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Yr 4 - GOSH > Postnatal Conditions > Flashcards

Postnatal Conditions Flashcards

1
Q

What is endometritis?

A

Inflammation of the endometrium, usually caused by infection.

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2
Q

What is postpartum endometritis?

A

Infection of the endometrium in the postpartum period, as infection is introduced during or after labour and delivery.

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3
Q

How is chidbirth a risk factor for endometritis?

A

The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.

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4
Q

Is endometritis more common after a c-section or vaginal delivery?

A

C-section

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5
Q

What can be given during a caesarean to reduce the risk of endometritis?

A

Prophylaxis Abx

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6
Q

What organisms can cause postpartum endometritis?

A

Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria.

It can also be caused by STIs such as chlamydia and gonorrhoea.

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7
Q

When endometritis occurs unrelated to pregnancy and delivery, what condition is it usually related to?

A

PID

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8
Q

Presentation of postpartum endometritis?

A

Can present from shortly after birth to several weeks postpartum:

1) foul smelling discharge or lochia

2) bleeding that gets heavier or does not improve with time

3) lower abdo or pelvic pain

4) fever

5) sepsis

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9
Q

What 2 investigations can help establish the diagnosis in postpartum endometritis?

A

1) vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)

2) urine culture & sensitivities

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10
Q

Why may an US be helpful in investigating postpartum endometritis?

A

US may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

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11
Q

Management of postpartum endometritis?

A

1) Septic patients will require hospital admission and the septic six

2) Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics.

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12
Q

What Abx are typically indicated in septic patients with postpartum endometritis?

A

clindamycin and gentamicin

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13
Q

What Abx are typically indicated in the management of postpartum endometritis in the community?

A

A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

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14
Q

What is postpartum thyroiditis?

A

A condition where there are changes in thyroid function within 12 months of delivery.

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15
Q

What are the 3 stages of postpartum thyroiditis?

A

1) thyrotoxicosis (usually in the first three months)

2) hypothyroidism (usually from 3 – 6 months)

3) normal thyroid function returns within one year (but high recurrence rate in future pregnancies)

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16
Q

What antibodies are found in 90% of patients with postpartum thyroiditis?

A

Thyroid peroxidase antibodies

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17
Q

Cause of postpartum thyroiditis?

A

Not entirely clear.

The leading theory is that pregnancy has an immunosuppressant effect on the mother’s body, to prevent her from rejecting the fetus.

Once delivery has occurred, there can be an exaggerated rebound effect, with increased immune system activity and expression of antibodies (e.g. thyroid peridoxase Abs).

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18
Q

What may be a key symptom of postpartum thyroiditis?

A

Postnatal depression - there should be a low threshold for testing thyroid function in women.

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19
Q

When are TFTs typically performed after delivery?

A

6-8 weeks after delivery

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20
Q

Typical treatment of postpartum thyroiditis?

A

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

2) Hypothyroidism: levothyroxine

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21
Q

How often do women with postpartum thyroiditis require monitoring?

A

Annually with TFTs, even after the condition has resolved.

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22
Q

Purpose of annual monitoring in postpartum thyroiditis?

A

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

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23
Q

Define postpartum anaemia

A

Hb <100 g/l in the postpartum period.

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24
Q

When is postpartum anaemia more common?

A

After delivery due to acute blood loss.

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25
Q

What would indicate the need to do a FBC the day after delivery (to assess for anaemia)?

A

1) PPH over 500ml

2) C-section

3) Antenatal anaemia

4) Symptoms of anaemia

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26
Q

Treatment of postpartum anaemia in:

1) Hb <100 g/l
2) Hb <90 g/l
3) Hb <70 g/l

A

1) start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)

2) consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)

3) blood transfusion in addition to oral iron

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27
Q

Who is an iron infusion considered in?

A

1) Hb <90 g/l

2) Women that have poor adherence or oral treatment

3) Women that cannot tolerate oral iron

4) Women that fail to respond to oral iron

5) Women that cannot absorb oral iron (e.g. inflammatory bowel disease)

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28
Q

What do iron infusions carry a risk of?

A

Allergic & anaphylaxis reactions.

They should be used with particular caution in patients with a history of allergy or asthma.

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29
Q

Why is active infection is a contraindication to an iron infusion?

A

As many pathogens ‘feed’ on iron, meaning that IV iron can lead to proliferation of the pathogen and worsening infection.

It is important to wait until the infection is treated before giving an iron infusion.

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30
Q

What is Sheehan’s syndrome?

A

A rare complication of PPH where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland.

Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death.

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31
Q

What part of the pituitary gland does Sheehan’s syndrome affect?

A

It only affects the anterior pituitary gland (so hormones produced by the posterior pituitary are spared).

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32
Q

What does the anterior pituitary gets its blood supply from?

A

A low-pressure system called the hypothalamo-hypophyseal portal system.

This system is susceptible to rapid drops in blood pressure.

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33
Q

What 5 hormones does the anterior pituitary release?

A

1) ACTH

2) GH

3) FSH & LH

4) TSH

5) Prolactin

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34
Q

What 2 hormones does the posterior pituitary release?

A

1) Oxytocin

2) ADH

35
Q

Presentation of Sheehan’s syndrome?

A

1) reduced lactation (lack of prolactin)

2) amenorrhoea (lack of LH & FSH)

3) adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)

4) hypothyroidism with low thyroid hormones (lack of TSH)

36
Q

Management of Sheehan’s syndrome?

A

Replacement of missing hormones:

1) Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)

2) Hydrocortisone for adrenal insufficiency

3) Levothyroxine for hypothyroidism

4) Growth hormone

37
Q

What is mastitis?

A

Mastitis refers to inflammation of breast tissue.

This is a common complication of breastfeeding.

It can occur with or without associated infection.

38
Q

What can mastitis be caused by in lactating women?

A

Obstruction in the ducts and accumulation of milk.

39
Q

What can help prevent lactational mastitis?

A

Regularly expressing breast milk.

40
Q

What are the 2 main causes of mastitis?

A

1) obstruction in the ducts and accumulation of milk.

2) infection

41
Q

How can infection lead to mastitis?

A

Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation.

42
Q

Most common organism causing infection in inmastitis?

A

Staph. aureus

43
Q

Presentation of mastitis?

A

1) Breast pain and tenderness (unilateral)

2) Erythema in a focal area of breast tissue

3) Local warmth and inflammation

4) Nipple discharge

5) Fever

44
Q

Management of mastitis caused by blockage of ducts?

A

Conservative:

1) continued breastfeeding

2) continued expression of milk

3) breast massage

4) heat packs, warm showers & simple analgesia

45
Q

If infection is suspected in mastitis, what is management?

A

1) Abx:
- flucloxacillin (1st line)
- erythromycin (if allergic to penicillin)

2) A sample of milk can be sent to the lab for culture and sensitivities.

3) Continue breastfeeding, even when infection is suspected (or expression of milk)

46
Q

What is a rare complication of mastitis?

A

Breast abscess (may need surgical incision and drainage).

47
Q

When can candidal infection of the nipple occur?

A

After a course of Abx.

48
Q

Complication of candidal infection of the nipple?

A

Can lead to recurrent mastitis: as it causes cracked skin on the nipple that create an entrance for infection.

49
Q

What symptoms may be seen in the infant when the mother has candidal infection of the nipple?

A

Oral thrush & candidal nappy rash

50
Q

How may candidal infection of the nipple present?

A

1) sore nipples bilaterally, particularly after feeding

2) nipple tenderness and itching

3) cracked, flaky or shiny areola

4) symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

51
Q

Management of candidal infection of the nipple?

A

Both mother AND baby need treatment, or it will reoccur:

1) Topical miconazole 2% after each breastfeed

2) Treatment for the baby (e.g. miconazole gel or nystatin)

52
Q

What does retained products of conception refer to?

A

When pregnancy-related tissue (e.g. placental tissue or fetal membranes) remain in the uterus after delivery.

It can also occur after miscarriage or termination of pregnancy.

53
Q

In what 3 scenarios can retained products of conception occur?

A

1) after delivery
2) after miscarriage
3) after termination of pregnancy

54
Q

What is a significant risk factor for retained products of conception?

A

Placenta accreta (when the placenta grows too deeply into the uterine wall).

55
Q

Presentation of retained products of conception?

A

1) vaginal bleeding: gets heavier or does not improve with time

2) abnormal vaginal discharge

3) lower abdo or pelvic pain

4) fever (if infection occurs)

56
Q

What is the investigation of choice for confirming the diagnosis of retained products of conception?

A

US

57
Q

What is the standard management of postpartum retained products of conception?

A

To remove them surgically: evacuation of retained products of conception (ERPC).

58
Q

What occurs in the evacuation of retained products of conception (ERPC)?

A

This is a surgical procedure involving a general anaesthetic:

1) cervix is gradually widened using dilators

2) the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping)

59
Q

What may evacuation of retained products of conception (ERPC) be referred to as?

A

“dilatation and curettage”

60
Q

What are 2 key complications of evacuation of retained products of conception (ERPC)?

A

1) endometritis
2) Asherman’s syndrome

61
Q

What is Asherman’s syndrome?

A

Where adhesions (sometimes called synechiae) form within the uterus.

62
Q

How can evacuation of retained products of conception (ERPC) cause Asherman’s syndrome?

A

1) Endometrial curettage (scraping) can damage the basal layer of the endometrium.

2) This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected.

3) There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.

63
Q

What is the major complication of Asherman’s syndrome?

A

Infertility

64
Q

What is the spectrum of postnatal mental health illness?

A

1) baby blues (70%): seen in the majority of women in the first week or two after birth

2) postnatal depression (10%): with a peak around three months after birth

3) puerperal psychosis (0.2%): starting a few weeks after birth

65
Q

How many women does postnatal depression affect?

A

Approx 1 in 10

66
Q

Who are the baby blues most commonly seen in ?

A

1st time mothers

67
Q

Symptoms of baby blues?

A

1) mood swings
2) low mood
3) anxiety
4) irritability
5) tearfulness

68
Q

How long do the baby blues typically last?

A

Only last a few days and resolve within two weeks of delivery.

69
Q

Treatment for baby blues?

A

Reassurance and support, the health visitor has a key role.

70
Q

When does postnatal depression typically peak?

A

Approx 3 months after birth.

Symptoms should last at least two weeks before postnatal depression is diagnosed.

71
Q

Management of mild, mod & severe cases of postnatal depression?

A

Mild: additional support, self-help and follow up with their GP

Mod: antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy

Severe: may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

72
Q

What are the 2 SSRIs of choice in for a woman who is breastfeeding?

A

1) sertraline
2) paroxetine

73
Q

What can be used as a screening tool for postnatal depression?

A

Edinburgh postnatal depression scale

74
Q

What score on the Edinburgh postnatal depression scale suggests postnatal depression?

A

≥10 (out of 30)

75
Q

When does puerpal psychosis typically occur?

A

2-3 weeks after delivery

76
Q

Symptoms of puerperal psychosis?

A

1) delusions
2) hallucinations
3) depression
4) mania
5) confusion
6) thought disorder

77
Q

Management of puerperal psychosis?

A

1) Admission to the mother and baby unit

2) CBT

3) Medications (antidepressants, antipsychotics or mood stabilisers)

4) Electroconvulsive therapy (ECT)

78
Q

What is the mother and baby unit?

A

A specialist unit for pregnant women and women that have given birth in the past 12 months.

They are designed so that the mother and baby can remain together and continue to bond.

Mothers are supported to continue caring for their baby while they get specialist treatment.

79
Q

What can SSRIs taken during pregnancy result in?

A

Neonatal abstinence syndrome (also known as neonatal adaptation syndrome).

80
Q

How does neonatal abstinence syndrome present?

A

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.

81
Q

What is the most common cause of puerperal pyrexia?

A

Endometritis

82
Q

Define puerperal pyrexia

A

a fever exceeding 38 ºC within the first 14 days postpartum

83
Q
A

Yr 4 - GOSH (45 decks)

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