Maternal Post Partum Problems Flashcards
how long is the puerperium
= time from delivery until 6 weeks
what is the puerperium defined as 6 weeks after delivery
the time taken for the uterus to involute
END=most of the physiological changes of pregnancy have returned to the pre-pregnancy state
what two things can occur after the 6 weeks after delivery
However lactation and psychological strains continue after 6 weeks
what are the two causes of maternal death
Direct cause
Indirect cause
define the direct and indirect cause of maternal death
Direct cause of maternal death because of complications during pregnancy and after delivery
If the person had not been pregnant then this wouldn’t have happened
Indirect maternal death is due to prediagnosed medicial condition, would not have worsened and women would not have died if it wasn’t for the pregnancy
what are the most common cause of indirect maternal death
Cardiac death
what is the most common cause of direct maternal death
- thrombosis and thromboembolism
2. maternal suicide
what is cardiac death in material death increasing
- increase in maturational age of mothers, therefore they are more likely to have an MI
- migration and thus people with rheumatic fever enter the UK and not aware they have Rheumatic fever and therefore they die
What is a primary post partum haemorrhage
> 500ml blood loss from the genital tract within 24 hours of delivery
- commoner
what is a secondary post part haemorrhage
abnormal bleeding from the genital tract, from 24 hours after delivery - 6 weeks
what is the indcidence of a primary post partum haemorrhage
5%
what are the 4 causes of primary PPH
T: Tone = uterus not contracting (70%)
T: Tissue = placenta/membranes left behind (20%)
T: Trauma = episiotomy/tear which keeps bleeding (9%)
T: Thrombin = clotting disorders that need to be corrected (1%).
describe how thrombin causes primary post partum haemorrhage
the tone, trauma and tissue can lead to the person bleeding profusely this leads to a disseminated coagulation state as there is a lack of coagulation factors left
- this prevents them from being able to stop bleeding
What are the predisposing factors to a primary PPH
Antepartum haemorrhage in this pregnancy
Placenta praevia (15x risk)
Multiple pregnancy (5x risk)
Pre-eclampsia (4x risk)
Nulliparity (3x risk)
Previous PPH (3x risk)
Maternal obesity (2x risk)
Maternal age (increases with age)
Multiparity (parity > 4)
what are the intrapartum risk factors for a PPH
Emergency Caesarean section (9x risk)
Elective CS (4x risk)
Retained placenta (5x risk)
Episiotomy (5x risk)
Operative vaginal delivery (2x risk)
Labour >12 hours (2x risk)
>4kg baby (2x risk)
Maternal pyrexia in labour (2x risk)
What do you do in a PPH
Call for help
Crash call code = 22 22
Airway, Breathing, Circulation.
Two large bore IV canula
Oxygen by mask(10-15 L/min)
Blood – FBC, Xmatch 4 units of blood, urea and electrolytes, clotting profile
SIMULTANEOUSLY: communication, resuscitation, monitoring and investigation, arresting the Bleeding
what is uterine atony
- uterine is a tone cause of PPH
- it is when the uterine fails to contract after birth
How do you treat uterine atony
- do a bimanual uterine massage and compression
- this is when you put your fist inside the vagina and with the other hand you try and massage the uterus
- then ask for oxytoxic agents such as syntometrine, syntocinon, prostaglandins
List some oxytocin agents
syntometrine
syntocinon
prostaglandins
list the uterotonics that can be used and what with
- Syntometrine – drug that is commonly used (made up of oxytocin and ergometrine)
IVI syntocinon 40units in 500ml over 4 hours – drug that causes the uterus to contract (sometimes used in labour)
PGE1 misoprostol 800mg PR - give 4 or 5 tablets into the rectum and this can cause the uterus to go into contraction
PGF2α carboprost 250mcg IM - this causes the uterus to go into contraction, can give 8 doses every 15 minutes in order to control the bleeding
Give IV/IM ergometrine 500 mcg - this causes vasoconstriction
What are the two surgical procedures that can be used for PPH
Barki Balloon
B lynch
What is a Barki Balloon
- this is advice that is placed in the uterus and is used for temporal control and reduction of bleeding
- when it inflates it keeps the uterus contracted and stops the bleeding
What is a B Lynch
- this is when you open the women up
- put a brace suture in in the anterior and posterior way and tie it up so it holds and squeezes the uterus which helps control the bleeding
what happens in a uterine artery embolisation
- this is used to help treat PPH
- pellets are inserted into the femoral artery and then into the uterine artery and these block the blood supply to the uterine body
what other vascular approach can you use for PPH
Bilateral ligation of the uterine arteries or of the internal iliac arteries
You should resort to a …
Resort to hysterectomy SOONER RATHER THAN LATER (especially in cases of placenta accreta or uterine rupture)
in what cases should you especially resort to a hysterectomy
especially in cases of placenta accreta or uterine rupture
Where does secondary PPH present
- this commonly presents in the community as prolonged or excessive bleeding
what are the causes of secondary PPH
Infection = endometritis
- 1-3% after spontaneous vaginal delivery.
- commonest cause of postnatal morbidity days 2 -10
tissue = retained products of conception
How is secondary PPH investigated by
FBC, CRP Blood cultures High/low vaginal swab MSU Ultrasound may be used if RPOC suspected
How do you treat secondary PPH
- Broad spectrum IV antibiotics
- if RPOC (retained products of conception) evacuate after 24 ours of antibiotics
what are the 5 key haemorrhage messages
- Anticipate Avoid
- Early recognition
- Prompt Effective Resuscitation
- Control bleeding quickly
- Human Factors.
what is the main protective physiological change against PPH and what does this predispose us in
- main protective physiological change against PPH is increasing clotting factors and reducing anticoagulants this predispose us to thromboembolic disease
what is the leading cause of direct maternal death
Thromboembolic disease
What are pre-exisitng risk factors for thromboembolic disease
1, Previous VTE 2, Thrombophilia Congenital /Acquired 3, Age over 35 years 4, Obesity (BMI >30) 5, Parity >4 6, Gross varicose veins 7, Paraplegia 8, Sickle cell disease 9, Inflammatory disorders
What are the pregnancy related risk factors for thromboembolic disease
1, Surgical procedure eg LSCS, MROP 2, Dehydration 3, Sepsis e.g. pyelonephritis 4, Pre-eclampsia 5, Excessive blood loss 6, Prolonged labour 7, Immobility after delivery
What are the symptoms of deep vein thrombosis
Painful swollen leg (lower leg/whole leg)
Redness/oedema of leg
Pain: LIF/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
- seizures
What is the management of thromboembolism
Early mobilisation Good hydration TEDs LMW heparin prophylaxis Avoid COCP
Why do you not give warfarin
tetrogenicity and it is difficult to control the coagulation as it needs active dose management therefore it would be even more difficult with pregnancy
What investigations do you use for thromboembolism
History
Examination
Investigations ABG USS CXR V/Q SCAN &/or CTPA ECG (MRV)
How do you treat thromboembolism
LMWH 1mg/kg
Safe if breastfeeding
Warfarin – don’t do this
Follow up
almost a 1/4 of women who died between 6 weeks and 1 year after pregnancy died from..
mental health related causes
What are the signs of mental health problems after pregnancy
Postpartum blues
Postpartum depression
Postpartum psychosis
describe postpartum blues
o Tearfulness, lability, reactivity. o Predominant mood: happiness. o Peaks 3-5 days after delivery. o Unrelated to environmental stressors o Unrelated to psychiatric history.
describe postpartum depression
o Common affliction among women during pregnancy
o 5-25% of pregnant women and new mothers
o Treatment largely the same as for clinical depression in general.
What are the symptoms of postpartum psychosis
Loss of contact with reality.
Hallucinations.
Severe thought disturbance.
Abnormal Behaviour.
Mania
Excited, over-talkative, uninhibited and intensely overactive.
Depression.
Differs from PND in the great severity of their symptoms and the presence
of features like confusion, delusions and stupor.
Atypical Psychoses
Confusion/perplexity, catatonic features, thought disorder, auditory
hallucinations and delusions.
o Usually first 10 days following childbirth.
define mania
- excited, over-talkative, uninhibited and intensely overactive
what is depression
differ from postnatal depression in the great severity of their symptoms and the presence of features like confusion, delusions and stupor
What is atypical psychoses -
confusion or perplexity, catatonic features, thought disorder, auditory hallucinations and delusions
When do you admit the mother to the baby unit
Mother has any of the following:
- rapidly changing mental state,
- suicidal ideation (particularly of a violent nature),
- pervasive guilt or hopelessness,
- significant estrangement from the infant,
- beliefs of inadequacy as a mother,
- evidence of psychosis.
what are the causes of pregnancy induced hypertension
a, Gestational hypertension: Late onset hypertension, without proteinuria
b, Pre-eclampsia: Hypertension with proteinuria and after 20 weeks of pregnancy
c. Eclampsia: Pre-eclampsia + convulsions.
define gestational hypertension
Late onset hypertension, without proteinuria
How do you manage gestational hypertension
Continue use of antenatal antihypertensive treatment if 149/99 or over.
Consider using reducing antihypertensive treatment if their blood pressure falls
below 140/90mmHg, reduce if below 130/80.
define pre-eclampsia
hypertension with proteinuria and after 20 weeks of pregnancy.
how do you treat pre-eclampsai
Women who with pre-eclampsia who have given birth, carry out a urinary reagent-strip test at the postnatal review (6-8 weeks after the birth). If persistent: Further review 3 months after birth (kidney function).
what is eclampsia
Eclampsia is defined as one or more convulsions in association with pre-eclampsia.
44% Post natal
38% Antenatal
18% Intrapartum
How do you control fits
Loading Dose: MgSO4 (8mls + 12mls saline) over 20 minutes
Maintenance Dose: 1-2g MgSO4/hr (20 + 30).
o Maintain for 24 hours post-delivery.
Therapeutic Levels: 2-4mmol/litre.
What different causes of cardiac death
o Sudden adult death syndrome o Aortic dissection o Acute coronary syndrome o Cardiomyopathy o Other cardiac Conditions
