Obs - Puerperium

Question 1

When do periods restart postnatally?

When can pregnancy occur?

Answer 1

Periods:
Not breastfeeding: approx 5-6 weeks
Breastfeeding: longer eg 8

Pregnancy; 3 weeks

Question 2

What is the mechanism of lactation?

Answer 2

Prolactin from anterior pituitary stimulates milk secretion
o High at birth
o Rapid decline in E2 and p4 causes milk secreted o Prolactin antagonised by E2/P4

 Oxytocin from posterior pituitary stimulates ejection in response to nipple suckling o Stimulates further prolactin release

Question 3

Define postpartum haemorrhage?

Answer 3

Definied as >500ml blood loss <24h after delivery, or >1000ml after C section

Question 4

When there is collapse in absence of external blood loss, what are the Dfx?

Answer 4

Antepartum - placental abruption

Post partum- retained placenta (that is partially separated), Uterine inversion

Question 5

List causes of PPH?

Answer 5

Uterine atony
Retained placenta
Episiotomy
Perineal tears

uterine rupture?

Question 6

How is major postpartum haemorrhage managed?

Answer 6

ABC; 14g cannula access, fluids, bloods,catheter

Medical treatment; manual uterine compression, oxytocin

Theatre: balloon tamponade, brace suture

Last resort theatre: bilateral uterine/iliac artery ligation. Uterine embolisation. Hysterectomy.

Question 7

What is the difference between APH and PPH management?

Answer 7

In APH, remember, bleeding resolves post delivery of foetus and placenta. So surgical methods usually not required - unless hysterectomy in placenta praevia.

Question 8

Blood loss between 24h and 6 weeks post delivery is known as?

Answer 8

Secondary PPH

Question 9

Dfx for Secondary PPH?

Answer 9

Endometritis
o Retained placental tissue
o Incidental gynaecological pathology
o Gestational trophoblastic disease - tumours that arise from trophoblast of placenta.

Question 10

How is secondary PPH managed?

Answer 10

Vaginal swabs - rule out infection
FBC - rule out anemia
 Cross match - in preparation for resus
 US used – difficult to differentiated clot and placental tissue

 ERPC
 Abx
 Histological examination of evacuated tissues

Question 11

What organism is the most common infectious cause of antenatal and postnatal pyrexia?

Answer 11

Antenatal - GBS

Postnatal - Group A strep (pyogenes ), staph, ecoli

Question 12

List causes of postpartum pyrexia?

Answer 12

UTI, chest infection, mastitis, perineal and wound infection are also common

May also be due to DVT

Question 13

If a patient has a hx of serious mental illness, and risks suicide postnatal, how would you manage this?

Answer 13

Give SSRIs in pregnancy - safe

Both for depression and BPAD?

Question 14

How is BPAD managed in pregnancy?

Answer 14

CANNOT take the usual drugs: lithium, valproate.

SSRIs, snris, tcas are safe.

Obviously whole issue about assess if stopping drug is worth the risk.