Pregnancy

Question 1

Susan, aged 34, presents for her first postpartum visit with Alicia, her three-week old baby who has been exclusively breastfed since she was born. Susan tells you breastfeeding is more difficult than it was for her first baby. She has damaged nipples and the lactation consultant she saw two days ago told her she had a poor latch that improved somewhat with counseling. You notice the nipple turns white (vasospasm) after latching, and is painful after breastfeeding. During Alicia’s physical exam, you notice a tight lingual frenulum that restricts tongue mobility (suction on your finger is only posterior, and she can’t bring her tongue to her lips). Her birth weight was 3,475 g and she now weighs 3,410 g.

What are the indications for office-based frenotomy in this scenario? List three.

What are contraindications to frenotomy? List 2.

Answer 1

Maternal pain
Poor latch
Damaged maternal nipples
Poor weight gain.

Contraindications are bleeding disorders and failure to receive vitamin K at birth

Ref: CFPC Self Learning Modules Vol 32.3 June 2017

Question 2

Adverse outcomes after office-based frenotomy include risk of bleeding, pain, infection, damage to adjacent structures, failure to improve breastfeeding, and reattachment of the frenulum. How can the last be prevented?

Answer 2

Exercises should be done after the procedure to prevent reattachment of the frenulum. These involve the caregiver using his or her index finger to firmly push into the wound and upward in a J shape. This should be done five to six times per day for seven to 10 days.

Question 3

What are risk factors for pre-eclampsia? List 4.

Answer 3

Major risk factors:
Prior pre-eclampsia
Known antiphospholipid syndrome
Known type I or type II diabetes mellitus
Chronic hypertension
Assisted reproductive therapy in the current pregnancy
Prepregnancy or early first-trimester body mass index over 30

Moderate risk factors:
Prior placental abruption
Prior stillbirth
Prior fetal intrauterine growth restriction (IUGR)
Maternal age over 40
Nulliparity
Multifetal pregnancy
Known chronic kidney disease
Known systemic lupus erythematosus

D’Souza R, Kingdom J.Preeclampsia.. CMAJ.2016 Nov 1;188:1178

Question 4

In women at high risk of pre-eclampsia, what medication can be given to significantly reduce the risk and how is it given?

Answer 4

Low-dose acetylsalicylic acid (ASA)

(e.g., 81 mg at bedtime) at 12 to 20 weeks’ gestation, stopped at 37 to 38 weeks. The use of ASA is safe for mother and fetus.

D’Souza R, Kingdom J.Preeclampsia.. CMAJ.2016 Nov 1;188:1178