PPH - PAEDS Flashcards
What is a full term pregnancy?
37-42 weeks
What are the 3 trimesters
1 - 12 13-27 28+
What is defined as misscarrige
loss of pregnancy before 20weeks
What the roll of Gonadotropin hormone on pregnancy
doubles every 2 days and creates nausea
What the roll of progesterone on pregnancy
Inhibits smooth muscle, increases ligament laxity Fatigue is a side effect of raised progesterone levels
What the roll of estrogen on pregnancy
Enables uterus and placenta to improve vascularization Major role in milk duct development
What the roll of Relaxin on pregnancy
Hormone produced by ovary and placenta Important effects during early pregnancy and in preparation for birth
What are the physiological changes during pregnancy
Plasma increase by 50% Increase cardiac output by 40% increase oxygen demand 15% Increase temperature mm. relaxation in gastro walls
What are the hormonal changes during pregnancy?
- hair loss/ growth - mood change - breast changes - stretch marks
Routine test during pregnancy?
- ultrasound 11 & 20w - BP - Blood test: Rhd, Anemia, SIT, - Urine (sugar - protein) -Diabetes -Streptococcus
What are the Medical emergencies during pregnancy
- preeclampsia - abortion - ectopic pregnancy - premature rupture of membranes - placenta abruption
What are s&s of preeclampsia
High blood pressure, protein in urine, sudden swelling in face, hands and feet. Persistent headache, blurred vision
What are s&s of ectopic pregnancy?
one-sided abdominal pain, vaginal bleeding, bowel pain, diarrhoea and vomiting, shoulder tip pain
What are s&s of placenta abruption?
vaginal bleeding, continuous abdominal pain, continuous lower back pain, painful abdomen, uterine contractions
What are the conditions not to be missed during pregnancy?
- Hyperthermia - Dehydration - vaginal bleeding - Supine hypotensive disorder - placenta previa - Diabetes: increased thrust, urination, tiredness
Common conditions during pregnancy?
- Nausea -Constipation -Oedema -increased Micturition -Carpal tunnel -Pelvic / rib / spinal pain ( especially pubic symphysis and SIJ) Varicose veins -Reflux -Shortness of breath Fatigue
What are the dietary requirements during pregnancy
The dietary requirements are equivalent to an additional snack - Folate - Protein
What foods to avoid during pregnancy?
deli, cheese, uncooked, listeria, high level mercury.
What are the exercise recommendation for pregnancy
fitness helps with mood swings, stamina, strength, flexibility
What are the adverse effects of osteopathic treatment on pregnant women?
Minor adverse effects reported. Consider joint laxity as risk factor
What are the osteopathic considerations for pregnancy
What are the brace and support garments available
- Serola belt - best (SIJD or pubic symph)
- belly band belt
- compression leggins
what are the Australian options locations to have birth?
Public maternity hospital
Private obstetrician
Private Midwife
Home Birth
What are the Stages of Labour?
- Regular contractions with 3cm dilation
- Easly labour: 3cm to 8-12h
- active labour: 3cm TO 7cm 3-5h
- Transition: 7cm - 10cm dilation 30min-2h (pushing for longer than 2h trauma to body and pelvis)
- Full dilation 10cm to birth
- Delivery of placenta (pushing continues - risk of haemorrhage as placenta may rip uterine wall when it detaches)
What are the fetal position at birth
- Cephalic presentation is Ideal: left occiput anterior with chin tucked - baby facing Lt. side so to turn facing head to spine.
- The left side of the maternal pelvis
- Fetal occiput anterior: face first - leads to truma and emergency c-section
What are breach and shoulder presentations
Breech:
- Frank
- Complete
- Footling
- Shoulder
Encourage active birth
- Exercise
- Moving around (walk, stand, leaning
- Squat
- Kneeling
- Wall press-up
- Gravity helps the baby move
What are pain management none medical techniques during birth?
- Heat - cold
- Massage
- Bath
- Tens machine
- acupressure
- Intradermal water injections
What are pain management medical techniques during birth?
- Gas (nitrous oxide)
- Pethidine (makes baby sleepy)
- Epidural (helps woman relax)
- spinal block
What are the risk associated with epidural?
How is labour induced?
- Artificial rupture of membranes
- Oxytocin
- Prostaglandin
- Cervical balloon catheter
What are the two options for assisted delivery?
- Vacuum
- Forceps
What is an Episiotomy?
Cut into perineum and posterior vaginal wall
Things t consider after delivery?
- Post partum bleeding (lochia) stops after 2-4w
- C-section recovers 6-8w
- Stitches tear:
- 1st degree: skin deep
- 2nd degree: mm. and skin
- 3rd degree: mm., skin, perineum, sphincter
- 4th degree: Extends to rectum
What is diastasis Recti?
Separation of linea Alba
- Hormonal change
- wight gain
- Abb mm. weakness
How to measure abdominal separation?
- Knees of patient bent, place hand above navel pointing towards feet Patient raise heat and shoulders up, feel for gap or dip
- Normal – 1 finger space or less
- Diastasis recti – 2 or more finger spaces
What is the treatment for abdominal separation
- Deep abdominal muscle exercises
- No sit-ups!!
- Abdominal support belts/shorts
- Avoid lifting anything heavy
Post-Natal depression S&S
Affect 10-15% - refer to GP for blood tests
- Feeling depressed or miserable
- Increased crying
- Reduced interest in things normally enjoyed
- Not able to sleep or sleeping more than usual
- Reduced appetite or overeating
- Preoccupation with morbid thoughts
- Excessive feelings of guilt and/or failure
- Feeling disconnected with baby or that they don’t have a bond with the baby
When to treat a baby?
- Any birth complications / interventions
- Any signs of feeding difficulties Unsettled,
- reflux
- Tongue-tie
- Plagiocephaly (flat head syndrome)
What to ask about a pregnancy Hx?
First pregnancy?
Conception?
Illnesses, interventions, mothers overall health.
Any complications?
Hx of the delivery?
- Gestational age?
- Induced?
- Vaginal or caesarian delivery?
- How long were stages of labour?
- Apgar scores? (initial activity after birth)
Apgar scoring system
First check of babies health at 1min 5min 10min after birth
- Appearance,
- Pulse,
- Grimace,
- Activity,
- Respiration
How is weight measured?
Make sure the baby is on the same line of weight or above
Hx of Baby?
- Weight increase
- Feeding (formula, breast, frequency, amount, vomit, reflux)
- Sleeping (routine, position) (cry while supine?)
- Pattern of unsettled
- Systems screen (bowel movement, consistency, constipation, urination, burping)
- Meds & vaccines
- Accidents, surgery, illness?
Observation and initial examination of baby
- Observation
- General obs
- skin colour,
- skin spots,
- location of hair spots,
- palmar creases,
- alertness
- Head shape
- Any flattening on one occiput,
- bulging in forehead or eyes,
- ear levels Mouth, palate, gums, tongue, frenulum
- Abdominal examination
- Palpation,
- listening with a stethoscope if necessary for bowel movements, symmetry, umbilicus
- Neuro exam
- Cranial nerves,
- Romberg’s,
- Babinski’s
- Primitive reflexes
What are the primitive reflexes?
- Palmar grasp
- Plantar grasp
- Rooting reflex (tongue)
- Startle reflex
- Asymmetric tonic neck reflex
- Trunk bend stimulus
- Pacing and stepping reflex
Musculoskeletal Examination of the baby
Hips
- Ortolani and Barlows maneuvers (hip dislocation)
- Leg length,
- fat fold symmetry
- Club foot (inversion and supination of foot )
Shoulders and arms
- Torticollis
- Clavicle fracture (birth injury)
- Brachial plexus injury
What are the baby skull sutures?
New born cranium:
- 2 frontal bones,
- 2 parietal bones,
- 1 occipital bone
Sutures
- Metopic suture: form top of head to middle of forehead. 2 frontal bones meet
- Coronal suture: extends from ear to ear. Frontal bones meet w/ parietal bones Sagittal suture: middle of the top of head. 2 parietal bones meet
- Lambdoid suture: extends across back of head. Parietal bones meet with the occipital bone
Baby’s fontanelles
- Anterior (soft spot): junction for 2 frontal and 2 parietal bones. Has pulse (Gentle palpation)
- Posterior: junction of 2 parietal bones and occipital bone
- Sphenoidal fontanelle
- Mastoid fontanelle
Appropriate latching on
fit most of the areola in the mouth, chin should be under the areola
Mom- baby holds for breastfeeding
- Sidelying
- Football hold
- Laidback
- cradle position
- Cross cradle position
***dont hold baby up let pillows carry the weight
What to do if a mother cannot breastfeed
- Express breastmilk
- Use donor milk
- Use formula
- Use a combination of both
**9/10 women breastfeed but only 4 will continue after 4months
What is a tongue-tie
Structural abnormality of the lingual frenulum it has an adverse effect on feeding and speech
Signs of latching difficulty
What is a frenectomy?
the procedure used to treat tongue, lip or buccal tie
they use water laser to snip the membrane
Mandatory stretching every 4h to help with post-surgery to avoid re-attachment
Why does a baby feel uncomfortable lying in the back
when they have been over-exerting in latching, the baby bounds up through front and tongue so releasing the anterior body and upper thoracics will comfortably let them lie on their back
What is silent reflux?
reflux without content
reflux can lead to good
ceases after 4 months
How to diagnose GORD in babies?
type of vomit
if it shows mucous = stomach content
uncomfortable lying on their back
irritable
discomfort while feeding
What is the treatment for reflux in babies?
- increase frequency decrease amount of feed
- Burp more often during feed
- put crib at an angle
- Meds under advice from GP
When to refer a baby
- Blood
- fever
- GORD
- refuse to feed
- regurgitate
- Chronic respiratory infections
Conditions in the baby not to be missed?
-
Pyloric stenosis:
- enlarged muscles around pyloris
- surgical repair
- lots of vomit
-
Intussusception
- Abdominal emergency
- Bowel telescope up on itself
- Intense abdominal pain
- knees to chest
-
Hip Dysplasia
- femur separated from the acetabulum
- Bridged position at birth
- Girls 4>1 Boys
How to diagnose hip dysplasia
Symmetric but and legs folds
even hip abduction
Knee height difference
After 8 weeks - Barlow: Hip adduction + compression “clunk”
After 8 weeks - Ortolani: abduction and traction and feel
Vaccination policy for oteopaths?
What are the developmental milestones?
The motor skills children are expected to develop at a certain age
What are the 3 month milestones
Gross Motor skills
- 3/12- lying supine head midline
- 3/12-no head lag when pulled from supine to sitting
- 3/12- lift head when on tummy
Fine Motor skills
- 3/12- plays with hands, hands in mouth
- 3/12- will hold things but unaware they are holding it
5-8 months milestones
Gross motor skills
- 5/12- rolling
- 7-8/12- sitting by themselves
Fine Motor skills
- 6/12 – reaching and grasping objects and putting into mouth
- 6/12 – transferring objects from one hand to another
- 6-12 months poking and pointing with index finger
12-18 months milestones
Gross motor skills
- 10-12/12- crawling
- 1 year- cruising on furniture
- 19/12- walking
Visual Milestones 0-3months
seeing near and far.
Birth- can see, pupils react to light, will follow face 1⁄4 circle
3/12- very alert, follow face 1⁄2 circles
Hearing Milestones 0-3 months
hear information, listen and interpret
Birth- startled by a sudden noise
3/12- may be distressed by a sudden noise
Speech milestones 0-12
understand and learn a language
6/52- starting to make ‘coo’ noises
3/12- quite vocal
9-10/12- using words
Social Behaviour 0-3
eating, communication, relationships
6/52- smile
3/12- loves to be talked to and played with
When to refer if a milestone is delayed
- Baby not responding to sounds
- Appears baby cannot see things of has white or cloudy eyes Squints a lot after 3/12, eyes not focusing
- If baby is not interested in what is going on around them Cannot hold head up on tummy by 3-4/12
- Persistent and excessive crying after 3-4/12
- No babbling by 6/12
- If baby doesn’t use or move both arms and both legs
- Baby not sitting by themselves by 10/12
- Not weight bearing by 1 year
Common problems related with maintaining primitive reflexes beyond normal
4 Months
- Moro (startle): over sensitive and reactive to sensory stimulus
- Rooting (suckling): difficulty with solid foods, poor articulation
- Palmer: difficulty with fine motor skills, messy hand writing
6 Months
- Asymetrical tonic reflex: poor hand-eye coordination, poor visual tracking while learning to read and write
- Spinal Galant reflex: may affect posture, coordination, attention, ability to sit still, wet the bed
Treatment for retained primitive reflexes?
fatigue reflex – generally do something that over stimulates reflex until it starts to go away
Frequency of exercises is more important than intensity
What is Plagiocephaly ?
Misshapen baby head after 6/12
most common on supine sleeping
How to prevent and manage Plagiocephaly?
- tummy time
- move cot around
- use toys to get rotation
- helmet 23h/24 a day - before 1yr.
Osteo
treatment for Cx, Tx, upper ribs, cervical musculature, jaw
Why to encourage tummy time?
- Improve development of neck, back, shoulder mm.
- 0-3m = couple minutes several times
- 3+ more than 1h tummy time
Milestones for children 1-8yr
Case Hx questions for toodlers
Duration of Symptoms Trauma
Preceding illness (a simple viral infection can preced transient synovitis or reactive arthritis)
Fever or systemic symptoms
Pain levels and measures taken to reduce pain
Daily pattern – worse in Am/PM only with activity?
Previous injuries
Musculoskeletal examination on children
Musculoskeletal examination on children - ortho test
- Always do scoliosis
- AROM - All joints – knee pain can come from hip, thigh pain from the spine
- Internal rotn hip loss: Legg-Perthes disease, slipped capital femoral epiphysis Trendelenburg
- Galeazzi (knee heights)
- Faber
- Pelvic compression
- Psoas sign
Causes of limping in children
In most children limping is caused by a mild, self-limiting event like a sprain, strain or contusion
change inactivity
Always investigate can be life-threatening (osteomyelitis??)
Woodling not normal after 3
DDx for limping in children
- Trauma (eg fracture, sprain etc)
- Overuse syndromes
- Infections (osteomyelitis, septic arthritis) Malignancy
- Rheumatological disorders and reactive arthritis Intra-abdominal pathology (appendicitis) Inguinoscrotal disorders (eg testicular torsion) Transient synovitis of the hip
- Non-accidental or inflicted injury (abuse) ??
When to refer a child limp for investigation? what test are done
If in doubt refer
Imaging:
Xrays – Perthes, tumours, dysplasia of hips
Ultrasound – septic hip
Bone scan – osteomyelitis, Perthes, occult fracture CT/MRI usually only done after orthopedic consultation
Red flags for children
- Fever, systemic upset (malaise, weight loss, night sweats)
- Lymphadenopathy, hepatosplenomegaly Bone pain
- Pain described as deep, not localised and not associated with trauma
- Persistent night waking
- Incongruence between history and presentation/pattern of physical findings
- Regression - ALERT - can’t do the same as before sign of underline pathology
Common malignancies in children
Cancer
- Osteosarcoma
- Ewings sarcoma
- Acute lymphoblastic leukemia
- Rhabdomyosarcoma
Infection
- Osteomyelitis
- Septic Arthritis
Clinical features of Osteosarcoma
- Forms from osteoblasts. Usually at the ends of long bones
- Most common in 10-25 years old
- Pain and swelling over bone or joint, most commonly affects the knee
- Bone that breaks for no reason
Clinical features Ewings Sarcoma
- Forms in bone marrow, tends to be extensive in the bone shaft
- Peak incidence between 10 and 25 years old
- Pain or swelling, pain worse at night
- Lump that feels soft and warm in legs, arms, chest or hips
- Fever, tiredness, weight loss
Clinical features of Acute lymphoblastic leukemia (ALL)
- Overproduction of immature white blood cells
- Most common type of childhood leukemia and most common childhood cancer More common in children aged 0-14
- Slow healing, infections, unexplained bleeding or bruising
- Anaemia: tired, dizzy, pale, shortness of breath
Clinical features Rhabdomyosarcoma
- Can occur anywhere, but head and neck, trunk, extremities and genitourinary system most common
- Lump or swelling that keeps getting bigger Bulging eye, headache
- Difficulty urinating or with bowel motions
Clinical features osteomyelitis
- subacute onset of limp
- refusal to use limb
- localized pain on movement
- renderness
- soft tissue redness and swelling
- fever +/-
Clinical features of septic arthritis
- Refusal to use limb
- acute onset limp
- pain on movement or rest
- limited ROM
- soft tissue tenderness and redness
- fever
clinical features transient synovitis
diagnosis of exclusion
- Most common reason for a limp in children aged 3-8
- “irritable hip”, involves inflammation of the synovium of the hip joint
- Recent history of viral URTI
- Usually able to walk but with pain.
- Pain usually felt in the groin, sometimes in the front of the thigh or knee
- Child otherwise afebrile and well
- Decreased ROM in hip especially internal rotation
Clinical features of Perthes disease
- Avascular necrosis of bone, breaks more easily and heals poorly
- Usually occurs in children aged 4-10 years old and more common in boys
- Insidious onset, but may occur after injury to hip
- Usually unilateral
- Symptoms:
- gradual onset of pain in the hip and sometimes the knee.
- Limping, slow joint movements, sometimes wasting of thigh mms
Clinical features Slipped Capital Femoral Epiphysis
- Epiphyseal plate on femur slips down and backwards
- Can happen spontaneously and not associated with injury
- More common in boys, and obesity is a significant risk factor
- Symptoms develop slowly,
- may seem like a pulled muscle in groin, hip, thigh or knee
- On examination show shortening of one leg
- Usually a progressive condition, most children need operation to resolve
Clinical features of juvenile arthritis
- Umbrella term used to describe the many autoimmune and inflammatory conditions that can develop in children under 16
- No known cause, possible genetic predisposition
- No cure, early diagnosis and treatment are essential. Remission is possible
- Common symptoms are joint pain and swelling, but some types affect the musculoskeletal system while others involve eyes, skin, muscles and gastrointestinal tract
clinical features of growing pains
Cause is unknown, no evidence that growth is painful. Doesn’t happen only when growth is occurring
_Cramping, aching or throbbing pain_s of the thigh, shin and calf; typically at evening or night
Moving the legs does not make the pain better or worse
Pain does not cause a limp
May awaken child at night, disappears by morning
No pain with activity
Conditions that affect children during groth spurs
Iselins syndrome
- Traction apophysitis of the tuberosity of the fifth met, due to peroneus brevis tendon
- Most seen between 8 – 13 year old
History:
- Pain in lateral aspect of foot
- Worse with activity, better with rest
- Not always history of trauma to the foot
Phys exam:
- Tenderness over base of 5th met
- Pain with resisted eversion and extreme plantar flexion
Treatment:
- REST
- Analgesics
- Ice pack after activity
- Slow, guided return to sports / aggravating activities
- Manual therapy to help improve flexibility and function of leg
- Very severe symptoms may require case immobilization or controlled ankle motion walker (CAM boot)
- If conservative management fails and results in nonunion of the bone, surgical excision
Severs disease
Traction apophysitis at calcaneus
Active children aged 9 – 13, especially those who do running or jumping
History:
- Pain over posterior heel
- Pain worse with activity or impact
Phys exam:
- squeeze test - positive
- Hypertonic Achilles tendon Positive squeeze test
- Pain over calcaneal apophysis
Treatment:
- REST
- Analgestics
- Ice to the area after activity
- Slow, guided return to sports/ aggravating activities
- Stretching or massaging Achilles tendon, gastrocs, plantar fascia etc
- Use a heel cup or heel pad Taping
- Immobilization if pain is severe, ongoing or persistent
Osgood schlatters disease
OSD traction apophysitis at tibial tubercle. Bilateral 20-30% of the time
More common in boys. Boys 12-15, girls 8-12y. More common in jumpers or sprinters
History:
- Pain on anterior aspect of knee
- Aggravated with running, jumping, squatting, kneeling
Phys exam
Enlarged tibal tuberosity Tenderness over tibial tubercle Pain on resisted knee extension
Treatment:
*
Aphophisitis of pelvis or hip
Eccentric contraction of a muscle causes avulsion
Most often in ages 14-17, more in males. Occurs mostly in sports involving kicking
History
‘pop’ feeling in pelvic
Pain and weakness on affected side
Phys exam
- Antalgic gain
- Anterior hip/pelvis pain
- Pain at mm origin with active resisted
Treatment:
- Bed rest
- Ice after activity Activity modification
- Rehab aimed to increase flexibility and improve range of motion
Osteochondritis dissecans
Splitting of osteochodrosis, small area of avascular subchondral bone
Most often on convex articular joint surface (knee, elbow, ankle, hip, talus)
History
- Pain that is vague and poorly localized Ongoing swelling in joint
Phys exam
- Localised tenderness Stiffness and swelling
- Wilsons test for knee – pain w/ int rotn and extn of knee, rel of pain w/ external rotn
Treatment:
- Stable lesions:
- Restricted weight wearing/load bearing of joint
- Bracing
- Instability, expanding lesions, conservative management failure
- Arthroscope
- Fixation
- Chondral resurfacing
What are non-accidental injuries in children
When is reporting mandatory for children
Scoliosis
F>M
Idiopathic
- Infintile: 2
- JuvenileL 2-10
- Adolescent: 12+ most common
Congenital
Neuromuscular
Paralytic
What is the clinical presentation of scoliosis
What is Adams test for scoliosis
What are the red flags for scoliosis
Left thoracic curves – convex left / concave right
- Spinal cord tumors Neuromuscular disorders
- Arnold-Chiari malformations or occult syrinx
- Severe pain
- Neurological
- Neurological deficits
- Midline hairy patches Café au lait spots
What is the best scan for scoliosis
EOS
What is the treatment for scoliosis
*
Sheuermans disease
M>F
Treatment for Scheuermanns
Less than 60 degrees kyphosis
- Stretching, lifestyle modification, physical therapy
- No significant long term sequelae
Kyphosis 60 – 80 degrees and/or symptomaticBracing for 12-24 months
- Most effective in skeletally immature patients
- Does not improve curve, but impedes progression
Kyphosis more than 75degrees with unacceptable deformity, pain and/or neurological deficit
- Surgery
Why children and teens get HA
Headache is one of the main reasons children are taken to emergency departments
Most are benign and have common triggers – missed meals, dehydration, tiredness etc
Discerning between primary and secondary HA is essential, to ensure any serious conditions are not missed
Red flags for HA
Changing quality of headache from usual
- HA that occurs in awakening or awakens child from sleep Declining school performance
- Functional changes (vision, gait, coordination, behavior)
Examination for HA in children
Initial questions:
Onset, duration, temporal pattern, frequency, location, quality, severity
Back ground factors:
Medication use, systemic illness, fever, vomiting, visual symptoms, seizures, trauma, family history
WHen to refer for imaging in children HA
HA management in children
- Lifestyle factors – regular meals and hydration, avoiding trigger foods Regular sleeping routine
- Balance between school, sports, TV, computer games
- Relaxation and meditation
- Headache diary – record times, places, events, foods, sleep etc every day to try determine any patterns or triggers
- Consider referral to dentist for assessment of TMJ, teeth, grinding etc Musculoskeletal treatment as per HA type
- Also need to consider co-occurring psychological problems and psychosocial factors
Concussion in children
Concussion plan for children to return to sport
What are the red flags for concussion
Management for concussion
