Obs and gynae Flashcards
What are baby blues?
Brief period of feeling emotional and tearful 3-10 days after giving birth
How common is baby blues?
Majority (67%)
Potential causes of baby blues
- Significant hormonal changes
- Recovery from birth
- Fatigue and sleep deprivation
- Responsibility ofcaring for neonate
- Establishing feeding
- All the other changes and events around this time
Risk factors for baby blues
First-time mother
Presentation of baby blues
3-10 days after birth, peaking at day 5
* Mood swings
* Low mood
* Anxiety
* Irritability
* Tearfulness
Management of baby blues
Self-limiting and resolves within 2 weeks of delivery
Reassurance and support
How common is depression in pregnant and postnatal women?
12%
Which antidepressant is prefered in pregnancy?
SSRIs (fluoxetine) preferable to tricyclic antidepressants
What is puerperal psychosis?
Acute onset of a manic or psychotic episode shortly after childbirth, usually developing in the first 2 weeks following birth
How common is puerperal psychosis?
2 in 1000
Risk factors for puerperal psychosis
- First-time mother
- Family history of puerperal psychosis/bipolar affective disorder
- Personal history of puerperal psychosis
- Bipolar affective disorder
- Schizophrenia
Presentation of puerperal psychosis
Abrupt onset of psychotic symptoms days to weeks following delivery
* Hallucinations
* Delusions, usually about the baby (deformed, evil, otherwise affected)
* Insomnia
* Tearfulness
* Agitation
* Rapidly changing mental state
* Depression
* Mania
* Confusion
* Thought disorder
Management of puerperal psychosis
!Psychiatric emergency!
* Mental health liaison/crisis team
* Admission to mother and baby unit with one-to-one care
* Tranquiliser
* ECT
* Psychotherapy and relapse prevention
* Contraception
Complications of puerperal psychosis
- Suicide
- Mother killing baby
Prognosis of puerperal psychosis
Full recovery
25% recurrence in subsequent pregnancies
65% develop bipolar affective disorder in later life
Side effects of antidepressants on baby
- Short-term withdrawal response
- Possibly longer-term neurodevelopmental effects
What is sepsis?
Large immune response to infection, causing systemic inflammation and affecting the functioning of the organs in the body
When should infection be suspected in mothers after giving birth?
Rise in temperature to 38 or more, maintained for 24 hours
Recurring temperature from first to 10th day after childbirth or abortion
What are the most common types of infections postpartum?
- Chorioamnionitis (chorioamniotic membranes and amniotic fluid)
- UTI
What are the most important pathogens in severe postpartum infections?
- Group A streptococcus
- Staphylococcus
- E. Coli
Risk factors for infection after giving birth
- Obesity
- DM
- History of pelvic infection
- Prolonged rupture of membranes
- Cervical cerclage
- Trauma: vaginal, c-section, wound haematoma
- Retained placental tissue
- Group A streptococcus infection in close contacts
- Impaired immunity
Presentation of chorioamnionitis
- Fever > 38
- Offensive lochia
- Abdominal pain
Presentation of sepsis
- Fever > 38
- RR > 25
- Systolic BP < 90
- Purpuric rash
- Lactate > 2
- HR > 130
- V or less on AVPU
- Requires oxygen
- Reduced urine output
What examinations would you do if you suspected an infection in someone who has recently given birth?
- Abdomen (wound infection after c-section, enlarged tender uterus)
- Breasts (mastitis)
- IV access sites
- Chest
- Legs
What investigations would you do if you suspect sepsis?
- Blood cultures
- Blood gas (lactate, pH, glucose)
- FBC (WBC, neutrophils)
- U&E
- LFT
- CRP (inflammation)
- Clotting (DIC)
What investigations would you do to find the source of infection in a person who has recently given birth?
- Urine cultures
- High vaginal swab
- Throat swab
- Sputum culture
- Wound swab
- Lumbar puncture (meningitis, encephalitis)
What should you suspect in someone with pyrexia who has recently given birth?
- Infection
- DVT (low-grade pyrexia)
How to manage sepsis in someone who has recently given birth?
Call for help from senior obstetrician and midwives
Sepsis 6:
1. Blood cultures
2. Venous lactate
3. Empirical broad-spectrum antibiotics (piperacillin, tazobactam and gentamicin OR amoxicillin, clindamycin and gentamicin)
4. IV fluids
5. Oxygen
6. Catheterisation and urine output
Where should women with existing mental health concerns before or during pregnancy be referred to and why?
Perinatal mental health services
* Advice and specialist input
* Ongoing management of psychiatric medications
* Plans for delivery to ensure they are followed up closely with help from midwives, health visitors, GPs, family and friends
What is postnatal depression?
Depressive episode within the first 12 months after delivery
Risk factors for postnatal depression
- Lack of social support - poor relationship with partner, unstable or absent family, lack of support from relatives and friends
- History of depression or other psychiatric illnesses
- Family history of depression or other psychiatric illnesses
- Antenatal thyroid dysfunction
- First-time mother
- Ambivalence about pregnancy
- Pregnancy complications
- < 16 when giving birth
- Poor or inadequate antenatal care
Presentation of postnatal depression
Depressive symptoms, typically 3 months after giving birth
* Fatigue and tiredness
* Feelings of being a bad mother
* Overwhelming feelings of responsibility
* Insomnia
* Lack of emotional bonding
* Excessive or unrealistic worry about the baby (not being able to care for them, harming them)
* Irritability
* Social withdrawal
Red flags in postnatal depression
- Suicidal ideation
- Feelings of incompetence as a parent
- Estrangement from child
- Hallucinations
What can be use to screen for postnatal depression?
Edinburgh postnatal depression scale (EPDS)
Which antidepressant is best for those breastfeeding?
SSRI (paroxetine)
What are some non-pharmacological treatments for postpartum depression?
- Additional social support and assistance in caring for the baby
- Psychoeducation
- Self-help CBT
- Couples therapy
- Group therapy
Management of severe postnatal depression
- Urgent referral to specialist mental health services
- Inpatient care on the mother and baby unit
Complications of postnatal depression on the baby
- Sudden infant death syndrome
- Harm
- Failure to thrive
- Attachment disorder
- Developmental delay
- Depression in adolescents and young adults
- Compromised mother-infant interaction
What is a genital tract fistula?
Hole between the vagina/uterus and any adjacent organ
Most common genital tract fistulae
- Vesicovaginal fistula (vagina and bladder)
- Rectovaginal fistula (vagina and rectum)
Causes of genital tract fistulae
- Childbirth
- Surgery
- Radiotherapy
Symptoms of genital tract fistulae
Continuous leakage of urine (vesicovaginal) or faeces (rectovaginal)
How do you test for genital tract fistula?
Vaginal inspection with Sims speculum
How can you test for a small genital tract vesicovaginal fistula?
Swabs in vagina
Methylene blue in bladder
1st line management of small vesicovaginal fistulae
Drain bladder continuously for 14 days
May close spontaneously
Management for rectovaginal fistulae and larger fistulae
Surgery
Why may a fistulae happen 5-14 days after the procedure?
When the traumatised ischaemic tissue sloughs
