Puerperal presentations

Question 1

Describe the physiological changes that occur when breastfeeding initiates [3]

Answer 1

Progesterone, oestrogen, prolactin, growth hormone and adrenal steroids cause hypertrophy in pre-existing alveolar-lobular structures in the breast. There is also formation of new alveolae by budding from the milk ducts, with proliferation of milk-collecting ducts.

Although there are high levels of lactogenic hormones (prolactin and placental lactogen) in pregnancy, only minimal amounts of milk are formed, because estrogen and progesterone inhibit their effects.

Prolactin is released by the action of suckling at a nipple

Question 2

Describe some common presentations that occur post-birth [6]

Answer 2

Perineal recovery – including breakdown
Recovery post caesarean section
Post-partum anaemia
Haemorrhoids
Sex and dyspareunia
Pelvic Girdle Pain
Urinary Incontinence
Nightsweats
Hair loss

Question 3

What is the definition of puerperal pyrexia/Infection? [1]

Answer 3

Presence of fever >38°C in a woman in the first 14 days after giving birth

Question 4

What are the genital [2] and non-genital causes [5] of genital infection

Answer 4

Genital:
- Endometritis
- Perineal wound infection

Non-genital:
- Abdominal wound infection
- UTI
- Resp complications
- Breast infections
- Thrombophlebitis

NB: Sepsis is the 2nd most direct cause of death after thrombosis

Question 5

Name predisposing factors for endometritis [5]

Answer 5

• Caesarean section
• Prolonged prelabour rupture of membranes
• Intrapartum chorioamnionitis
• Prolonged labour
• Multiple pelvic examinations
• Other risk factors, e.g. anaemia, low socio-economic status

Question 6

What are the signs and symptoms of endometritis? [4]

Answer 6

Signs and symptoms
* Fever usually in proportion to the extent of infection
* Foul smelling, profuse, and bloody discharge
* Subinvolution of uterus
* Tender bulky uterus on abdominal examination

Question 7

What are potential causes of UTI after birth? [4]

What are most common organsims? [3]

What are most common symptoms? [3]

Answer 7

Causes:
* Hypotonic bladder may result in stasis and reflux of urine
* Catheterization, birth trauma, pelvic examinations during labour

Presenting symptoms:
- increased frequency of micturition, dysuria, or urgency

Most common organisms involved:
- E. coli, Proteus , and Klebsiella

Question 8

What are common respiratory complications post birth? [3]

Answer 8

• Complications due to atelectasis, aspiration, and/or bacterial pneumonia.

Question 9

What is the management for post-partum infection for sepsis with undefined source? [3]

Answer 9

1. Cefuroxime and Metrondizole (add amakacin if w septic shock)

Question 10

What is the management for post-partum abdominal-pelvic infection (including endometritis)?

Answer 10

1. Co-amoxclav
2. Cefuroxime and Metrondizole (add amakacin if w septic shock)

Question 11

What is the management for Caesarean Wound Infection and Perineal Wound Infection?
- If mild / superficial cellulitis [1]
- If moderate to severe [1]

Answer 11

If mild / superficial cellulitis:
- Flucoxacillin

If moderate to severe:
- co-amox

Question 12

Secondary postpartum haemorrhage:
Any ‘abnormal’ bleeding occurring 24h to 6wks postnatally

The two most common causes are: [2]

Answer 12

Retained products of conception (RPOC)
Infection (endometritis)

Question 13

What are the red flag symptoms for sepsis in community for post-partum period?

Answer 13

• Pyrexia >38°C
• Sustained tachycardia (more than 90 bpm)
• Breathlessness (respiratory rate >20 breaths per minute - a serious symptom)
• Abdominal or chest pain
• Diarrhoea and/or vomiting
• Uterine or renal angle pain and tenderness
• Woman is generally unwell or seems unduly anxious/distressed

Question 14

What is the leading cause of death of post-partum period? [1]

Answer 14

VTE