Postpartum Period

Question 1

How does the genital tract change after pregnancy?

Answer 1

Uterus contracts to occlude blood vessels that supplied the placenta

Size reduces over 6 weeks
Internal os shuts by 3 days
Discharge maybe blood stained for 4 weeks, then yellow or white

Menstruation after 6 weeks

Question 2

How does the cardiovascular system change after pregnancy?

Answer 2

CO and plasma volume decrease back to normal within a week

Odema and BP may take 6 weeks

Question 3

How does lactation occur?

Answer 3

Prolactin from anterior pituitary stimulates milk secretion
- decrease in oestrogen and progesterone after birth reduces their antagonistic effects on prolactin

Oxytocin from posterior pituitary stimulates ejection in response to nipple suckling

Can be inhibited by stress acting on hypothalamus

Question 4

What is PPH?

Answer 4

Loss of >500ml of blood within 24 hours of delivery

Occurs in 10%

Question 5

What causes PPH?

Answer 5

Retained placenta - may not show as blood accumulates in uterus

Atonic uterus

Tear

Question 6

What are risk factors for PPH?

Answer 6

Previous history
Previous C-section
Coagulation defect
Instrumental/C-section delivery
Retained placenta
APH
Polyhydramnios
Grand multiparity

Question 7

How is PPH prevented?

Answer 7

Oxytocin for 3rd stage of labour

Ergometrine causes vomiting and is contraindicated in hypertensive women

Question 8

How is PPH managed?

Answer 8

Cross-match blood
Remove retained placenta
Give oxytocin to contract uterus
Examination under anaesthetic
Prostaglandin

Surgery -> hysterectomy

Question 9

What is secondary PPH?

Answer 9

Excessive blood loss

Between 24hr and 6 weeks after delivery

Question 10

What causes secondary PPH?

Answer 10

Endometritis +/- retaind placental tissue

Uterus is enlarged and tender with open cervical os

Question 11

What is the management of secondary PPH?

Answer 11

Vaginal swabs
FBC + cross match
Give Abx
Evacuation of retained products of conception

Question 12

What is postpartum pyrexia?

Answer 12

Maternal fever of >38 in first 14 days

Question 13

What causes postpartum pyrexia?

Answer 13

Genital tract sepsis post C-section
Group A strep
Staph aureus
E coli

DVT

Question 14

What other infections occur in postpartum?

Answer 14

UTI
Chest infection
Mastitis
Perineal infection
Wound infection post C-section

Question 15

What psychiatric problems arise postpartum?

Answer 15

Third day blues

Postnatal depression - EPDS, consider postpartum thyroiditis

Puerperal psychosis - usually around 4th day

Question 16

What other medical problems present in postpartum?

Answer 16

Pre-eclampsia takes 24hrs to clear
Retention of urine
UTI
Incontinence
Paravaginal haematoma
Constipation and haemorrhoids

Question 17

What is the difference between early and neonatal death?

Answer 17

Neonatal death within 28 days of delivery

Early neonatal death within 7 days

Question 18

What is the perinatal mortality rate?

Answer 18

Sum of stillbirths and early neonatal deaths

Corrected - excludes stillbirths and early neonatal deaths due to congenital malformations

Question 19

What is the perinatal mortality rate in UK?

Answer 19

7.5 per 1000

Stillbirth rate is 5.1/1000

Question 20

What are risk factors for perinatal mortality?

Answer 20

Lower socioeconomic status
Below 17 and >40
Smoker
Obese
Asian/Afro-Caribbean

Question 21

What are the main causes of perinatal mortality?

Answer 21

Preterm delivery
IUGR
Prematurity
Congenital infections

Question 22

What is the definition of a maternal death?

Answer 22

During pregnancy or within 42 days of cessation

Any cause related to or aggravated by pregnancy

Late death - between 42 days and 1 year

Can be split into direct and indirect

Question 23

What is the maternal death rate in UK?

Answer 23

11.4/100,000 pregnancies

Question 24

What are the main causes of maternal mortality globally?

Answer 24

Haemorrhage
Obstructed labour
Infection
Severe pre-eclampsia
Illegal abortions

Question 25

What are the main direct causes of maternal mortality in the UK?

Answer 25

Sepsis - group A strep

Hypertensive disease - intracranial haemorrhage associated with poorly controlled BP

VTE -> PE and cerebral venous thrombosis

Haemorrhage

Question 26

What are the main indirect causes of maternal mortality in UK?

Answer 26

Cardiac disease

Psychiatric disease