Postnatal Flashcards
Define postpartum haemorrhage
Classifications of severity
Loss of at least 500ml of blood within 24hrs of birth
• Minor (up to 1L)
• Mod (up to 2L)
• Major (more than 2L)
Primary: within first 24hrs
Secondary: within 6 (or 12) weeks post partum
11 risk factors for postpartum haemorrhage
- Macrosomia
- Big placenta
- Clotting issues (low platelets)
- Pre-eclampsia
- Obesity
- Antepartum haemorrhage
- Maternal anaemia
- Multiparity
- Retained placenta (prolonged 3rd stage)
- Smoking
- Trauma (instrumental delivery, prolonged 2nd stage)
Causes of postpartum haemorrhage
4 T’s
- Tone (placenta praevia, multiple pregnancy, pervious PPH, obesity, anaemia, prolonged labour, older mother, big baby)
- Trauma (C section, esp emergency, episiotomy, operative vaginal delivery, big baby)
- Tissue (retained placenta, partial placenta adhesion, membranes and clot stop uterus contracting)
- Thrombin (abruption, PET, pyrexia/sepsis)
How can the incidence of post partum haemorrhage be reduced?
Treat antenatal anaemia Proactive management Give oxytocin for 3rd stage/sindometrin if high risk Venous access MDT planning for placenta accreta
Name 5 uterotonics, class of drug and SE
- Syntocinon (oxytocin) stimulates upper uterine segment to contract rhythmically, SE anti-diuretic due to similarity to ADH
- Ergometrine (ergot alkaloid) smooth muscle contraction, SE hypertension, n+v
- Syntometrine
- Carboprost (prostaglandin) myometrial contraction SE n+v, diarrhoea, asthmatic wheeze
- Misprostol (prostaglandin) myometrial contractions SE n+v, diarrhoea
Non medical treatment of PPH
Balloon tamponade
Laparotomy
B-lynch suture to fold uterus
Secondary PPH causes
Infection
Retained products of conception
Child’s benefits of breastfeeding
Decreased risk of: • Asthma and atopic disease • Diarrheoa • Necrotising enterocolitis • Obesity and cardiovascular disease later in life • Otitis media, UTIs • T1DM and T2DM
Mum’s benefits of breastfeeding
Reduced risk of: • Breast and ovarian cancer • Postnatal depression • Post-partum haemorrhage • T2DM
What needs to be considered in breastfeeding?
Age of baby
Baby’s comoribities (esp renal/hepatic)
Mother’s medication
Frequency of breastfeeding
2-3hrly in 1st 6 months
Single comfort feed at night after weaning
What helps a drug not be secreted in breast milk?
High molecular weight (eg insulin and heparin)
High protein binding (eg warfarin and NSAIDs)
Low lipid solubility (loratadine)
Lower pH (amoxicillin)
What antibiotics are safe for breastfeeding mums?
Amoxicillin (lower pH)
Cefalexin (low conc in breast milk)
Trimethoprim short term (affects folate metabolism)
Metronidazole-> but bitter milk!
Which analgesics should be avoided in breastfeeding mums?
Codeine
Opioids should be avoided
Aspirin (Reye’s syndrome)
Which analgesics can be given to breastfeeding mums?
NSAIDs
Tramadol
Paracetamol
Which antidepressants are safe for breastfeeding mums?
Amitriptyline if babies are full term (monitoring required)
Sertraline & paroxetine are 1st line
TCAs but not doxepin
Which antidepressants are not safe in breastfeeding mums?
Fluoxetine
Doxepin
St John’s wort
MAOIs
What should be done if a mother is taking antidepressants while breastfeeding?
Monitor infant (behaviour change, poor feeding, sedation)
Breastfeed immediately before drug administration
Can substitute 1 bottle at peak drug concentrations (1-3hrs or 6-8hrs in SSRIs)
Which contraceptions are safe when breastfeeding?
- COCP can be started after 3 weeks or after 6 weeks if VTE risk factor
- Progesterone only pill/injection/implant are safe, can start any time
- IUS safe, insertion either within 48hrs post partum or after 4 weeks
Treatment of allergic rhinitis when breastfeeding?
No treatment unless severe
Topical if possible (sodium cromoglycate, nasal antihistamines, nasal flutiscasone)
Non sedating if oral (loratidine, certirizine)
Causes of late maternal deaths
Ocurring between 42 days-yr after abortion/miscarriage/delivery • Malignancy • Suicide • Acute MI • Aortic dissection • Cardiomyopathy • Sepsis
Symptoms of endometritis
Fever, shivering, abdo pain/offensive vaginal loss, unusual bleeding. If after 7 days: chlamydia?
Risk factors for endometritis
Treatment
C-section, young age, low socioeconomic status, prolonged labour, intrauterine balloon (to tamponade bleeding), twin delivery (more manual removal of placenta)
Broad spectrum abx
Common infections post-natally
- UTI, pyelonephritis
- Lower genital tract
- C-section incision/wound infection
- Mastitis
- Pneumonia
