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Year 4: OB-GYN > Postpartum: Routine Care > Flashcards

Postpartum: Routine Care Flashcards

1
Q

A routine care appointment is offered when after birth? [1]
What is check during this appointment? [4]

A

Six weeks post natal check by GP to check how mother is doing - at same time as 6 week newborn baby check
* General wellbeing
* Mood and depression
* Bleeding and menstruation
* Scar healing after episiotomy or caesarean
* Contraception
* Breastfeeding
* Fasting blood glucose (after gestational diabetes)
* Blood pressure (after hypertension or pre-eclampsia)
* Urine dipstick for protein (after pre-eclampsia)

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2
Q

Describe what is meant by a lochia [1]
How long does it last? [1]
What should be avoided during this time? [1]

A

a mix of blood, endometrial tissue and mucus post birth
- initially dark red colour that turns brown
- settles within 6 weeks
- avoid tampons as they have risk of infection

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3
Q

How does breastfeeding interact with menstruation after delivery? [2]

A

Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. This is normal.

Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea.

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4
Q

When does fertility return after giving birth? [1]

A

Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point

After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception).

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5
Q

How effective is lactational amenorrhea as contraception? [1]

A

Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).

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6
Q

Which methods of contraception are safe for breastfeeding? [3]

When can you put in the copper or IUS coils after birth? [2]

A

The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.

The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).

A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).

TOM TIP: Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.

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7
Q

A patient wants to start contraception after birth - what advise what you give them?

A

‘postpartum women (breastfeeding and non-breastfeeding) can start the POP at any time postpartum.’
- after day 21 additional contraception should be used for the first 2 days

Combined oral contraceptive pill (COCP)
* absolutely contraindicated - UKMEC 4 - if breastfeeding < 6 weeks post-partum
* UKMEC 2 - if breastfeeding 6 weeks - 6 months postpartum
* the COCP may reduce breast milk production in lactating mothers
* after day 21 additional contraception should be used for the first 7 days

The intrauterine device or intrauterine system
- can be inserted within 48 hours of childbirth or after 4 weeks.

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8
Q

Why is COCP after < 6 weeks post-partum an UKMEC4? [1]

A

Increased risk of VTE

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9
Q
A
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10
Q

Describe what is meant by post-partum endometritis [1]

When is it most commonly caused and how do you reduce the risk of this happening? [1]

A

Infection of the endometrium caused during / after labour as the process of delivery opens the uterus to allow bacteria from the vagina upwards

Endometritis occurs more commonly after caesarean section compared with vaginal delivery. Prophylactic antibiotics are given during a caesarean to reduce the risk of infection.

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11
Q

Describe the presentation of post-partum endometritis [4]

A
  • Foul-smelling discharge or lochia
  • Bleeding that gets heavier or does not improve with time
  • Lower abdominal or pelvic pain
  • Fever
  • Sepsis
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12
Q

How do you dx post-partum endometritis? [2]

A
  • Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
  • Urine culture and sensitivities
  • Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).
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13
Q

name a significant risk factor for retained products of conception [1]

Describe the presentation of RPOC [4]

A

Placenta accreta is a significant risk factor for retained products of conception.

Presentation
- Retained products of conception may be present in patients without any suggestive symptoms. It may present with:
* Vaginal bleeding that gets heavier or does not improve with time
* Abnormal vaginal discharge
* Lower abdominal or pelvic pain
* Fever (if infection occurs)

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14
Q

How do you dx retained products of conception? [1]

How do you manage? [2]

A

Investigation:
* Ultrasound is the investigation of choice for confirming the diagnosis.

Management:
Evacuation of retained products of conception (ERPC) - surgery under general anaethestic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”

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15
Q

What are two key complications of ERPC? [2]

A

Endometritis
Asherman’s syndrome
- where adhesions (sometimes called synechiae) form within the uterus. Endometrial curettage (scraping) can damage the basal layer of the endometrium. This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.

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16
Q

Postpartum anaemia is defined as a haemoglobin of less than [] g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.

A

Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period. Anaemia is common after delivery due to acute blood loss.

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17
Q

Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):

Hb under 100 g/l – [1]
Hb under 90 g/l – [1]
Hb under 70 g/l – [1]

A

Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):

Hb under 100 g/l – start oral iron (e.g. ferrous sulfate)

Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)

Hb under 70 g/l – blood transfusion in addition to oral iron

18
Q

When are iron infusions considered for post-partum anaemoa? [4]

A
  • May have poor adherence or oral treatment
  • Cannot tolerate oral iron
  • Fail to respond to oral iron
  • Cannot absorb oral iron (e.g. inflammatory bowel disease)
19
Q

What do you have to check before giving an iron infusion? [1]

A

TOM TIP: It is worth noting that active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous 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.

20
Q

Describe the spectrum of post-natal mental health illnesses [3]

A
  • 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
21
Q

Describe why baby blues may occur [6]

A

Baby blues may be the result of a combination of:
* 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

22
Q

How do you treat baby blues? [1]

A

Reassurance and support, the health visitor has a key role

23
Q

Which scale / questionnare can be used to screen for post-natal depression? [1]
What score would indicate a ‘depressive illness of varying severity’?

A

The Edinburgh Postnatal Depression Scale may be used to screen for depression:
- score > 13 [max 30] indicates a ‘depressive illness of varying severity

24
Q

When is post-natal depression most likely to occur [1] and peak? [1]

How do you treat? [1]

A

Most cases start within a month and typically peaks at 3 months

Management:
- reassurance and support are important
- Cognitive behavioural therapy
- SSRIs: sertraline and paroxetine

25
Q

When is puerperal pyschosis most likely to occur? [1]

A

Onset usually within the first 2-3 weeks following birth

26
Q

Describe the features of puerperal pyschosis? [6]

A
  • Delusions
  • Hallucinations
  • Depression
  • Mania
  • Confusion
  • Thought disorder
27
Q

How do you treat puerperal psychosis? [4]

A
  • Admission to the mother and baby unit
  • Cognitive behavioural therapy
  • Medications (antidepressants, antipsychotics or mood stabilisers)
  • Electroconvulsive therapy (ECT)
28
Q

What is the risk of giving SSRI antidepressants throughout pregnancy? [1]

How does this present? [2]

A

SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as 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.

29
Q

What are the benefits of breastfeeding to the infant [3] and mother [2]

A

To the infant:
* Antibodies and protection against infection
* Reduced atopic eczema and asthma
* Reduced rates of obesity later in childhood

To the mother:
* Reduced risk of diabetes mellitus and heart disease
* Protective against breast and ovarian cancer

30
Q

Describe what mastitis can be caused by [2]

A

Mastitis:
- Infection: most commonly staph auerus
- Obstruction in the ducts and accumulation of milk

31
Q

Describe the managment of mastitis [3]

A
  • Manage conservative management as for breast engorgement
  • Breastfeeding should be encouraged
  • Oral antibiotics can be used for symptoms not improving after 12-24 hours or if breast milk culture is positive - First line is flucoxacillin
  • Fluconazole may be used for suspected candidal infections.
32
Q

When is candidal infection of the nipple most likely to occur? [1]

What is there a risk of if this occurs? [1]

A

often after a course of antibiotics - lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection

33
Q

How do you treat candida of the nipple:
- Baby [1]
- Mother [1]

A

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)
34
Q

Which systemic condition might cause low milk supply? [1]

A

Hypothyroidism

35
Q

Which abx are cautioned for breastfeeding? [+]

A

Antibiotics which are cautioned or contra-indicated include:
- ciprofloxacin (potential joint problems)
- nitrofurantoin (G6PD deficiency)
- teicoplanin, clindamycin (antibiotic-associated colitis)
- co-trimoxazole.

36
Q

Aspirin as a painkiller should be avoided because of the increased risk of [] in paediatric viral infections.

A

Aspirin as a painkiller should be avoided because of the increased risk of Reye’s syndrome in paediatric viral infections.

37
Q

What is the rec. advise about HIV+ve mothers and breast feeding? [1]

A
  • Anti-retroviral drugs reduce the risk of transmission of HIV through breastfeeding
  • However, current recommendations advise that HIV-infected mothers should refrain from breastfeeding
38
Q

Describe what is meant by post-partum thyroiditis? [1]
- What are the three stages? [3]

A

Postpartum thyroiditis is a condition where there are changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.
Stages include:
* Thyrotoxicosis (usually in the first three months)
* Hypothyroid (usually from 3 – 6 months)
* Thyroid function gradually returns to normal (usually within one year)

39
Q

What is the management for post-partum thyroiditis? [2]

A

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

Hypothyroidism:
- levothyroxine

40
Q

Describe what is meant by Sheehan’s syndrome

A

Sheehan’s syndrome is a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland.
- Sheehan’s syndrome only affects the anterior pituitary gland. Therefore, hormones produced by the posterior pituitary are spared.

41
Q

When would you suspect Sheehans syndrome? [3]

A

Those who just gave birth and:
- failure to lactate (earliest sign) &
- absent menstruation
- features of hypopituitarism: hypothyroidism and cortisol deficiency
- Loss of hair

Year 4: OB-GYN (40 decks)

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