Prescribing postnatal care and the puerperium psychiatry Flashcards
What are 3 main possible problems in pregnancy, related to drugs?
Teratogenicity - organ formation completed at end of first trimester
Miscarriage/death
growth restriction
Which conditions are more common in pregnancy?
VTE - body preparing for blood loss in child birth
haemorrhage
Pain
Infection
Hypertension
What can we give a woman as VTE prophylaxis/treatment?
Unfractionated heparin (not commonly)
LMWH - tinzaparin
Alteplase may be used only if life threatening (unsure of effects)
What CANNOT be given for VTE/treatment? Why is this?
Warfarin
stillbirth
prematurity
haemorrhage
ocular defects.
Fetal warfarin syndrome: nasal hypoplasia
hypoplasia of the extremities developmental delay.
How do you manually compress uterus (to stop bleeding)?
2 fingers in vagina
Pressure on fundus to try and contract it down
What things can cause postpartum haemorrhage?
Infection
Prone to bleeding
Multip (>4 children)
Trauma: cervical trauma, tear etc.
Where should the uterus be palpable following delivery?
below umbilicus
When is misoprostol given in gynaecology?
To start a termination pregnancy or if someone is bleeding after miscarriage
Management of miscarriage 800mcg
causes cramping in uterus, helps it to expel anything that’s inside
Cervial softner
When is mifepristone given? What dose?
mid-trimester loss/TOP
given to prime cervix before any other treatment
200mg
When is methotrexate given?
given in ectopic pregnancy
usually given as one off dose, or given as a second dose
EXTREMELY TOXIC TO PREGNANCY
When is tranexamic acid given?
menorrhagia
post-partum haemorrhage
What type of drug is tranexamic acid?
anti-fibrinolytic
When is mefenamic acid given? What type of drug is it?
period pain
NSAID
What type of drug is prostap/gonapeptyle? What does it do? When is it given?
GnRH analogues
Induces a massive drop off of oestrogen (chemical hysterectomy)
Given in endometriosis - treat (or one dose can be used of diagnosis)
Can also be used to shrink fibroids
When are progesterones given? (POP, injection, mirena)
All used to suppress ovulation
Can be used as a form of contraception
What pain relief can be used in pregnancy?
paracetamol
opiates (can cause neonatal resp. depression, but generally safe codeine/diamorphine)
entonox
Why must you avoid NSAIDS in pregnancy?
miscarriage and malformation in 1st trimester
premature closure of the DA in 3rd trimester
What can happen if a woman take opioids regularly for a long period of time?
Baby may need further care after birth
Why don’t you give trimethoprim in first trimester?
anti-folate
increases risk of neural tube defects
teratogenic
Why don’t you use nitrofurantoin in the third trimester?
neonatal haemolysis
What ABX would you give to a pregnant woman with a UTI?
penicillins and cephalosporins
What ABX should you avoid in pregnancy? why?
co-amoxiclav - necrotising enterocolitis
tetracyclines - brown teeth
trimethoprim in 1st trimester - teratogenic and anti-folate
nitrofurantoin in 3rd trimester - neonatal haemolysis
What investigation should you do for a woman who has lost >500mls of blood?
FBC day after delivery?
What is endometritis?
infection within uterus
After how many days does endometritis occur?
2-10 days
Does C-section make endometritis more or less common?
more
How might endometritis present?
Offensive vaginal loss
Symptoms: Fever, malaise, rigors, tachycardia Headache Abdo pain/suprapubic tenderness/uterine enlargement Offensive lochia Secondary PPH
What investigations would you do for a women in whom you suspected endometritis?
FBC
CRP
HVS
Blood cultures
NOT USS in first instance
in which leg will most DVTs occur?
L
which investigation for DVT/PE has a higher risk for the mum? which one for the baby?
CTPA - mum
V/Q can - baby
How long do you generally have to wait before starting/re-starting progesterone pill after childbirth?
6 weeks afterwards
What is the main cause of post-natal/post-partum haemorrhage? What are other causes?
Uterine atony
Four Ts: tone
trauma
tissue/infection
thrombin
How can uterine atony be treated medically?
Uterotonics:
Syntoncinon = synthetic oxytocin (bolus 5 units IV, followed by infusion)
Syntometrine (3rd stage management): combo of oxytocin 5 units and ergometrine 500mcg
(IM bolus)
Misoprostol - prostaglandin 800mcg PR
Haemabate 250mcg IM
What ABX are safe to give a pregnant woman with RTI?
Penicillins
Marcolides
What ABX are safe to give a pregnant woman with PPROM?
Erythromycin 250mg QDS PO 10/7 to prevent chorioamnionitis
What ABX would you give a woman with chorionamionitis?
Cefuroxime 1.5g TDS IV AND Metronidazole 500mg TDS IV
What ABX would you prescribe a woman with endometritis?
Co-amoxiclav 1.3g iv tds
Clindamycin + Metronidazole if penicillin allergic
What antihypertensives would you prescribe a pregnant woman?
Labetalol - beta blocker (contraindicated in asthma).
Nifedipine - calcium channel blocker (good in black/africa/carribean patients)
Why should you NOT use ACEi or ARBs in pregnancy?
fetal renal damage in 2nd and 3rd trimester
possible malformation in 1st trimester
What anticonvulsant is first line in eclampsia?
MgSO4 iv
What are first line anti-epileptics for pregnant women?
Lamotrogine
Levieracetam
Why shouldn’t valproate be used in pregnancy for epilepsy?
Associated with neural tube and development defects
What dose of folic acid should be given to pregnant women with epilepsy (or those trying to conceive)? Why?
5mg folic acid
Neural tube defect reduction
What is puerperium?
6 week period following birth
changes that occurred during pregnancy and childbirth revert to non-pregnant state
What are some maternal physiological changes that occur during puerperium?
Involution (funds below umbilicus immediately - no longer palpable 2/52)
Lochia - blood + necrotic decidua
Lactation - due to raised prolactin and oxytocin levels
If a woman has a Hb of 80-100g/l after childbirth, how would you treat this?
oral iron
If a woman has a Hb of <80g/l and is symptomatic after childbirth, how would you treat this?
blood transfusion
If a woman has a Hb that is not low enough to warrant transfusion, but is symptomatic, how would you treat this?
IV iron
When does endometritis generally present after birth?
day 2-10
When is endometritis more common?
After section
How does endometritis present?
Offensive vaginal loss
Fever, malaise, rigors, headache
Tachycardia
abdo pain, suprapubic tenderness/uterine enlargement
offensive lochia
secondary PPH
How would you investigate for endometritis?
FBC
CRP
HVS
Blood cultures
NOT USS IN FIRST INSTANCE
What is the most common cause of endometritis?
Group A strep
What are other causes of endometritis?
Staph
Enterococcus
E coli
anaerobes: cocci
How would you treat puerperium endometritis?
Co-amoxiclav
Cefuroxime + metronidazole
What are common sites of infection after birth?
Uterus, vagina etc. Perineum UTI Chest Throat Breast
What are common puerperium breast problems?
Breast engorgement
Mastitis (not always infective, can be due to blocked ducts)
Sore/cracked nipples
How might thromboembolism present?
unilateral calf pain
redness or swelling
SOB or chest pain
How would you investigate a woman in the puerperium for thromboembolism?
Obs
ECG
Leg dopplers
VQ scan/CTPA
How would you manage a woman with thromboembolism during puerperium?
LMWH
Warfarin
What are the different types of post-natal depression?
Baby blues
Postnatal depression (PND)
Puerperal psychosis
What are some PND symptoms?
MOOD CHANGES: FEELING LOW MISERABLE TEARFUL IRRITABLE WITH OTHERS
SLEEP DISTURBANCE
NO ENERGY
POOR APPETITE
ANXIETY
PANIC ATTACKS
FEELING WORTHLESS
UNABLE TO COPE
SUICIDAL THOUGHTS
HARMFUL THOUGHTS possibly to baby
What post-natal care is given to women?
Maternal observations
Pain relief
Observe lochia and involution
Observe wounds - perineal and LSCS
Ensure passing urine, eating, drinking, stool, flatus
VTE assessment, VTE prevention advice
HB check
Rubella vaccination
Anti-D
Early neonatal feeding/neonatal care
