Post-partum Complications Flashcards
What are the baby blues?
These affect up to 75% of mothers; it is a few days of depression that occurs within a few days of birth.
What are the symptoms of baby blues?
- Weepy and irritable
- Labile emotions
- Trouble sleeping
What is the treatment for baby blues?
Reassure the mother as this self resolves usually, and explain the symptoms. Safety net for progression into depression.
What is post natal depression? What is the epidemiology surrounding it?
It affects 10-15% of mothers within a year of birth and risks include a personal or family history, recent life events, younger maternal age and marital discord.
Without treatment most will recover, but a tenth will remain depressed.
What are the symptoms of post-natal depression?
This usually presents around 6 weeks with a gradual onset.
- Fatigue and irritability
- Anxiety
- Depressive cognitions surrounding the child
- Distressing compulsions regarding the child
Severe symptoms:
- Early morning wakening
- Diurnal mood variation
- Low energy/libido
- Anhedonia
- Risk to self or child
What is the treatment of post-natal depression?
Biopsychosocial:
- Remedy of social factors
- Non-directive counselling
- Interpersonal psychotherapy
- Cognitive behavioural therapy
- Drug therapy
Pharmacological:
- Use medication carefully if breastfeeding
- Tricyclic (better for breastfeeding) or SSRIs appropriate
- Amitriptyline low dose
Admission:
- Admit if suicidal
- Mother and baby units prevent separation
What are the complications of post-natal depression?
Immediate
- Physical morbidity
- Suicide/infanticide
- Prolonged psychiatric morbidity
- Damaged attachment to infant
- Damaged development of infant
Later
- Social/cognitive effects on child
- Marital breakdown
- Future mental health problems
What is puerperal psychosis?
This is psychosis within 6 weeks of birth, and occurs once in every 5-1000 births. The highest risk factor is a personal history (80% recurrence).
What are the symptoms of puerperal psychosis?
- Rapid onset, and begins with insomnia and restlessness.
- Perplexity, confusion
Psychotic symptoms can be:
- Delirium, delusions, hallucinations
- Loss of insight
- Risk of self harm, suicide, or harm to child
- Depressive symptoms
What is the treatment of puerperal psychosis?
Admit all mothers, and protect mother and child
- Antipsychotics
- Antidepressants if needed
- Lithium if needed
- Benzodiazepines if needed
- ECT in severe cases
Most will recover within 2 months, but will need antidepressants for 6.
What is the prognosis of puerperal psychosis?
Most will recover within 6-13 weeks, with a third of patients having recurrent psychosis going forward. The risk of recurrence in future pregnancy is approximately 1 in 2. Consider prophylactic lithium on day 1 of puerperium in those with a history.
What is the cause of postpartum affective disorders?
Not well understood however, possible because of:
- Fall in oestrogen triggers dopamine hypersensitivity
How is mental health screened after pregnancy?
The Edinburgh questionnaire screens for mental health during and after the pregnancy. They should be asked ideally at 6 weeks after birth, and 3-4 months after the birth.
A score of 10 or more denotes depression.
What are the risk factors for postnatal depression?
- Past history
- Depression in pregnancy
- Social isolation
- Poor relationships
- Severe postnatal ‘blues’
What are the risk factors for puerperal psychosis?
- Previous history
- Family history
- History of severe postpartum depression
What is post-partum haemorrhage?
This is defined as a blood loss of over 500ml. Major obstetric haemorrhage is defined as a blood loss of >1000ml or that which requires a blood transfusion of >5 units of blood.
What are the risk factors for postpartum haemorrhage?
- Haemoglobin below the normal range
- Uterine atony (macrosomia, multiple pregnancy, prolonged labour, induction of labour
- Placenta praevia/accrete
- Perineal trauma
Haemorrhage usually comes from three main areas:
- Uterus
- Placenta
- Cervix/vagina
What are the signs and symptoms of haemorrhage?
Symptoms:
- Anxiety
- Thirst
- nausea
- Cold
- Pain
- Dizziness
Signs:
- Rising fundus
- Peritonism
- Reduced urine output
- Tachycardia
- Tachypnoea
- Hypotension
What is the management of postpartum haemorrhage?
- Do not delay fluid resuscitation and blood transfusion
- Be proactive and act on bleeding without delay
- Consider early recourse to hysterectomy if medical/surgical interventions prove ineffective
- Obtain planned consent for interventions for those at risk
Describe the obstetric haemorrhage protocol
Initiate protocol:
- Call for senior help
- Scribe for documentation of timing of events
Try to stop bleeding
- Uterine compression/rub
- Empty uterus of clots
- Empty bladder
- Bimanual compression of uterus if atony is cause
- 2x IV large bore access
- FBC, cross-match, coagulation profile, group and save
- Fluid replacement: cross-matched or O-ve blood
If uterine compression doesn’t work, stepwise agents:
1) 5-10 units of IV/IM oxytocin
2) 40 units oxytocin in 100ml normal saline over 4 hours
3) 800-1000 micrograms of rectal misoprostol
4) Syntometrine (ergometrine 500 micrograms plus 5 units Syntocinon)
5) Repeat ergometrine 500 micrograms IM
6) Carboprost 0.25mg IM at repeated intervals >15 minutes apart, up to 8 doses (CI: asthma).
If ongoing bleeding, consider:
- DIC, replace clotting agents
- Senior help
- Transfer to theatre (uterine balloon, iliac ligation, uterine artery embolisation, hysterectomy)
Afterwards:
- Clear documentation
- Debrief staff and family
- Risk report
