Postnatal Care

Question 1

presentation of postpartum endometritis

Answer 1

MC after C-section (prophylactic abx)

Can present from shortly after birth to several weeks postpartum with:
Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis

Question 2

what is a significant risk factor for RPOC

Answer 2

placenta accreta

Question 3

presentation of RPOC

Answer 3

Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)

Question 4

2 key complications of ERPC (Evacuation of retained products of conception) aka dilatation and curettage

Answer 4

Endometritis
Asherman’s syndrome
- curettage (scraping) damages basal layer of endometrium –> scar as adhesions within uterus –> infertility

Question 5

define postpartum anaemia

Answer 5

hb <100g/l in PP period
anaemia common after delivery bc acute blood loss

It is essential to optimise the treatment of anaemia during pregnancy, so that women have optimal haemoglobin and iron stores before delivery.

Question 6

when do you do a FBC day after delivery?

Answer 6

PPH > 500ml
Caesarean section
Antenatal anaemia
Symptoms of anaemia

Question 7

treatment of postpartum anaemia

Answer 7

Hb <100 g/ –> oral iron (ferrous sulphate TDS 3 months)
Hb <90 –> iron infusion + oral iron (Ferinject)
Hb <70 –> blood transfusion + oral iron

• active infection = contraindication to iron infusion bc bugs eat the iron so must wait

Question 8

spectrum of postnatal depression

Answer 8

Baby blues is seen in the majority of women in the first week or so after birth
Postnatal depression is seen in about one in ten women, with a peak around three months after birth
Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth

Question 9

cause of baby blues

Answer 9

Significant hormonal changes
Recovery from birth
Fatigue and sleep deprivation
The responsibility of caring for the neonate
Establishing feeding
All the other changes and events around this time

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

Question 10

triad of postnatal depression

Answer 10

like normal depression
Low mood
Anhedonia (lack of pleasure in activities)
Low energy

symptoms for > 2weeks, around 3 months after birth

Question 11

management of postnatal depression

Answer 11

Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

Question 12

how do you assess for postnatal depression?

Answer 12

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.

There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

Question 13

what is puerperal psychosis?

Answer 13

onset between two to three weeks after delivery.
Women experience full psychotic symptoms, such as:
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder

Question 14

Management of puerperal psychosis

Answer 14

need urgent assessment and input from specialist mental health services.

Admission to the mother and baby unit (given birth in last 12 months)
CBT
Meds (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)

Question 15

consequences of SSRIs taken in pregnancy in baby

Answer 15

neonatal abstinence syndrome (aka neonatal adaptation syndrome).
It presents in the first few days after birth with symptoms such as irritability and poor feeding.
Neonates are monitored for this after delivery. Supportive management is usually all that is required.

Question 16

Management of mastitis

Answer 16

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

if not working or think mastitis bc infection (febrile) –> flucloxacillin, erythromycin (pen allergy)
can send milk for MC+S

Women should be encouraged to continue breastfeeding, even when infection is suspected. It will not harm the baby and will help to clear the mastitis by encouraging flow. Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast.

A rare complication if not adequately treated, is a breast abscess. This may need surgical incision and drainage.

Question 17

presentation of candida of the nipple

Answer 17

Often after a course of antibiotics.
–> can lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection.

It is associated with oral thrush and candidal nappy rash in the infant.

signs:
Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

Question 18

treatment of candida of the nipple

Answer 18

Both the mother and baby need treatment, or it will reoccur.

Treatment is with:
Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)

Question 19

What is postpartum thyroiditis?

Answer 19

changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease.

It can involve thyrotoxicosis , or hypothyroidism, or both

Over time the thyroid function returns to normal, and the patient will become asymptomatic again.
A small portion of women will remain hypothyroid and need long-term thyroid hormone replacement.

Question 20

what is the pathophysiology of postpartum thyroiditis?

Answer 20

pregnancy = immunosuppressant effects to prevent rejecting fetus

deliver –> rebound effect, inc immune system activity and expression of antibodies
- includes TPO ab

Question 21

3 stages of postpartum thyroiditis

Answer 21

not all W follow this pattern tho

1. Thyrotoxicosis (usually in the 1st 3m)
2. Hypothyroid (usually from 3 - 6 m)
3. Thyroid function gradually returns to normal (usually within 1 year)

Question 22

when do you assess for postpartum thyroiditis?

Answer 22

low threshold
W with suggestive symptoms, esp postnatal depression
perform 6-8 weeks post delivery

Question 23

how do you manage postpartum thyroiditis?

Answer 23

refer to endocrine
Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)

Hypothyroidism: levothyroxine

annual monitoring of TFTs even once resolved –> help identify those with long-term hypothyroidism

Question 24

how often do you monitor W with postpartum thyroiditis?

Answer 24

annual monitoring of thyroid function tests, even after the condition has resolved.

Monitoring is to identify those that go on to develop long-term hypothyroidism.

Question 25

What is Sheehan’s syndrome?

Answer 25

rare complication of PPH
drop in circles blood vol –> avascular necrosis of pit gland

Low BP and dec perfusion of pit gland –> ischaemia and cell death in pituitary

only affects ant pituitary gland (products made by post pit spared)

Question 26

Why does Sheehan’s syndrome only affect anterior pituitary?

Answer 26

ant pit blood supply
- from low pressure system = hypothalamo-hypophyseal portal system.
This system is susceptible to rapid drops in BP

post pit
- blood supply from various arteries, and is therefore not susceptible to ischaemia when there is a drop in BP

Question 27

what hormones are affected in Sheehan’s syndrome?

Answer 27

The ones released by ant pit
Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin

The posterior pituitary releases (not affected by Sheehan’s syndrome):
Oxytocin
Antidiuretic hormone (ADH)

Question 28

What is the presentation of Sheehan’s syndrome?

Answer 28

Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary, leading to signs and symptoms of:
Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)

Question 29

Management for Sheehan’s syndrome?

Answer 29

under endocrinologist.
It will involve replacement for the missing hormones:
- Oestrogen and progesterone as HRT for the female sex hormones (until menopause)
- Hydrocortisone for adrenal insufficiency
- Levothyroxine for hypothyroidism
- Growth hormone