Maternal Post-Partum Problems Flashcards
What is puerperim?
- time from delivery until 6 weeks
- time taken for uterus to involute
What does puerperim end?
- most of physiological changes of pregnancy return to pre-pregnancy state
- only lactation and psychological strains continue after 6 weeks
What is the most prevalent cause of maternal death?
- cardiac disease
obesity, older age, increased immigrant populations
What is post-partum haemorrhage?
- excessive bleeding following delivery
- 5% incidence
- most common cause of maternal deaths
What is primary post-partum haemorrhage?
> 500ml blood loss from genital tract within 24 hours of delivery
What is secondary post-partum haemorrhage?
Abnormal bleeding from genital tract
From 24 hours after delivery to 6 weeks
What are the causes of primary post partum haemorrhage?
Tone (uterus not contracting - 70%)
Tissue (placenta/membranes left behind - 20%)
Trauma (episiotomy/tear which keeps bleeding - 9%)
Thrombin (clotting disorders that need to be corrected - 1%)
What are the pre-disposing factors of primary post partum haemorrhage?
Antepartum haemorrhage Placenta praevia Multiple pregnancy Pre-eclampsia Previous PPH Maternal obesity Maternal age Multiparity
What is the significance of uterine atony?
- felt at umbilicus if pregnancy, cricket ball consistency when contracted
- cause of PPH
- uterine fails to contract after birth
- managed by bimanual uterine massage and compression and oxytocic agents if not contracted enough
How is primary PPH managed?
- call for help/crash call/ABC/IV canula/oxygen by mask/FBC/transfusion/urea and electrolytes/clotting profile
- uterotonics
- surgery
- uterine artery embolisation
What is uterotonics?
- syntometrine (oxytocin synthetic and ergomtrine for vasoconstriction)
- misoprostol (PG E1)
- carboprost (PG F2alpha)
(increase contraction of uterus)
How does surgery treat PPH?
- bakri balloon (device used for temporary control and reduction of PHH, inflates keeping uterus contracted stopping bleeding) and continue syntometrine drip
- B-lynch (mechanical compression of atonic uterus using sutures)
- check placenta is fully removed and try to remove some with hands manually if you think it has not
- uterine artery embolisation
How can uterine artery embolization be used for PPH?
- catheter to deliver small particles blocking blood supply to uterine body relieving blood loss
- resort to hysterectomy sooner rather than later (especially if placenta accrete where vessels grow too deeply to uterine wall = uterine rupture)
What is secondary PPH?
Commonly presents as prolonged/excessive bleeding
What are the causes of secondary PPH?
- infection (endometritis)
- tissue (retained products of conception)
What is the commonest cause of postnatal morbidity during days 2-10?
Endometritis
How is secondary PPH treated?
- broad spectrum IV antibiotics (90% cases)
- RPOC (retained products of conception) -> evacuate after 24 hours of antibiotics
What are the 4 key haemorrhage messages?
- anticipate avoid
- early recognition
- prompt effective resuscitation
- control bleeding quickly
- human factors
What is the most common direct cause of maternal deaths?
Thromboembolic disease
What are pre-existing risk factors of thromboembolic disease?
- previous VTE/gross varicose veins
- thrombophilia (congenital/acquired)
- age over 35 years
- obesity
- paraplegia
- sickle cell disease
- inflammatory conditons
What are pregnancy related risk factors of thromboembolic disease?
- surgical procedures
- dehydration
- sepsis
- pre-eclampsia
- excessive blood loss
- prolonged labour
- immobility after delivery
What are the symptoms of deep vein thrombosis?
- painful swollen leg
- redness/oedema of leg
- pain in groin/buttock
What are the symptoms of pulmonary embolism?
- chest pain (sudden onset)
- breathlessness (sudden onset)
- dizziness/syncope/collapse tachycardia
- hypoxia
What are the symptoms of cerebral vein thrombosis?
- headache
- seziures
How is thromboembolism managed?
- early mobilisation
- good hydration
- TEDs
- LMW heparin
- avoid COCP
How is thromboembolism investigated?
- history
- examination
- tests to exclude other diseases (ABG, CXR, ECG)
How is thromboembolism treated?
- LMWH 1mg/kg (safe if breastfeeding)
- warfarin once INR is at normal level, teratogenic, but can give post natally switching from LMWH
What are the symptoms of postpartum blues?
- tearfulness/inability/reactivity
- predominant mood of happiness
- peaks 3-5 days after delivery
- unrelated to environmental stressors or psychiatric history
What are the symptoms of postpartum/perinatal depression?
- common affliction among women during pregnancy
- 5-25% of pregnant women and new mothers
- treatment largely same as for clinical depression in general
What are the symptoms of postpartum psychosis?
acute mental illness
- loss of contact with reality
- hallucinations
- severe thought disturbance
- abnormal behaviour
- mania
- depression (confusion, delusions, stupor)
- atypical psychoses
- first 10 days following childbirth
What is mania?
excited
over-talkative
uninhibited
intensely overactive
What is the 2nd leading cause of direct maternal deaths?
hypertensive disorders
What are the types of pregnancy-induced hypertension?
- gestational hypertension
- pre-eclampsia
- eclampsia
What is gestational hypertension?
- late onset without proteinuria
How is gestational hypertension managed?
- antenatal antihypertensive treatment continue if 149/99 or over
- consider reducing antihypertensive if bp falls below 140/90, reduce if below 130/80
What is pre-eclampsia?
hypertension with proteinuria and after 20 weeks of pregnancy
- urinary reagent strip test at postnatal review (6-8 weeks after birth)
- if persistent further review 3 months after birth (kidney function)
What is eclampsia?
Pre-eclampsia and convulsions
How are fits controlled?
- loading dose: 8ml MgSO4 over 20 minutes
- maintenance dose: (1-2g/hr)
- therapeutic levels: 2-4mmol/L
What types of cardiac problems are there?
- sudden adult death syndrome
- aortic dissection
- acute coronary syndrome
- cardiomyopathy
- other cardiac conditions
What are direct and indirect causes of maternal death?
Direct - only due to pregnant state
Indirect - due to other factors than pregnancy
What are the intrapartum risk factors of primary PPH?
Emergency C section Retained placenta Episiotomy Operative vaginal delivery Labour >12 hours
