postpartum depression or with h/o depression, psychosis or bipolar disorder
-delusions of religious nature or belief that the baby is evil or Satanic (concordant with pt’s religious background)
-pt may attempt to harm baby (4% risk of successful infanticide)
-presents within 2 weeks postpartum
-sx:
-Psychosis
-Hallucinations
-Insomnia
-Agitation
-Suicidal ideation or plan, or attempt
RF for postpartum psychosis
-Primiparity
-Prior history of psychiatric illness
-Bipolar disorder
-Postpartum psychosis
-Depression
-Discontinuation of mood stabilizers
-Perinatal infant mortality
-Obstetrical complications
-Family history of postpartum psychosis or bipolar disorder
-Lack of partner support
-Sleep deprivation
management of postpartum psychosis
-Represents a true psychiatric emergency
-Admit to psychiatric unit
-Baby to go to family or to Social Services (foster care) until patient can care for infant
-reproductive psychiatrist for any future pregnancy
-Treatment:
-Mood stabilizers
-Antipsychotics
-Benzodiazepine
-Lithium (CANNOT breastfeed while using lithium)
-Propranolol
-Electroconvulsive therapy
which of the following best identifies the means by which the dx of mastitis is made in postpartum pt
-US of the breast
-culture and sensitivity of breast milk
-MRI of the breast
-hx and PE!!!!!!!!!!!!!!
