Post-Partum Problems Flashcards by Emilia McColm

Define puerperium. When is it said to have ended?

Time from delivery until 6 weeks
The time for the uterus to involute.
When most of the physiological changes of pregnancy have returned to the pre-pregnancy state (apart from lactation and psychological strains).

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What are the potentially life-threatening post-partum problems? (6)

Postpartum Haemorrhage
Thromboembolic disease
Psychiatric disorders
Pre-eclampsia 
Sepsis
Cardiac disease

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What was the maternal death rate in 2012-2014 (per 100,000 births)?

8.5 per 100,000

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Maternal deaths - how many died due to medical and/or mental health problems in pregnancy (%)?
How many of these women had these conditions before they became pregnant (%)?

2/3

3/4

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Maternal deaths - how many died from direct complications of pregnancy (%)?

1/3

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What is the biggest cause of maternal death (2012-14) according to MBRRACE-UK?

SBAR should be used to improve communicaiton. What does it stand for?

Cardiac disease

Situation
Background
Assessment
Recommendation

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What is post-partum haemorrhage?

Excessive bleeding following delivery

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What is primary post-partum haemorrhage?

> 500ml blood loss from the genital tract within 24 hours of delivery

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What is secondary post-partum haemorrhage?

Abnormal bleeding from the genital tract, from 24 hours after delivery to 6 weeks

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Which is more common - primary or secondary PPH? What is the incidence?

Primary - it is the leading worldwide cause of maternal death
5%

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What are the four main causes of primary PPH?

Tone - uterine atony (70%)
Tissue - retained placenta (9%)
Trauma - vulval or vaginal lacerations (20%)
Thrombin - coagulopathy (1%)

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What causes 80% of primary PPH?

Uterine atony (tone)
Retained placenta/fragments of placenta (tissue)

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What causes 20% of primary PPH?

Vulval or vaginal lacerations (trauma)

Coagulopathy (thrombin)

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What are the predisposing factors for primary PPH? (9)

Antepartum haemorrhage in this pregnancy
Placenta praevia
Multiple pregnancy
Pre-eclampsia
Nulliparity (never having given birth)
Previous PPH
Maternal obesity
Maternal (increased) age
Multiparity (having given birth to >4 children)

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What are the intrapartum risk factors for primary PPH? (7)

Emergency or elective C-section
Retained placenta
Episiotomy
Operative vaginal delivery
Labour >12 hours
>4kg baby
Maternal pyrexia in labour

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How is primary PPH managed? (7)

IV access (2 x 14 gauge cannulae)
Monitor clinically
Oxygen by mask
Indwelling urinary catheter (to ensure bladder is empty)
Bimanual uterine compression (to stimulate contractions)
Uterotonics
Surgery

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Explain more about the uterotonics (agent used to induce contraction/oxytocic agents) for primary PPH? (5)

Syntometrine
IVI syntocinon (40 units in 500ml over 4 hours)
PGE1 misoprostol (800 mg rectally)
PGF2α carboprost (250mcg by IM injection)
Give IV/IM injection of ergometrine (500 mcg)

What surgery can be done for primary PPH? (7)

Examination under anaesthetic (lower genital tract)
Check the placenta
Suture tears
Intrauterine balloon (Bakri)
Uterine artery embolisation or bilateral ligation (of uterine arteries or internal iliac arteries)
B-lynch suture (to compress an atonic uterus)
Hysterectomy

What are the causes of secondary PPH? (2)

Infection (e.g. endometritis)

Retained products of conception

How is secondary PPH managed?

How many % of cases treated improve within 48-72 hours?

Broad spectrum IV antibiotics
If RPOC evacuate after 24 hours of antibiotics

90%

The main protective physiological change in pregnancy against PPH is increasing clotting factors and reducing anti-coagulants. Why is this dangerous?

It predisposes to thromboembolic disease

What are the pre-existing risk factors for TED? (9)

Previous VTE
Thrombophilia
Age over 35 years
Obesity
Parity >4
Gross varicose veins
Paraplegia
Sickle cell disease
Inflammatory disorders

What are the pregnancy risk factors for TED? (7)

Surgical procedure
Dehydration
Sepsis
Pre-eclampsia
Excessive blood loss
Prolonged labour
Immobility after delivery

What are the symptoms of a DVT? (4)

Painful swollen leg (lower leg or whole leg)
Pain in left iliac fossa, groin, buttock, or lower abdomen
Redness
Oedema

What are the symptoms of pulmonary embolism? (6)

``` Sudden chest pain Sudden breathlessness Dizziness Syncope Tachycardia Hypoxia ```

What are the symptoms of a cerebral vein thrombosis? (2)

Headache | Seizures

How is TED managed? (5)

``` Early mobilisation Good hydration Compression stockings Low molecular weight heparin (1mg/kg) Avoid combined contraceptive pill ```

What are the cardiac post-partum problems? (4)

Sudden adult death syndrome Aortic dissection Acute coronary syndrome Cardiomyopathy

Connective tissue diseases post-partnum... (4).

Lupus Antiphospholipid syndrome Scleroderma Ehlers-Danlos syndrome

What is 'baby blues'? How long does it last? What should be considered if it persists?

Brief episode of misery, tearfulness, sleeplessness, irritability, impairment of concentration, isolation and headache that affects at least half of all women following delivery (especially those having their first baby) Lasts a few hours - several days (peaks 3-5 days after delivery) Postnatal depression

What is puerperal psychosis? | What are the symptoms?

An acute mental illness (usually first 10 days following childbirth) Loss of contact with reality, hallucinations, severe thought disturbance and abnormal behaviour, mania, depression, atypical psychosis (confusion, catatonia, thought disorder, auditory hallucinations and delusions)

How many % of all new mothers does puerperal psychosis affect?

0.1-0.2%

Describe mania.

Excited, over-talkative, uninhibited and intensely overactive

What differs in depression seen in puerperal psychosis in comparison to post-natal depression?

Presence of confusion, delusions, and stupor | More severe symptoms

When might a mother be admitted to the mother and baby unit? (6)

``` Mother has any of the following: rapidly changing mental state suicidal ideation pervasive guilt or hopelessness estrangement from the infant beliefs of inadequacy as a mother evidence of psychosis ```

How many % of pregnant women and new mothers does perinatal depression affect?

5-25%

What are the major differences between baby blues and postnatal depression?

With baby blues, the predominant mood is happiness. Baby blues is present in 50-80% of women and is unrelated to psychiatric history and environmental stressors. Baby blues doesn't persist.

How many women who died between six and one year after pregnancy died from mental-health related causes?

1/4

What investigations are done for TED? (6)

``` Arterial blood gas Ultrasound Chest x-ray V/Q SCAN &/or CTPA ECG (MRV) ```

How many % of women have endometritis after spontaneous vaginal delivery? How is this related to postnatal morbidity?

1-3% after spontaneous vaginal delivery. | Commonest cause of postnatal morbidity days 2 -10

What investigations are done for secondary PPH?

``` Full blood count and CRP Blood cultures High/low vaginal swab MSU Ultrasound (if RPOC suspected) ```

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Post-Partum Problems Flashcards

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