Maternal Post-Partum Problems

Question 1

Puerperium

Answer 1

Time from delivery until 6 weeks

Time taken for uterus to involute

Question 2

End of puerperium

Answer 2

Most of physiological changes of pregnancy have returned to pre-pregnancy state
However, lactation + psychological strains continue after 6 weeks

Question 3

Post Partum Haemorrhage

Answer 3

Excessive bleeding following delivery

Question 4

Primary PPH

Answer 4

> 500ml blood loss from genital tract within 24h delivery

Commoner

Question 5

Secondary PPH

Answer 5

Abnormal bleeding from genital tract, from 24hr after delivery –> 6 weeks

Question 6

PPH Incidence

Answer 6

5%

Leading worldwide cause of maternal death

Question 7

PPH Causes

Answer 7

4 Ts
Tone (70%)
Trauma (20%)
Tissue (9%)
Thrombin (1%)

Question 8

PPH Predisposing factors

Answer 8

Antepartum haemorrhage in pregnancy
Placenta praevia (15x risk)
Multiple pregnancy
Pre-eclampsia
Nulliparity
Previous PPH
Maternal obesity
Maternal age (increases with age)
Multiparity

Question 9

Intrapartum Haemorrhage RFs

Answer 9

Emergency C section
Elective CS
Retained placenta
Episiotomy
Operative vaginal delivery
Labour > 12hrs
>4kg baby
Maternal pyrexia in labour

Question 10

Uterine Atony

Answer 10

Most common cause PPH
Initial step- bimanual uterine massage and compression
Oxytocic agents- syntometrine, syntocin, prostaglandins

Question 11

Uterotonics

Answer 11

Syntometrine
IVI syntocinon 40 units in 500ml over 4 hours
Misoprostol
Carboprost
Ergometrine

Question 12

Surgery PPH

Answer 12

Examination under anaesthetic
Check placenta
Suture tears
Insert intrauterine balloon
Uterine artery embolization

Question 13

Hysterectomy PPH

Answer 13

Sooner rather than later

Especially in cases of placenta accrete or uterine rupture

Question 14

Secondary PPH causes

Answer 14

Infection- endometritis

Tissue- retained products of conception

Question 15

PPH investigations

Answer 15

FBC
Blood culture
High/low vaginal swab
MSU
Ultrasound if RPOC suspected

Question 16

Secondary PPH treatment

Answer 16

Broad spectrum IV antibiotics

90% cases treated improve within 48-72 hours

Question 17

Thromboembolic disease

Answer 17

Main protective psychological change against PPH is increasing clotting factors and reducing anticoagulants
–> BUT predisposes to TED

Question 18

Thromboembolic disease pre-existing factors

Answer 18

Previous VTE
Thrombophilia
35+
Obesity
Gross varicose veins
Sickle cell
Paraplegia
Inflammatory disorders

Question 19

Thromboembolic disease Pregnancy related RFs

Answer 19

Surgical procedure
Dehydration
Sepsis
Pre-eclampsia
Excessive blood loss
Prolonged labour
Immobility after delivery

Question 20

DVT symptoms

Answer 20

Painful swollen leg
Redness/oedema
Pain- left iliac fossa/groin/buttock
Non-specific lower abdo pain

Question 21

PE symptoms

Answer 21

Chest pain
Breathlessness
Dizziness
Syncope
Hypoxia

Question 22

Cerebral VT symptoms

Answer 22

Headache

Seizures

Question 23

Thromboembolic disease management

Answer 23

Early mobilisation
Good hydration
TEDs
LMW heparin prophylaxis
Avoid COCP

Question 24

Thromboembolic disease treatment

Answer 24

LMWH 1mg/kg
Safe if breastfeeding

Warfarinise

Question 25

Postpartum “blues”

Answer 25

Tearfulness, reactivity
Peaks 3-5 days after delivery
Present in 50-80% of women

Question 26

Perinatal depression

Answer 26

During pregnancy + first postpartum year

5-25% pregnant women + new mothers

Question 27

Puerperal psychosis

Answer 27

Loss of contact with reality
Hallucinations
Severe thought disturbance
Abnormal behaviour
Often no insight
Sudden
Usually within first 10 days following birth
Mania, depressive or atypical psychosis
0.1-0.2% new mothers

Question 28

Mania psychoses

Answer 28

Excited, over-talkative, uninhibited and intensely overactive

Question 29

Depression psychoses

Answer 29

Differ from postnatal depression in the great severity of their symptoms and the presence of features like confusion, delusions and stupor

Question 30

Atypical psychoses

Answer 30

Confusion or perplexity, catatonic features, thought disorder, auditory hallucinations and delusions

Question 31

Pregnancy induced hypertension

Answer 31

Gestational hypertension- late onset hypertension, without proteinuria
Pre-eclampsia- hypertension with proteinuria after 20 weeks pregnancy
Eclampsia- pre-eclampsia + convulsions

Question 32

Post natal Pre-eclampsia treatment

Answer 32

Urinary reagent-strip test at postnatal review (6-8 weeks after birth)
If proteinuria persists at postnatal review, further review at 3 months to test for kidney function
–> referral to kidney specialist

Question 33

Eclampsia

Answer 33

One or more convulsions in association with pre-eclampsia

Question 34

Control of Eclampsia fits

Answer 34

Loading dose- 4g MgSO4 infused over 20 mins
Maintenance dose- 1-2g MgSO4/hr
Maintain 24hrs post delivery
Pulse Oximetry
Therapeutic levels 2-4mmol/litre

Question 35

Cardiac

Answer 35

Leading cause of direct maternal deaths
Sudden adult death syndrome
Aortic dissection
Acute coronary syndrome
Cardiomyopathy

Question 36

Connective tissue disease

Answer 36

Systemic lupus erythematosus (SLE)
Antiphospholipid syndrome (APS)