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cOGTEXT > Post-Partum Problems > Flashcards

Post-Partum Problems Flashcards

1
Q

what is the puerperium?

A

6 weeks following birth

period of repair and recovery

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2
Q

how does vaginal discharge change over first 3 weeks of puerperium?

A

3-4 days = fresh red blood (“rubra”)
4-14 days = brownish-red, watery (“serosa”)
10-20 days = yellow (“alba”)

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3
Q

what is uterine involution?

A

group of changes which occur during puerperium

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4
Q

what changes occur in uterine involution?

A

endometrial lining regenerates by day 7
fundus returns to physiological location within pelvis by 2 weeks
uterine weight decreases to 5% of immediate post birth weight

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5
Q

does lower repro tract return to normal after pregnancy?

A

no

regress but never return to pre-pregnancy state

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6
Q

by which month of pregnancy will breasts have fully adapted to produce milk?

A

5th or 6th month

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7
Q

what is colostrum?

A

first milk a breastfed baby will receive
thick yellowish substance
contains more protein and vitamins than later milk
essential for early immunological protection in newborn

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8
Q

how is lactation initiated?

A

expulsion of the placenta in stage 3 of labour

also the decrease in oestrogen and progesterone levels

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9
Q

what inhibits milk production during pregnancy?

A

high levels of oestrogen and progesterone block release of prolactin from anterior pituitary

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10
Q

is prolactin produced in pregnancy?

A

yes

but its prevented from carrying out its function of milk production

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11
Q

how does prolactin cause milk production?

A

after birth, hormone levels drop abruptly (while prolactin is still being produced at high levels)
prolactin is therefore released triggering milk production by lactocytes in mammary alveoli

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12
Q

how is prolactin release maintained?

A

via a positive feedback mechanism whereby the suckling infant promotes prolactin production by stimulating nipple mechanoreceptors

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13
Q

what is the let-down reflex?

A

mechanism of milk release from the breast during feeding
suckling stimulates production of oxytocin from posterior pituitary > oxytocin stimulates myoepithelial cells which surround breast alveoli > myoepithelial cells contract in response to oxytocin and squeeze milk out of the nipple

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14
Q

what else can trigger let down reflex?

A

pain
alcohol
sight and cry of an infant

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15
Q

path of milk from production to leaving nipple?

A

milk produced in lactocytes in mammary alveoli
myoepithelial cells squeeze milk from alveoli so it drains into lactiferous ducts
milk pools in lactiferous sinus before being discharged through nipple pores

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16
Q

is breastfeeding recommended by WHO?

A

exclusive breastfeeding for first 6 months is recommended
its recommended that breastfeeding should continue past 6 months but alongside introduction of appropriate solid foods for up to 2 years or as long as mother chooses

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17
Q

what is mastitis?

A

inflammation of the breast

can be due to infectious and non-infectious causes

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18
Q

most common cause of mastitis?

A

infectious
staph aureus = most common infecting organism
coag +ve staph = 2nd most common cause

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19
Q

what can cause a non-infective mastitis?

A 
duct ectasia (blocked lactiferous duct)
foreign body such as breast implant or nipple piercing
20
Q

how can lactation mastitis occur in breastfeeding?

A

most commonly linked to improper breastfeeding technique
trauma to breast and subsequent milk stasis and ineffective milk release make the breast more likely to harbour bacteria and therefore more prone to infection

21
Q

risks of maltreatment of lactation mastitis?

A

can lead to an abscess (usually in peripheral breast in breastfeeding women)

22
Q

what should a focused history of mastitis evaluate for?

A

MAIDS

  • milk stasis?
  • abscess present?
  • Inflammation?
  • discharge from nipple?
  • systemic symptoms of infection?
23
Q

how is mastitis diagnosed?

A

clinical diagnosis

24
Q

empirical treatment of lactation mastitis?

A

full course of staph aureus sensitive antibiotics as soon as signs of the condition appear
- flucloxacillin 500mg orally every 6 hrs for 7 days
- augmentin 625mg every 8 hrs for 7 days
should examine patient every few days to check therapeutic response
important that breastfeeding continues (can even use a breast pump for infected breast if needed)

25
Q

what is done if patient is showing signs of an abscess?

A

breast US

aspiration with an 18-guage needle for culture should be performed to confirm the diagnosis

26
Q

PPH definition?

A

blood loss of 500ml or more after the birth of the baby

27
Q

primary vs secondary PPH?

A 
primary = bleeding occurs within 24 hrs of delivery
secondary = bleeding occurs between 24 hrs and 6 weeks post delivery
28
Q

minor vs major PPH?

A 
minor = 500 - 1000ml
major = >1000ml or signs of cardiovascular collapse or ongoing bleeding
29
Q

how can severity of PPH be related to size of patient?

A

estimate blood volume as equivalent to 100mls per kg and multiple this by patients weight in kg
eg a 65kg patients blood volume would be estimated at 6500ml (6.5L)

30
Q

causes of PPH (4Ts)?

A

tone (uterine atony) = main cause
trauma = 2nd most common
tissue (retained products of conception) = 3rd most common
thrombin = least common cause

31
Q

antenatal risk factors for PPH?

A

placental problems (praevia, accreta, percreta)
previous history of retained placenta, C-section or PPH
multiple pregnancy
polyhydramnios
obesity
fetal macrosomnia

32
Q

intrapartum risk factors for PPH?

A 
operative vaginal delivery
syntocinon/syntometrine use (induced labour)
retained placenta
c-section
labour >12 hrs
perineal tear/episiotomy during delivery
33
Q

initial assessment and stabilisation of PPH?

A 
ABCDE
oxygen (15l/min via non-rebreather mask)
get IV access
bloods
cross-match 6 units red packed cells
check vital signs every 15 mins
determine cause of bleeding
consider initiating massive haemorrhage protocol
early blood transfusion
give tranexamic acid 0.5-1g IV to stop the bleeding (regardless of cause)
34
Q

how can you stop the bleeding non-surgically in PPH?

A 
uterine massage
expel clots manually 
give 5 units syntocinon
insert catheter to minimise bladder pressure on uterus
give 500mcg IV ergometrine if no response to syntocinon
exclude repair/trauma
give carboprost 250mcg IM every 15 mins
give misoprostol 800mcg PR
35
Q

surgical methods of stopping the bleeding in PPH?

A

balloon insertion to put pressure on bleeding blood vessels
arterial embolisation via interventional radiology
“B-lynch” sutures
uterine artery ligation
internal iliac ligation
hysterectomy is a last resort

36
Q

how is fluid replacement done in PPH?

A

2 large bore IV access
rapid fluid resuscitation (crystalloid, 0.9% saline)
blood transfusion early (consider O- if life threatening)
if DIC/coagulopathy occurs then give FFP, cryoprecipitate, platelets
use a blood warmer

37
Q

how can secondary PPH be prevented?

A

give thromboprophylaxis
debrief the couple
manage anaemia with iron supplementation

38
Q

how common is perineal tear?

A

9 in 10 first time mothers

39
Q

what are the 4 degrees of tear?

A

1 = involves skin only
2 = involving skin and perineal muscles such as levator ani, usually needs stitches
3 + 4 = extend to external anal sphincter muscle, may need surgery as mother may experience faecal incontinence due to overstretching of pudendal nerve branches

40
Q

how as an episiotomy different from perineal tear?

A

episiotomy is a surgical cut made with patients consent

41
Q

how is anaesthesia used in episiotomy?

A

local anaesthetic injected along the site of the tear/episiotomy to anaesthetise branches of pudendal nerve (12)

42
Q

blood supply to foetus while in the womb?

A

via placenta
umbilical vein (belonging to foetus) carries oxygenated blood from placenta to two areas (little bit to foetal liver and rest to foetal IVC via ductus venosus)
this causes blood to mix as the IVC carries oxygenated blood
the mixed blood drains into the right atrium of the heart as the deoxygenated blood from SVC

43
Q

function of foramen ovale in the foetus?

A

small hole in the septum where blood from the right atrium can pass into the left atrium
exists to relieve pressure on the right side of the heart caused by increased pulmonary resistance

44
Q

possible paths of blood flow once it enters right atrium?

A

can drain into the right ventricle to then be pumped via the pulmonary arteries to the lungs
or
can pass into the left atrium via the foramen ovale

45
Q

why is there increased pulmonary resistance in the foetus?

A

alveoli contain fluid rather than air which means they lack oxygen
as a result, nearby arterioles vasoconstrict in response to the alveoli’s hypoxic state and increase the pulmonary resistance

46
Q

what other structure helps relieve the pressure on the right side of the foetal heart due to increased pulmonary resistance?

A

ductus arteriosus

47
Q

what does the ductus arteriosus do?

A

vessel which connects the pulmonary arteries to the aort

cOGTEXT (17 decks)

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