OB-GYN Revision 10 Flashcards
A routine care appointment is offered when after birth? [1]
What is check during this appointment? [4]
Six weeks post natal check by GP to check how mother is doing - at same time as 6 week newborn baby check
* General wellbeing
* Mood and depression
* Bleeding and menstruation
* Scar healing after episiotomy or caesarean
* Contraception
* Breastfeeding
* Fasting blood glucose (after gestational diabetes)
* Blood pressure (after hypertension or pre-eclampsia)
* Urine dipstick for protein (after pre-eclampsia)
Describe what is meant by a lochia [1]
How long does it last? [1]
What should be avoided during this time? [1]
What indicates pathology? [1]
a mix of blood, endometrial tissue and mucus post birth
- initially dark red colour that turns brown and quite heavy
- settles within 6 weeks
- avoid tampons as they have risk of infection
- blood clots indicates pathology
How does breastfeeding interact with menstruation after delivery? [2]
Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. This is normal.
Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea.
When does fertility return after giving birth? [1]
Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point
After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception).
Which methods of contraception are safe for breastfeeding? [3]
When can you put in the copper or IUS coils after birth? [2]
The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.
The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).
A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).
TOM TIP: Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.
Describe the presentation of post-partum endometritis [4]
- Foul-smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
How do you dx post-partum endometritis? [2]
- Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
- Urine culture and sensitivities
- Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).
A patient wants to start contraception after birth - what advise what you give them?
‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days
Combined oral contraceptive pill (COCP)
* absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
* UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum
* the COCP may reduce breast milk production in lactating mothers
* after day 21 additional contraception should be used for the first 7 days
The intrauterine device or intrauterine system
- can be inserted within 48 hours of childbirth or after 4 weeks.
name a significant risk factor for retained products of conception [1]
Describe the presentation of RPOC [4]
Placenta accreta is a significant risk factor for retained products of conception.
Presentation
- Retained products of conception may be present in patients without any suggestive symptoms. It may present with:
* Vaginal bleeding that gets heavier or does not improve with time
* Abnormal vaginal discharge
* Lower abdominal or pelvic pain
* Fever (if infection occurs)
How do you dx retained products of conception? [1]
How do you manage? [2]
Investigation:
* Ultrasound is the investigation of choice for confirming the diagnosis.
Management:
Evacuation of retained products of conception (ERPC) - surgery under general anaethestic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”
What are two key complications of ERPC? [2]
Endometritis
Asherman’s syndrome
- where adhesions (sometimes called synechiae) form within the uterus. Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.
Postpartum anaemia is defined as a haemoglobin of less than [] g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.
Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.
Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):
Hb under 100 g/l – [1]
Hb under 90 g/l – [1]
Hb under 70 g/l – [1]
Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):
Hb under 100 g/l – start oral iron (e.g. ferrous sulfate)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron
What do you have to check before giving an iron infusion? [1]
TOM TIP: It is worth noting that active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.
Describe why baby blues may occur [6]
Baby blues may be the result of a combination of:
* Significant hormonal changes
* Recovery from birth
* Fatigue and sleep deprivation
* The responsibility of caring for the neonate
* Establishing feeding
* All the other changes and events around this time
Which scale / questionnare can be used to screen for post-natal depression? [1]
What score would indicate a ‘depressive illness of varying severity’?
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
- score > 13 [max 30] indicates a ‘depressive illness of varying severity
When is post-natal depression most likely to occur [1] and peak? [1]
How do you treat? [1]
Most cases start within a month and typically peaks at 3 months
Management:
- reassurance and support are important
- Cognitive behavioural therapy
- SSRIs: sertraline and paroxetine
When is puerperal pyschosis most likely to occur? [1]
Onset usually within the first 2-3 weeks following birth
Describe the features of puerperal pyschosis? [6]
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Thought disorder
When would you suspect Sheehans syndrome? [3]
Those who just gave birth and:
- failure to lactate (earliest sign) &
- absent menstruation
- features of hypopituitarism: hypothyroidism and cortisol deficiency
- Loss of hair
Lecture
Name two risks that increase risk of post-partum pyschosis [2]
- ↑risk: bipolar disorder, Hx of postpartum psychosis (note risk of relapse)
Lecture:
Describe the onset of post partum psychosis [2]
Severe episodes have a rapid onset
Immediate post partum period has the highesr risk
