MATERNAL POST-PARTUM PROBLEMS

Question 1

Within the UK:

What is leading of cause of maternal mortality? [1]

What is second commonest direct cause of maternal death? [2]

Answer 1

Thrombosis and thromboembolism: leading direct cause of death

Maternal suicide and haemorrhage: the second commonest direct cause of maternal death

Question 2

The puerperium?
- Is the time between birth till [] [1]
- What is most significant changes occur to maternal body during this time? [1]

Answer 2

Puerperium:

• Birth until 8 weeks
• Return of uterus to normal state / involute

Question 3

During puerperium:
- What is average amount of shrinking per day of uterus? [1]
- By day 10-12 where should the uterus be? [1]
- How does uterine involuation occur? [2]

Answer 3

• Shrinks 1cm / day
• By day 10-12: should be below pubic symphysis: should NOT be able to palpate
• MoA: ischamia / spiral arteries contract to cause atrophy; phagocytosis removes elastic / fibrous tissue

Question 4

What can delay uterine involution? [5]

Answer 4

Full bladder
Loaded rectum
Uterine infection like endometritis or parametritis (CT around uterus)
Retained products of conception: placenta
Fibroids
Broad ligament hematoma

Question 5

What is the normal amount of blood loss during pregnancy for vaginal [1] and C section delivery? [1]

Answer 5

Normal:
- Vaginal: ~ 500ml blood
- C section: ~ 1000ml bloood

Question 6

Explain MoA causing PPH

Answer 6

Normally:
* contraction of the uterus in the third stage of labour causes compression of intramyometrial blood vessels,
* Stops bleeding

Postpartum hemorrhage:
* uterine atony: compression of vessels does NOT occur. Atony can occur following delivery of the placenta, or when part of the placenta is retained.
* Brisk venous bleeding

Question 7

What are 4 causes of PPH? [4]

Answer 7

4Ts:

T – Tone (uterine atony – the most common cause)
T – Trauma (e.g. perineal tear)
T – Tissue (retained placenta)
T – Thrombin (bleeding disorder)

Question 8

What is difference between primary and secondary PPH? [2]

What are primary [4] and secondary [2] PPH associated with?

Answer 8

Primary PPH: bleeding within 24 hours of birth:
- Polyhydamnios
- Macrocosmic fetus
- Uterus overstretched
- Multifetal preg.

Secondary PPH: from 24 hours to 12 weeks after birth:
- Infection
- Retained products of conception

Question 9

Treatment of Primary PPH?
- Massage? [1]
- Drugs? [2]
- Surgery? [4]

Answer 9

Massage:
* Bimanual uterine massage and compression (one hand in vagina, pushing agaisnt the body of the uterus & the other hand compresses fundus from abdomen. Causes the uterus to contract)

Drugs: causes myometrium to contract – normal functioning
* Oxytocin agents
* prostaglandins

Surgery:
* suture tears:

• Bakri balloon: takes up 300ml of saline and is placed in the uterus, completely clear of the internal cervical os. Assisted by uterotonics, the balloon in the uterus will be hugged by the contracting uterus and drain blood out.
• B-lynch:hold uterus tight via stitching from anterior - posterior surface. Maintains compression
• uterine artery embolisation:: femoral artery –> internal iliac -> uterine artery: close artery

Question 10

Which drugs are used to treat PPH? [5]

Answer 10

Oxytocin (slow injection followed by continuous infusion)
Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension)
Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma)
Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction
Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

Question 11

The treatment/management of secondary PPH is usually []? [1]

Answer 11

The treatment/management of secondary PPH is usually broad spectrum IV antibiotics, and 90% of cases will improve within 48-72 hours of the antibiotics.

Question 12

Future treatment for Secondary PPM? [1]

Answer 12

Tranexamic acid

Question 13

Explain MoA of Tranexamic acid for PPH

Answer 13

Analogue of lysine
Binds to plasminogen and stops conversion of plasmin: causes bigger clots to form

Question 14

Treatment for thromboembolic disease in post-partum mother? [1]

Answer 14

Heparin (does not cross into breast milk)

Question 15

What is a positive Homon’s sign for investigating thromboembolic disease? [1]

Answer 15

Positive Homon’s sign: Pain with forced dorsiflexion of the foot

Question 16

Antenatal depression is (potentially) caused by? [1]

Which condition is antenatal depession highly linked to? [1]

Other causes? [5]

Answer 16

Antenatal depression causes:
- Hormonal imbalance: Linked to Hyperemesis gravidarum - itself linked to progesterone levels
- Previous miscarriages or difficult birth experiences
- History of depression
- Isolation, poor support, stressful living conditions, major life events
- Unplanned pregnancy
- Difficult childhood experiences and poor self-esteem
- Struggling with a pressure to do things right

Question 17

Difference in timing between postpartum affective instability (baby blues) and post natal depression?

Answer 17

Baby blues:
- Symptoms peak on 4th or 5th day after delivery and usually last for the first 2-weeks postpartum

Postnatal depression:
- 2 weeks till a year postpartum
- Worse symptoms

Question 18

Treatment for postpartum blues? [1]

Answer 18

• No specific treatment other than support and reassurance
• Further evaluation is necessary if symptoms persist longer than 2 weeks

Question 19

Which screening scale is used for post natal depression? [1]
What score requires further evaluation? [1]

Answer 19

Edinburgh Postnatal Depression Scale (EPDS):
* 0 item, self-rated questionnaire used extensively for detection of postpartum depression
* Score of 10 or more on EPDS or an affirmative answer on question 10 requires further evaluation
* Presentation is clinically indistinguishable from major depression

Question 20

Post partum depression symptoms most commonly occur in first:

1 month
2 months
3 months
4 months
5 months

Answer 20

Post partum depression symptoms most commonly occur in first:

1 month
2 months
3 months
4 months
5 months

Question 21

Explain the hormonal causes of postnatal depression? [1]

Answer 21

• Oestrogen, progesterone and cortisol fall to zero dramatically within 48hrs of delivery. BUT this happens to all mothers. SO Women with postpartum depression express different transcripts associated with oestrogen and or progesterone metabolism

Question 22

FYI - Other causes of Post-natal depression:

Answer 22

Psychosocial factors
* Women who report inadequate social supports, marital discord or dissatisfaction or recent negative life events more likely to experience postpartum depression
* No consistent obstetric factors identified

Biologic vulnerability
* Women with previous history of depression, family history of mood disorder or depression during pregnancy at increased risk
* Previous history of postpartum depression or psychosis 90% recurrence
* Postpartum depression 20 times more likely in women with history of depression
* Gestational diabetes independently associated with increased postpartum depression risk
* Sleep disturbance and insomnia associated with increased risk of postpartum depression

Question 23

What drug class are the first line of pharmalogical therapy for post natal depression?

Answer 23

Selective serotonin reuptake inhibitors (SSRIs): sertraline, citalopram

Question 24

Which drugs are used as pharmalogical therapy for post natal depression? [4]

Answer 24

SSRIs: Selective serotonin reuptake inhibitors:
* Citalopram (SSRI)
* Sertraline (SSRI)

(SNRI) serotonin-noradrenaline reuptake inhibitor:
* Duloxetine (SNRI)

TCA: Tricyclic antidepressants
* Nortriptyline