Postnatal Flashcards
Function of the placenta?
- fetal homeostasis
- gas exchange
- nutrient transport
- waste product transport
- acid base balance
- hormone production
- transport of IgG
What is contained within the umbilical cord?
- 3 blood vessels
- 1 x umbilical vein (oxygenated)
- 2 x umbilical artery (deoxygenated)
What are the 3 fetal shunts?
- ductus venosus
- foramen ovale
- ductus arteriosus
Explain ductus venosus?
- connection between the umbilical vein and inferior vena cava
- at the liver
- oxygenated
Explain foramen ovale
- right to left shunt in heart
- becomes the fossa ovalis
Why does blood avoid the lungs?
- lungs collapsed and fluid filled
- high resistance to flow
- only a small fraction of RV output goes via lungs
Within increasing gestation what do type 2 pneumocytes produce?
- they produce surfactant
- reduces resistance
What hormones prior to and during delivery slow fluid secretion and promote reabsorption?
- cortisol
- thyroid hormones
- catecholamines
Explain circulation changes postnatally?
- pulmonary vascular resistance drops
- systemic vascular resistance rises (prostaglandin drop, oxygen as a constrictor)
- ductus arterioles constricts
- foramen ovale closes
Remnant of the ductus arteriosus in an adult is called?
- liagmentum arteriosus
Symptoms of postnatal depression?
- tearfulness, irritability, anxiety, lack of enjoyment, poor sleep
- develops 2-6weeks post natally
Describe baby blues?
- common/normal
- develops within days postnatally
- brief period of emotional instability
- support and reasurrance
Explain puerperal psychosis?
- usually within 2 weeks postnatally
- sleep disturbances, confusion, mania, delusions
- treat as an emergency
Treatment of puerperal psychosis?
- admission
- antidepressants
- antipsychotics
- mood stabilisers
- ECT
Treatment of mild/moderate postnatal depression
- self help
- counselling
Treatment of moderate/severe postnatal depression
- psychotherapy
- antidepressants
- admission
First line antidepressant in pregnancy?
- SSRI
- Sertaline or fluoxetine
Risk of valproate and carbamazepine in pregnancy?
- highly teratogenic
- high risk of NTD
Lithium in pregnancy?
- avoid if possible
- known association with Ebstein’s anomaly (cardiac defects)
- do not use in breast feeding
Which antipsychotic should be avoided in pregnancy and why?
- clozapine
- risk of infant agranulocytosis
In utero glucose homeostasis?
- from placenta
- glycogen stores created in liver and muscle
Explain thermoregulation in utero?
- mum responsible
- during 3rd trimester brown fat laid down
Explain thermoregulation after delivery?
- heat produced by breakdown of stored fat
- peripheral vasoconstriction
Explain glucose homeostasis post delivery?
- drop in insulin
- increase in glucagon
- mobilisation of hepatic glycogen stores for gluconeogenesis
Primitive reflex involved in breast feeding?
- rooting and suck
Explain haematopoiesis prior and after birth?
- prior birth = liver
- post delivery = bone marrow
Explain physiological jaundice?
- breakdown of fetal haemoglobin
- immature conjugation pathways
- rise in circulating unconjugated bilirubin
Concern if high levels of unconjugated bilirubin cross the BBB?
- Kernicterus
Normal weight loss of baby in first few days?
- up to 10% of birth weight
Explain persistent pulmonary hypertension of the newborn?
- failure of the pulmonary circulation pressure to drop
- persistence of ductus arteriosus and foramen ovale
Treatment of persistent pulmonary hypertension of the newborn?
- ventilation
- nitric oxide (pulmonary vasodilator)
- sedation
Respiratory distress following c - section?
- transient tachypnoea of the newborn
- loss of hormonal stress influence
- fluid filled lungs
Why are smaller babies at greater risk for hypothermia?
- reduced brown fat stores
- little subcutaneous stores
- large volume:surface area
Neonatal hypoglycaemia may be caused by what?
- maternal diabetes
- inappropriate insulin:glucagon
Define the puerperium period?
- from the end of 3rd stage of labour until 6 weeks
When is the uterus no longer palpable postpartum?
- after 10days
When is the cervical os typically closed by?
- typically 7-10days post partum
What is lochia?
- bloodstained for up to 14days
When does menstruation typically occur postpartum?
- after 6 weeks
When does ovulation typically occur postpartum?
- after 28days
Risk factors for endometritis?
- prolonged labour
- prolonged ROM
- multiple vaginal examinations
- retained tissue
- c-section
Describe 3rd degree perineal tears?
- 3A < 50% external anal sphincter
- 3B > 50% external anal sphincter
- 3C = internal and external anal sphincter
Treatment of endometritis?
- IV co-amoxiclav
- metronidazole
- +/- gentamicin
Define secondary postpartum haemorrhage?
- bleeding 24hrs-6weeks postpartum
typical causes of secondary postpartum haemorrhage
- endometritis
- retained placenta
Management of urinary retention?
- catherisation
- underlying cause?
- trial without in 24hrs
Treatment of mastitis?
- oral or IV flucoaxicillin
When can POP be started postpartum?
- immediately
When can COCP be started postpartum?
- wait 6 weeks
When can IUD or IUS be started post-partum?
- immediately within 48hrs or after 6weeks
Define micturition and explain the different bladder sphincters?
- micturition = emptying of the bladder
- internal urethral sphincter = involuntary
- external urethral sphincter = voluntary
Hypogastric innervation to the bladder?
- sympathetic (L1-2)
- relaxes detrusor, contracts IUS
- promotes storage
Parasympathetic nerves to the bladder?
- from pelvic nerves
- contraction of detrusor
- relaxation of IUS
- promotes micturition
What does self-regenerative mean?
- the more the bladder fills the greater the micturition reflex
3 main types of urinary incontinence?
- urge (urgency)
- stress (physical exertion)
- overactive (urge and frequency)
risk factors for urinary incontinence?
- age
- obesity
- parity
- exercise
- UTI
- diet
Explain stress urinary incontinence?
- when intravesical pressure > urethral closing pressure
- leakage upon exertion
- urethral hypermobility (impaired pelvic floor)
- intrinsic sphincter deficiency (weakness)
Overactive bladder may be secondary to what?
- pelvic floor injury
- incontience surgery
Taking a history of a women with urinary incontinence should include which 3 headings?
- storage symptoms
- voiding symptoms
- post-miturition symptoms
Investigations for urinary incontinence?
- urinalysis and culture
- frequency/volume chart for 3 days
- USS
- Cystoscopy
- urodynamics
Conservative management for urge urinary inconetinence?
- lifestyle
- fluid management
- bladder retraining
Medical management for urge incontinence?
- vaginal oestrogen
- anti-cholinergic
- beta 3 agonist
Surgical management for urge incontinence?
- botox
- percutaneous tibial nerve stimulation
- augmentation cystoplasty
Conservative management of stress urinary incontience?
- lifestly
- pelvic floor training
- incontinence ring
Medical management of stress incontinence?
- vaginal oestrogen
- duloxetine (last resort)
Surgical management of stress incontinence?
- bulking agents
- fascial slings
- colposuspension
Risk factors for prolapse?
- childbirth
- obesity
- older
- heavy lifting
- previous pelvic surgery
Symptoms of pelvic prolapse?
- dragging or pulling sensation
- tissue protruding
- back pain
- urinary or bowel symptoms
How is uterovaginal prolapses graded?
- 1st degree uterus in vagina
- 2nd degree- at introits
- 3rd degree - outside vagina
- 4th degree - e.g. procidenta - entirely outside vagina
Describe a procidentia prolapse?
- uterus completely outside the vagina
Anterior prolapse involved?
- cystocele
- urethrocele
Middle prolapse involves?
- enterocele (pouch of Douglas)
- vaginal prolapse
Posterior prolapse involves?
- rectocele
Conservative treatment of prolapse?
- lifestyle modifications
- pelvic floor exercises
- vaginal oestrogen (atrophic vaginitis)
- pessaries
Surgical management in prolapse?
- sacrospinous fixation
- laparoscopic sacrocolpopexy
- vaginal hysterectomy
- manchester repair
Describe a ring pessaries?
- 1st line
- continue sexual relations
- easy to remove and re insert
Describe a gellhorn pessrie
- less rigid that a shelf pessarie
- less routinely used for those sexually active
Why is pelvic girdle pain associated with pregnancy?
- relaxin hormone = softens the pubic symphysis
DRAM?
- Diastasis rectus abdominis muscle
- stretching of the linea alba
Bladder incontinence physio treatment?
- voiding techniques
- bladder training
- pelvic floor exercises
Bowel symptoms physio training?
- holding on programme
- pelvic floor exercises
