Puerperium

Question 1

Which antidepressant to consider if needed while breastfeeding?

Answer 1

paroxetine

Question 2

What is normal lochia like?

Answer 2

lochia rubra (red) for 3 days
lochia serosa (yellow) for next 10 days
lochia alba (white) for 4-6 weeks

Question 3

What to rule out in postnatal psychosis?

Answer 3

puerperal infection causing delirium

Question 4

What is pueperal pyrexia?

Answer 4

temperature >38 in first 14 days after delivery or miscarriage

Question 5

Management of endometritis

Answer 5

• urgent IV Abx (clindamycin + gentamycin)

- admit until afebrile for >24h

Question 6

Effectiveness of lactational amenorrhoea as contraception

Answer 6

98% effective in women who are:

1. fully breastfeeding, day and night (baby’s sole nutrient)
2. and are <6 months postpartum
3. and amenorrhoeic

Question 7

When can IUS/IUD be inserted postpartum?

Answer 7

either within first 48h or delayed until 4 weeks (due to risk of uterine perforation at insertion)

Question 8

Management of mastitis

Answer 8

• flucloxacillin PO for 7 days
• ibuprofen
• continue breastfeeding, or if too painful, express the milk
• consider checking breastfeeding technique

Question 9

Ix of ?DVT in pregnancy

Answer 9

compression or duplex US of deep veins

if -ve but still suspicious, commence treatment and repeat imaging in 1 week

Question 10

Ix of ?PE in pregnancy

Answer 10

ECG and CXR

CXR normal: compression/duplex US of deep veins

• if +ve and chest Sx: presume PE
• if -ve: V/Q lung scan

CXR abnormal: advice from radiology RE imaging

Question 11

D dimer in pregnancy

Answer 11

• not that helpful as commonly raised due to coagulation changes
• but if they are taken and are negative, low level suggests no VTE

Question 12

Management of VTE in pregnancy

Answer 12

• start Mx as soon as clinical suspicion of VTE, only stop once ruled out
• LMWH: enoxaparin or dalteparin bd
• refer to haematology for F/U
• continue anticoagulation for 6 months, or 6 weeks post partum
• consider switching to warfarin post-delivery (safe in breastfeeding)
• in next pregnancy: thromboprophylaxis throughout and for 6 weeks postpartum

Question 13

Thromboprophylaxis management in labour

Answer 13

• avoid regional anaesthesia until at least 12h after last dose of prophylactic LMWH, and 24h after last dose of therapeutic LMWH
• wait >4h after epidural catheter removed until next dose
• if high risk on stopping anticoagulation: consider unfractionated heparin or IVC filter