Pregnancy: Newborn and Delivery Flashcards
Who is offered GDM screening and when? What tests are done?
- offered to everyone at 24-28w, also 12-16w if high risk
One Step Screen
- 75g glucose
- 3 measurements: fasting, 1h, 2h (5.1,10,8.5)
- if anything is above a cutoff, Dx
- single visit, but high false (+) rate
Two Step Screen
- 50g glucose
- 1 measurement: 1h (under 7.8, 7.8-11, over 11)
- if between 7.8-11 then 75g test done (5.3,10.6,9)
- lower false (+) rate, no fast unless second test
How much more calories does a pregnant person need?
Iron?
Folic acid?
Omega FAs?
Vitamin A?
Why are all these needed?
- 350-450kcal/day, 1-3 extra servings/day from all 4 food groups
- 16-20mg/day iron in supplement (needed for hematopoiesis of both mom/fetus and fetal neurocognitive development)
- 0.4mg/day supplement folic acid (needed for maternal hematopoiesis and fetal NT development)
- 150g fish/week or 2 servings (also walnuts, flax seed, canola oil), needed for fetal neuro and retinal development
- vitamin A can be teratogenic so no more than 10,000 IU/day
*calcium and vitamin D are the same as pre-pregnancy
*vitamin B12 only a concern if vegan/celiac/ IBD
*zinc only a concern if low resource community
*choline important for cell membrane synthesis, neurotransmission, and brain development but not yet recommended
Things to avoid in pregnancy - why?
- listeria (unpasteurized milk/cheese, sushi, meat, raw sprouts)
- toxoplasmosis (meat, uncured meat if not frozen)
- salmonella (raw eggs)
- smoking (LBW, miscarriage, stillbirth, premature delivery, abruption, SIDS)
- weed (still birth, neuro development)
- alcohol (FASD/ARND, liver, kidney, eyes)
Exercise Recommendations in Pregnancy
- continue as before (do not exceed)
- walking 15m 2-3x/week
- avoid shear forces, stop/start/ trauma risks
- start pelvic floor exercises in intermediate postpartum (decreases urinary incontinence)
Vitamin D/B12/Calories/Iron/Vitamin A/C/ choline requirements while breastfeeding?
Vitamin D - prevents Ricketts/ RA/ osteoporosis/ etc.
- 400/day if exclusively bf in 1st year
- 800/day if northern indigenous in winter
Vitamin B12 - deficiency rare, concern of vegan/ pernicious anemia in mom
Calories - more than pregnancy (400-600cal/day) - will be hungrier!
Iron - less iron needed (only 9mg/day)
- stores depleted around 6 months, can delay CNS
- more vitamin A/C/ choline than pregnancy
- hydrate and rest, continue prenatal vitamin
Sensitivity
Specificity
False (+) Rate (equation)
PPV
Sensitivity - true (+) rate, ability to rule something out by correctly identifying who has it
= true (+)/ (true(+) + false (-))
Specificity - true (-) rate, ability to rule something in by correctly identifying who doesn’t have it
= true (-)/ (true (-) + false (+))
False (+) Rate = 1 - specificity
PPV - true (+)/ all (+) (proportion of + results that are actually truly diseased)
- a false positive does NOT indicate an ongoing risk
How does disease frequency affect test performance?
- even with the same Sn/Sp, there is a higher PPV if the prevalence is higher
- for population screening of a rare disease, need test with very high specificity
Differences between diagnostic and screening testing?
Diagnostic - symptomatic population, reference intervals (percentiles), increased precision and accuracy, lower throughput and higher cost
Screening - asymptomatic population, screening cutoffs, must have high sensitivity and specificity, higher throughput and lower cost
What is the Dobrow Criteria for Screening?
Disease - should be understood, clear target population, significant health concern
The Test - efficacious, affordable, allows for risk stratification
The intervention - effective, available, improves outcomes, burden of screening understood and accepted
The System - adequate infrastructure, coordinated, cost-effective, ongoing support
How does new born screening work?
- must be informed, it is an opt-out program
- must repeat testing if the infant is over 1500g or transfused prior to collection
- prenatal genetic screen –> trisomy 18/21, open NTDs, need confirmation from amnio or CVS
NIPS - detection of fetal cell-free DNA in maternal circulation, better performing but self-pay
Changes that occur to the BLOOD in pregnancy
- 40-45% increase in blood volume (plasma) - helps maintain perfusion to the placenta, protect against partition related blood loss (this is even more if it’s a twin pregnancy!)
- thrombocytopenia due to hemodilution, only a concern if platelets are under 150x10^9, can get as low as 100
- leukocytosis, WBC may go up to 25x10^9 in labour
- Hgb lowers - there is an increase in erythrocyte production but this is outweighed by increase in plasma volume (if under 105-110 consider iron supplement)
- iron demands increase in 2nd/3rd trimester, 27mg/day recommended
*screened for anemia at 28 weeks
Mass effect changes that occur during pregnancy?
- appendix may move
- worsens urinary frequency
Changes that occur in the KIDNEYS during pregnancy?
- hydronephrosis - uterus compresses ureters against the pelvic brim (more so on the right side as sigmoid colon cushions L), most renal colic in pregnancy is on the right side
- renal plasma flow increases (GFR increases by 50% by 2nd trimester)
- hypervolemia
- creatine decreases
- urinary frequency common
What changes occur with respect to RA in pregnancy?
- most autoimmune disease improve in pregnancy and flare postpartum
- RA flares increase risk of preterm delivery/ placental dysfunction
- change in meds - NSAIDs can cause oligohydramnios/ premature closure of ductus arteriosus, methotrexate is teratogenic so switch to hydroxychloroquine and sulfasalazine
What changes occur with RESPIRATION in pregnancy?
- diaphragm rises 4cm and thoracic circumference increases by 6cm
- total lung volume is mostly unchanged (small decrease)
- minute ventilation increases but respiratory rate is unchanged
- tidal volume and inspiratory capacity increase, FRC decreases, progesterone increases respiratory. drive
What changes occur in the HEART with pregnancy?
- what are some red flags?
- heart displaces due to the rising diaphragm - LAD on ECG and increased silhouette on CXR
- 90% will have systolic ejection murmur
- splitting of S1
- 3rd heart sound ventricular gallop (increased blood volume hitting a compliant LV)
- CO increases by 30-50%
- HR increases about 10bpm, palpitations common
- supine hypotension syndrome (SV lowers when supine and increases when lateral)
- LV mass increases by 30-35%, function is normal - this occurs due to decreased SVR
*red flags for palpitations are PROLONGED, syncope, chest pain, SOB
* failure to establish a low resistance high flow shunt often lead to hypertension in pregnancy, failure of trophoblasts to invade spiral arteries can lead to abnormal implantation
Definition of:
- Gestational HTN
- Pre-existing HTN
- Pre-eclampsia
Gestational - over 140 SBP or 90 DBP (at least 2 measurements 15m apart)
- develops around 20 weeks and resolves around 12 weeks postpartum
Pre-Existing - high BP prior to 20 weeks, persistent after 12 weeks postpartum
- risk of superimposed gestation HTN/pre-eclampsia
Pre-Eclampsia - gestation HTN with new proteinuria or presence of adverse features
- 20% of pre-eclamptic seizures occur without proteinuria
Risk factors for HTN Disorders in Pregnancy (HDP)?
Prevention of HDP?
- prior pre-eclampsia, pre-exisitng HTN, obesity, DM/CKD/SLE, age 35+, nulliparity, multiple pregnancies
- calcium 1g/day (anti-inflamm and decreases endothelial cell activation)
- low dose aspirin before 16w (prevents inflammation and thrombosis)
What is the etiology of HDP?
- decimal immune cell - EVT interactions –> inadeuquate placentation (early onset)
- normal placentation (macrosomia, multiple pregnancies) (late onset)
- endothelial cell activation
Pre-Existing HTN effects on pregnancy?
- med changes?
- decreases perfusion which can lead to IUGR, oligohydramnios, HDP
- BP (in normal pregnancy) should lower in 2nd trimester and then increase again at end of pregnancy
- avoid ACEi/ARBs, switch to labetalol and nifedipine
What are some adverse consequences of HDP?
- headache, eclampsia, GCS <13, stroke/TIA
- chest pain, dyspnea, pulmonary edema, MI
- increased WBC and INR, DIC, low platelets
- increased Cr and Uric Acid, AKI, dialysis
- N/V, RUQ or epigastric pain, increased AST/ALT/bilirubin, hepatic dysfunction or rupture
- placental abruption
Monitoring and treatment for HDP?
- monitor kick counts, should be 6 or more in 2h
- non-stress test
- U/S (growth, fluid, umbilical arteries)
- treat with labetalol/nifedipine/methyldopa to prevent hemorrhagic stroke
- treat with MgSO4 to prevent seizure
- DELIVER AS SOON AS BABY IS 37 WEEKS, if under 35 weeks weigh pros and cons, corticosteroids and MgSO4 to prevent cerebral palsy if under 32 weeks
What is primary vs secondary vs tertiary prevention?
Primary - reproductive carrier screening
Secondary - newborn screening and early treatment
Tertiary - treatment of symptomatic patients
Where is high definition vision?
- Macula (even better in the fovea, which is only cones)
Afferent vs Efferent visual pathways
Afferent - ganglion cells of retina project through optic nerve to the ipsilateral pretectal nucleus
Efferent - pupillary motor output from pretectal nucleus to the ciliary sphincter muscle of iris (dinger Westphal)
Myopia vs Hyperopia
Myopia - can’t see far, image is formed before the retina, long eyeball
Hyperopia - can’t see close-up, image formed behind the retina, short eyeball (more common in children)
Growth and development of newborn eyes
- newborn eye is 15-16mm, adult size by age 14
- newborn eyes has axial hyperopia which is neutralized by an increase in axial length
- vision in a newborn is 20/1200 (can fix a face within 1 meter), 20/600 at 1 month, and 20/200 at 4 months
- do not get to 20/20 until age 5
Important developmental milestones from 0-adulthood
- 0-3months - macula thins, brain learns to see
- 6 weeks - definite fixation and following reflexes
- first 3-4 months - time when issues should be resolved to prevent permanent problems
- 3-5 years - developing visual acuity
- few months to 7/8 years - when deprivation causes amblyopia
- time of deprivation to adult - period when amblyopia can be fixed
What are considered normal optic findings after normal delivery?
- retinal or subconjunctival hemorrhages that are limited to the sclera (pressure of delivery)
- eyelid edema or eversion
- dysconjugate movement up to 2 months (unless fixed)
Torticollis
Asymmetric Blink
Ptosis
- treatments?
- when to refer?
Torticollis - head turn that can make eyes appear straight, often a 6th nerve palsy
Asymmetric Blink - 7th nerve palsy, unable to move lips on affected side and nasolabial fold flattening
- most resolve within days, treat with cornea lubrication and investigate with electro testing if not
- could also be absence/ hypoplasia of depressor angle iris
Ptosis - drooping of levator palpebrae, 3rd nerve palsy (eye also down and out)
- often compensate with chin up and eyebrow raise
- Marcus gunn jaw winking - when jaw opens, eye opens
- refer if young or older and signs of palsy/abnormality
- treat with a frontal sling or elevator resection
Common lumps around the eye
- when to refer?
- hemangioma
- mucocele
- dermolipoma
- refer if mucocele not resolving by 2w/ infected
- hemangioma that affects eyelid/orbit
- stye not resolving by 2 months
- orbital mermaids
Cause of nasolacrimal duct obstruction
- risk factors
- sx
- dx
- tx
- membranous obstruction of valve of Hasner
- Down’s, craniosynostosis
- signs: mucous discharge, tearing, reflux with massage
- dx: fluorescin dye
- tx: massage, tear duct probing, surgery if longer than 12m
OR
- dacryocele
- tx: lacrimal probing no later than 1m after birth
- if progression to dacrocystitis, ABX and surgical decompression
Opthalmia Neonatorum (broad category)
- causes
- pink eye
- chlamydia, gonococcal, HSV, chemical irritant
- emergency! can cause blindness within 48h
Chlamydia Conjunctivitis
- timeline
- sx
- dx
- tx
- most common infectious cause
- 5-14 days postpartum
- discharge, pseudomembranes
Dx: culture of conjunctiva, spot tests (ELISA) and PCR
Tx: systemic erythromycin
Gonococcal Conjunctivitis
- timeline
- sx
- dx
- tx
- secondary to prohlyaxis
- 2-5 days postpartum
- profuse purulent discharge, eyelid edema
- dangerous! cornea can ulcerate/ perforate
Dx: culture and gram stain of conjunctiva
Tx: IM ceftriaxone, topical penicillin G
HSV Conjunctivitis
- risks for baby
- type? sx
- tx
- 50% risk if mom has primary disease, 30% if first episode, 1-3% if recurrent
- often type 2 in neonates, type 1 in children
- type 1 - bilateral conjunctivitis, vesicles, dendritic ulcer on corneal epithelium
- tx: acyclovir, head CT/MRI at end of therapy
Glaucoma
- why does it happen?
- sx
- tx
- big or cloudy eyes
- fluid is made by the ciliary body and flows into the trabecular meshwork. glaucoma occurs when fluid inflow is more than outflow
- i.e. absence of angle recess with iris directly in the trabceulum (congenital disorder)
- corneal edema, lacrimation, photophobia, optic disc cupping, buphthalmos, breaks in the descemet membrane
tx - goniotomy - needle placed into meshwork
Important aspects of infant vision assessment
-reaction to light (newborn)
- stimulus run to a face (6 weeks)
- red reflex - should be symmetric, no opacities/white/dark spots, strabismus (RR is more intense from deviated eye), leukocoria - white/yellow reflex, can indicate cataract or retinoblastoma (REFER)
Strabismus - estropea (in), exotropia (out), hypotropia (one eye out), hypertrophic (one eye up)
When should you refer a child with eye concerns?
- constant, intermittent but persists for 3 months
- nystagmus
- abnormal red reflex
- poor vision
- not tracking by 2 months
- not tracking at any age with nystagmus or abnormal pupil reactions
How is glucose managed from fetus to neonate?
- fetus gets ALL glucose from mom
- after cord clamping, glucose rapidly decreases and then increases over 2-3 hours
1st hour - resp quotient decreases to 0.8, suggesting a shift from glucose to significant fat contribution
day 1 - 50% endogenous glucose comes from glycogenolysis, 35% from gluconeogenesis
BF effect on glucose
- breast fed babies have less glucose but more ketones
- tolerate a decrease in glucose without clinical manifestations
How is glucose regulated?
- main energy source for the brain
- regulated by [plasma] and GLUT1 in the brain and GLUT3 in the cerebellum
- a drop in glucose activates alternate fuels such as pyruvate, lactate, ketones
Neurogenic vs. Neuroglycopenic symptoms of hypoglycaemia
Neurogenic
- adrenergic - tremors, irritable, tachypnea, pallor, anxiety and palpitations in adults
- cholinergic - sweating, hunger and parenthesis in adults
Neuroglycopenic
- poor suck, poor feeding, weak and high pitched cry, decreased LOC, seizures, hypotonia
*other (not specific) - apnea, bradycardia, cyanosis, hypothermia
Risks for neonatal hypoglycaemia
- low reserve - preterm, SGA, IUGR, low glycogen stores
- increased demand - hyperthermia, sepsis, polycythemic
- abnormal regulation - GDM (hyperinsulinemia results in less gluconeogenesis), hypercortisolemia, GH deficiency
How is screening for neonatal hypoglycaemia done?
- routine screening in term/healthy infants is not recommended
- if asymptomatic but at risk, screen every 3-6 hours starting at 2 hours
- if SGA/ preterm, screening is continued for 24 hours after birth
- if GDM/LGA, screening is continued for 12 hours after birth
- in general, screening continues until the vulnerable period has passed or [glucose] remains over 2.6 in first 72 hours and over 3.3. over 72 hours
When do we treat neonatal hypoglycaemia?
- if symptomatic, treated for glucose under 2.6mmol/L
- enteral supplement is given in asymptomatic babies if between 1.8-2.5
Why do we treat neonatal hypoglycaemia?
- longer time spent with NH results in impaired psychomotor and mental development
- assx with learning disabilities, seizure disorders, visual impairment (affects portico-visual pathways on MRI), neurodevelopment delay if severe (under 1mmol/L) or persistent (over 2/3 hours)
What cause of hypoglycaemia would you suspect if:
- acidemia, increased lactate
- acidemia, increased ketones
- non-acidemic, low ketones and high FFAs
- non-acidemic, low ketones and low FFAs
- acidemia, increased lactate - gluconeogenic enzyme deficiencies
- acidemia, increased ketones - GH or cortisol deficiency
- non-acidemic, low ketones and high FFAs - fatty acid oxidation effect
- non-acidemic, low ketones and low FFAs - hyperinsulinism
How do we treat neonatal hypoglycaemia? How do you calculate glucose infusion rate (GIR)?
- feeding, dextrose gel, IV dextrose, glucagon, dizoxide (prevents insulin release), glucose polymers
GIR = (IV rate (mL/h) x [dextrose] (g/100mL) x 1000mg/g)/ 60(min/h) x weight (kg)
i.e. D10W at 3mL/h, 1.5kg = 3 x 10 x 1000/ 60x 1.5 = 333.33 or 3.33mg/kg/min
Hyperbilirubinemia in Neonates
- risk factors
- results in jaundice once bilirubin is more than 85mmol/L (head), over 340mmol/L (feet)
- risk factors: visible jaundice <24h or before discharge, under 38 weeks gestation, previous sibling, male, mom over 25, asian or European, dehydration, exclusive or partial breast feeding
Physiological vs. Pathological Hyperbilirubinemia
Physiological - 2-3 days postpartum, decrease RBC lifespan, increased RBC mass, immature liver enzymes
Pathological - under 24 hours or over 2 weeks
- conjugated, excessive rate of increase (over 85 per 24 hours)
Causes of Unconjugated vs. Conjugates bilirubinemia in neonates
Unconjugated - bleeding (cephalohematoma, hemorrhage, delayed cord clamping, twin to twin or mom to fetus transfusion)
- Rh/ABO incompatibility, PKD, thalassemia
- dehydration, breast feeding day 10-14
- Gilbert’s
- HYPOthyroidism
- bowel obstruction (more enterohepatic circulation)
Conjugated - biliary atresia (PALE WHITE STOOLS), choledochal cyst
- hepatitis (CMV, HBV, sepsis)
- inborn errors of metabolism (CF, hypothyroidism, a.a disorders)
Kernicterus
- what is it
- sx
- risks
- prognosis
- deposition of unconjugated bilirubin into the brain
- early sx: lethargy, poor feed, respiratory distress, less reflexes, no moro reflex
- late sx: opisthotonus, bulging fontanelle, twitching, high pitched cry
- increased risk if premature, infection, hyperosmolic, asphyxia
- can lead to hearing loss, lowered IQ, rigidity, movement disorders, death
Treatment for Jaundice
- if high risk, phototherapy (look at bilirubin graphs for severity)
- blue/green light (460-490nm) most effective
- causes configurational and structural isomers that get excreted in bile, photooxidation products excreted in urine
- exchange transfusion if severe
Growth in the first year of life
- at birth - lose up to 010% BW, but regain by 7-10 days
- 0-6m - grow 1.5-2.5cm/month, HC grows 2cm/month, 20-30g/day, x2 BW by 5m
- 6m - 1y - grow 1cm/month, HC grows 0.5cm/month, 12-20g/day, x3 BW by 1 year
*highest calorie requirements EVER are as a fetus
Barker Hypothesis
- prenatal and childhood nutrition and health can lead to adverse health outcomes (CVD, T2DM, obesity)
Benefits of breast feeding
- protects against bacteremia, meningitis, diarrhea, UTIs, T2DM, leukaemia, obesity, SIDS
- each month reduces risk of hospital due to infxn
- helps with neurocognition and IQ
- source of LCPUFAs which develop brain and retina
for mom - improve bonding, decrease post partum bleeds, earlier return to pre-pregnancy weight, decreased risk of breast and ovarian cancers, decreased fertility for birth spacing
What are recommendations for breast feeding? What are contraindications?
- exclusive bf for first 6m, can continue up to 2 years+
- galactosemia, PKU, HIV, TB, HSV on breast, some meds
Why no alcohol when breast feeding?
- impaired motor development/ sleep, hypoglycaemia, less milk intake and flow
- elimination is 0 order kinetics so you cannot speed up expulsion
Milk Banks
- donors are screened for HBV/HCV/HIV
- milk is frozen and pasteurized
- never been a case of disease transmission
What is colostrum?
- first milk produced around delivery
- contains lymphocytes, IgA/G/M, lots of protein and less fat
- mild laxative effective which helps passing of bilirubin and meconium
When to transition to solid foods? What to avoid?
- 6 months (waiting too long can lead to Fe deficiency and allergies!)
- give if hungrier, can sit up without support, holds food in mouth, shows interest in food, can decline food
- homogenized cows milk at 9-12m, nothing else until 2 years
- avoid added salt/sugar, choking hazards, honey under 1 year (botulism)
Tier 1/2/3 of Birth Control
Tier 1 - implant, IUD, sterilization
Tier 2 - pill, patch, ring, shot
Tier 3 - withdrawal, condom, planning
Common abortion MYTHS (debunked)
- risk of dying is actually higher from birth than abortion
- abortion rates are declining due to better methods of contraception
- 1st term abortion poses NO risk of infertility, ectopic pregnancy, miscarriage, birth defects, preterm, LBW delivery, breast cancer, mental health
Surgical vs. Medical Abortion
- pros and cons of each
Surgical
- suction evacuation (1st trimester) - dilation and curettage, under 10 minutes
- dilation anf evacuation (2nd trimester) - prep cervix with osmotic dilators/ misoprostol (fetal demise if over 18 weeks)
Medical
- medical abortion (1st trimester, up to 70 days)
- termination induction of labour (2nd trimester) - mifepristone if outpatient, misoprostol if inpatient, fetal demise first
*surgery is quick, free, less bleeds and cramping, and 99% successful
- but it involves instruments, anesthesia, need a facility, rare complications
- medical can be done anywhere, no anesthesia or instruments
- but it can lead to cramps/ heavy bleeding, higher failure rate, may need multiple visits
Mifepristone/ Misoprostol
- approved in Canada 2015
- can use up to 63 days after LMP
- oral is less effective, best route is buccal/vaginal (less GI sx)
- 90% will abort in 24 hours
What are the common DDx for hemorrhage before 20 weeks and after 20 weeks?
Before - abortion, molar pregnancy, implantation bleed, ECTOPIC
After - placenta prevue, placental abruption, vasa previa
- cramping over 20 weeks is a threatened abortion (preterm labour)
Symptoms suggesting:
- Placenta Previa
- Placental Abruption
- Preterm Labour
- Vasa Previa (velamentous cord insertion with low lying placenta or bilobed/ succenturiate placenta)
- Placenta Previa - bright red bleed, no pain, no membrane rupture, fetal movements
- Placental Abruption - dark clots, painful (pain persists in-between contractions), no membrane rupture, maybe fetal movements
- Preterm Labour - mucous show, painful, ruptured membranes, fetal movements
- Vasa Previa - small bleed, no pain, no membrane rupture, no fetal movements
Risk factors for:
- Placental Abruption
- Placenta Previa
- Preterm Labour
- Placental Abruption - HTN in pregnancy, trauma, previous abruption
- Placenta Previa - no prenatal care or U/S, previous C-section/ previa, multiple pregnancies, old mom
- Preterm Labour - prior preterm birth, cervical surgery, infection, polyhydramnios, multiple babies
*smoking and cocaine are risks for all of these
Tests for antenatal hemorrhage
- vaginal exam is contraindicated if placental location is unknown
- U/S cannot rule in/out abruption
- CBC, group/screen, coagulation profile, Kleihauer Betke (determine if fetal blood is in the maternal circulation)
Management for antenatal hemorrhage
- stabilize (IV fluids, RBCs)
- prepare for delivery (corticosteroids if before 35 weeks, MgSO4 if before 32 weeks)
- C-section
*if mom Rh(-) give RhoGAM
Types of shock
- Hypovolemic - hemorrhage/ dehydration
- Distributive - sepsis, decreased vascular tone, anaphylaxis
- Cardiogenic - cardiomyopathy, arrythmia, hypoxia-ischemia
- Obstructive - cardiac tamponade, coarctation, PE, tension pneumothorax
What is cervical insufficiency?
- premature cervical dilation without any signs of labour
When is depression in pregnancy most common? Diagnosis?
When is suicide most common?
- 2nd and 3rd trimester
- 1 in 8 people will be depressed during pregnancy
*must have at least one of depressed mood or loss of interest/ pleasure for at least a 2 week period (5 sx total)
- Most suicides occur between 9-12 months postpartum, more common in rural and remote regions
Risk of not treating depression/ anxiety during pregnancy?
Depression - poor prenatal care, pre-eclampsia, SUD, impaired bonding, PPD worsening
- preterm, LBW, fussy, long term emotional and cognitive defects
Anxiety - ADHD, externalizing behaviours, child anxiety
Post Partum Blues
- transient, non-pathologic, 50-80% of new moms
- tearful, distressed
- usually 3-5 days postpartum and usually self-limiting by 2 weeks
- only 13% will progress to PPD
PPD
- during pregnancy or within 4 weeks of delivery or within 12 months of birth
- lack of enjoyment in baby, difficulty sleeping when baby asleep, worthlessness/guilt associated with parenting, intrusive thoughts of harming baby, suicidal as baby would be better off
Risk factors for perinatal mood disorders and perinatal major depression.
Mood - less sleep, immune dysregulation, genes, HPA axis, est/progest dysregulation
Major Depression - prior hx in self or family, discontinuing meds, medical/obgyn problems, bf difficulties, lack of support, ACEs, multiple births, low SES, abuse, infant illness
When do we screen for perinatal depression? With what?
- 28-32 weeks gestation
- 6-16 weeks postpartum
- screening is done with the Edinburgh Postnatal Depression Scale
- of they score any positive points on thoughts of harming themselves, discuss suicidality and hospitalize if yes
Non-Pharm Treatment for PPD - when to switch to meds?
- psychoeducation, CBT, IBT, MBCT, couples therapy
- Nutrition, Exercise, Sleep, Time alone, Supports (NESTS)
- IBT good if role disputes/transitions
- Switch to meds if cannot do ADLs, insomnia, panic attacks, thoughts of harm, psychotic symptoms
Pharmacological Treatments for PPD
- SSRIs are first line - sertraline (Zoloft), citalopram (Celexa), escitalopram (Cipralex), fluoxetine (Prozac)
- not contraindicated if benefits outweigh risks, take smallest dose and least amount of meds possible
- do NOT stop or lower before delivery
- no connection to ASD, may have transient risk with respiratory. distress/ temperature/ jitters
Postpartum Psychosis
- course
- sx
- technically a bipolar spectrum illness
- more common in 1st time moms
- rapid onset, lasts about 40 days
- occurs within 2 weeks of delivery
- insomnia, mood swings, OCD, mania, depression , delusions, hallucinations, disorganized behaviour, confusion
- EMERGENCY need to hospitalized, can lead to infanticide in 3%
Definition of maternal death, late maternal death, maternal morbidity ratio (MMR)
- while pregnant or under 42 days postpartum
- over 42 days but under 1 year postpartum
MMR = maternal deaths per 100,000 live births
Goals for ending MMR
- attend 4 or more antenatal visits
- skilled health personnel
- access postnatal care within 2 days of delivery
- access to ER care within 2 hours of travel time
- education
Postpartum Hemorrhage Defintion
- over 500mL if vaginal
- over 1L if C-section
*estimated blood loss os often only 50% of actual
Compensated vs. Mild vs. Moderate Shock
Compensated - under 1L, HR under 100
Mild - 1-1.5L, HR over 100, orthostatic changes in BP
Moderate - 1.5-2L, HR over 120, marked fall in BP
What are some possible etiologies of postpartum hemorrhage?
Tone - over distended, uterine muscle exhaustion, intra-amniotic infection, bladder distension preventing uterine contraction
Trauma - uterin rupture or inversion, excessive cord traction, operation, laceration
Tissue - retained placenta/ blood clots, incomplete placenta at delivery
Thrombin - DIC, gestational hypertension, coagulopathies
What are 4 signs of placental separation?
- Gush of blood
- Umbilical cord lengthens
- Uterus rises
- Uterus becomes globular
What is involved in active management of the 3rd stage of labour?
- utertonics - aid with contraction, speeds placental separation
- oxytocin 10 units IM after delivery, carbetocin 100mcg IV after C-section
- controlled cord traction to help speed up
- risks of uterine inversion or cord avulsion
Initial management steps for postpartum hemorrhage
- evaluate vital signs every 5 minutes
- 2 large bore IV accesses
- resuscitation with crystalloid (33% IV 77% interstitial), colloids, blood products (need to G/S, crossmatch)
- bimanual massage, utertonics to help with tone
*hypotension is a LATE sign
Drugs used to reduce postpartum bleeds
- Oxytocin (IM and IV)
- Carboprost (IM)
- Ergonovine (IM)
- Misoprostol (Buccal/ rectal)
Refractory Atony Tx
- balloon tamponade, uterine compression sutures, radiolgic uterine artery embolization, hysterectomy
Random Facts idk
- Resp rate over 20 and temp under 36 or over 38 are the same in pregnancy for criteria of Systemic Inflammatory Response Syndrome
- pregnancy makes SIRS/ sepsis criteria more sensitive and less specific
- it takes 30 minutes to infuse 1L of normal saline through a 22g IV
- 3L of normal saline is needed to replace 1L of blood loss (as only 1/3 actually enters the ECF)
