Postpartum Complications Flashcards
What is a Galactocele?
A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.
Galactocele typically occurs in
women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct.
Breast feeding: suppressing lactation
Techniques
stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline is the medication of choice if required
nipple pain: may be caused by
poor latch
frequent feeding in a breastfed infant is a sign of low milk supply
false
frequent feeding in a breastfed infant is not alone a sign of low milk supply
blocked duct (‘milk bleb’) sx
nipple pain when breastfeeding
blocked duct (‘milk bleb’) mx
Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried
treatment for nipple candidiasis whilst breastfeeding
should involve miconazole cream for the mother and nystatin suspension for the baby
Mastitis affects around 1 in 10 breastfeeding women.
true
Mastitis antibiotic indications
systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection
Mastitis antibiotics
first-line antibiotic is flucloxacillin for 10-14 days
Breastfeeding or expressing should continue during treatment.
If left untreated, mastitis may develop into a breast abscess.
True
This generally requires incision and drainage.
Breast engorgement is one of the causes of breast pain in breastfeeding women.
true
Breast engorgement usually occurs
in the first few days after the infant is born
Breast engorgement usually affects both breasts
true
sx breast engorgement?
The pain or discomfort is typically worse just before a feed.
Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle.
Fever may be present but usually settles within 24 hours.
The breasts may appear red.
what help relieve the discomfort of engorgement.
Although it may initially be painful, hand expression of milk
Raynaud’s disease of the nipple sx
Pain is often intermittent and present during and immediately after feeding.
Blanching of the nipple may be followed by cyanosis and/or erythema.
Nipple pain resolves when nipples return to normal colour.
Raynaud’s disease of the nipple mx
advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking.
If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).
Around 1 in 10 breastfed babies lose more than the ‘cut-off’ threshold in the first week of life.
true
What is the ‘cut-off’ threshold for poor infant weight gain
loss 10% in first week
ix baby lose more than the ‘cut-off’ threshold in the first week of life.
prompt consideration of the above breastfeeding problems.
The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory
The following drugs CAN be given to mothers who are breastfeeding:
antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines
psychiatric drugs: tricyclic antidepressants, antipsychotics
hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin
Which antibiotics should be avoided in breastfeeding
ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
Which psychiatric drugs should be avoided in breastfeeding
lithium, benzodiazepines
Which cardiovascular drugs should be avoided in breastfeeding
amiodarone
aspirin
Which endocrine drugs should be avoided in breastfeeding
carbimazole
sulfonylureas
Which rheumatoid drugs should be avoided in breastfeeding
methotrexate
cytotoxic drugs should be avoided in breastfeeding
true
The Edinburgh Postnatal Depression Scale may be used to screen for depression:
10-item questionnaire, with a maximum score of 30
indicates how the mother has felt over the previous week
score > 13 indicates a ‘depressive illness of varying severity’
sensitivity and specificity > 90%
includes a question about self-harm
Outline post-partum mental health problems & epidemiology for the following:
‘Baby-blues’
Postnatal depression
Puerperal psychosis
‘Baby-blues’ - Seen in around 60-70% of women
Postnatal depression - Affects around 10% of women
Puerperal psychosis - Affects approximately 0.2% of women
Onset of ‘Baby-blues’
Typically seen 3-7 days following birth and is more common in primips
Onset of Postnatal depression
Most cases start within a month and typically peaks at 3 months
Onset of Puerperal psychosis
Onset usually within the first 2-3 weeks following birth
Baby blues sx?
Mothers are characteristically anxious, tearful and irritable
Baby blues mx?
Reassurance and support, the health visitor has a key role
Postnatal depression mx?
As with the baby blues reassurance and support are important
Cognitive behavioural therapy may be beneficial.
Certain SSRIs
Postnatal depression mx - which SSRIs?
sertraline and paroxetine may be used if symptoms are severe
SSRIs are not secreted in the breast milk
false
whilst they are secreted in breast milk it is not thought to be harmful to the infant
Puerperal psychosis There is around a 25-50% risk of recurrence following future pregnancies
true
Postnatal depression mx - paroxetine is recommended by SIGN because
low milk/plasma ratio
Postnatal depression mx - fluoxetine
best avoided due to a long half-life
Post-partum thyroiditis - Three stages
- Thyrotoxicosis
- Hypothyroidism
- Normal thyroid function (but high recurrence rate in future pregnancies)
Post-partum thyroiditis antibodies?
Thyroid peroxidase antibodies are found in 90% of patients
Post-partum thyroiditis mx
the thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive. Propranolol is typically used for symptom control
the hypothyroid phase is usually treated with thyroxine
Postpartum haemorrhage (PPH) is defined as
blood loss of > 500mls and may be primary or secondary
Primary PPH
occurs within
24 hours
most common cause of PPH
uterine atony (90% of cases) Other causes include genital trauma and clotting factors
Risk factors for primary PPH include
previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis)
PPH mx - medical
ABC including two peripheral cannulae, 14 gauge
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
if medical options failure to control the bleeding then surgical options will need to be urgently considered
PPH mx - surgical
intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure
Secondary PPH
occurs when
between 24 hours - 12 weeks
Secondary PPH
occurs due to?
retained placental tissue or endometritis
Puerperal pyrexia may be defined as
a temperature of > 38ºC in the first 14 days following delivery.
Puerperal pyrexia causes
endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism
Puerperal pyrexia mx
if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)
