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Life Cycle > Puerperium > Flashcards

Puerperium Flashcards

1
Q

What is puerperium?

A

period between delivery and 42d after birth

constitutes multifactorial changes to maternal body

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2
Q

Why is puerperium important?

A

biggest causes of maternal death fall within this period:

  • sepsis
  • VTE
  • pre-eclampsia/eclampsia
  • haemorrhage
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3
Q

What is the most common direct cause of maternal death from pregnancy?

A

VTE

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4
Q

What is the major cause of indirect maternal death?

A

cardiovascular disease (from ageing and other co-morbidities)

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5
Q

What are the main reasons for patient complains in postnatal care?

A
  • understaffed
  • poor staff attitude/lack of interest
  • lack of info/access to care
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6
Q

What is the purpose of post-natal care?

A
  • facilitate normality for mother and baby (bonding and feeding routine)
  • identify, Ix and Mx abnormalities
  • support with lactation: prescribing e.g.
  • contraceptive advice
  • make plans for next pregnancy
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7
Q

What are the immediate hormonal changes postnatally?

A

placental hormones fall very quickly: E2, P, hPL, cortisol

  • uterine involution
  • CVS changes
  • coagulation changes
  • metabolic changes
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8
Q

What does UTERINE INVOLUTION postnatally involve?

A
  • autolysis by D10
  • postnatal bleeding (lochia) stops
  • menstruation is resumed as HPO axis in reinstated
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9
Q

What CVS CHANGES occur postnatally for the mother?

A
  • CO reduces to normal
  • TPR increases to normal
  • BP returns to normal baseline

normalised by 2wks postnatally

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10
Q

What is LOCHIA?

A
  • vaginal discharge after birth
  • contains blood, mucus and uterine tissue
  • typically continues for 4-6 wks after childbirth
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11
Q

What COAGULATION changes occur postnatally for the mother?

A
  • fibrinolysis back to normal within 30’

- pro-coagulant state remains (due to increases clotting factors increased)

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12
Q

What METABOLIC changes occur postnatally for the mother?

A
  • INS resistance goes immediately
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13
Q

How is lactation promoted in the mother postnatally?

A

Breast development: E2, P, hPL, PRL

Development of:

  • Glandular tissue
  • supporting stroma

Pre-labour: high E2 inhibits PRL activity

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14
Q

What hormonal changes promote lactation POST-DELIVERY?

A
  • reduced E2 = no PRL inhibition
  • increased PRL activity -> mild secretion in glandular cells
  • suckling: oxytocin release -> milk ejection reflex
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15
Q

What is colostrum?

A
  • produced in the first 48h after birth

Contains:

  • IgA (provides neonatal immunity for neonatal period)
  • lysozyme and macrophages
  • moderate carb, fat and protein content
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16
Q

When does milk production in the mother occur?

A
  • milk comes in ~3-4d after birth

Milk contains:

  • increased carb, fat and protein content
  • lactose
  • lactalbumin/casein
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17
Q

What is the function of lactalbumin in breast milk?

A
  • important role in milk production
  • produced in the epithelia of mammary glands
  • helps to convert maternal glucose -> lactose (via lactose synthase)
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18
Q

What are the PROS of breast feeding?

A
  • easy, free and convenient
  • promotes bonding
  • reduced atopy
  • reduced infections (esp. GI tract)
  • reduced breast Ca
  • mild contraceptive
  • promotes weight loss
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19
Q

What are the CONS of breastfeeding?

A
  • can be difficult
  • can be inconvenient
  • some may find embarrassing
  • painful
  • transmission of drugs (e.g. anti-thyroid: carbimazole)
  • perinatal infection transmission (e.g. HIV)
  • cannot delegate to someone else
20
Q

What lactational problems may occur?

A
  • failure of lactation RARE
  • cracked nipples and pain COMMON
  • acute mastitis (usually after cracked nipple)
  • Breast abscess (complication of untreated mastitis)
21
Q

What is acute mastitis?

A
  • usually occurs following cracked nipple
  • painful, red, hot breast and fever
  • caused by S. Aureus (skin commensal)
  • Mx: maintain feeding/expressing
  • Mx: Abx usually flucloxacillin
22
Q

How is a breast abscess managed?

A
  • maintain feeding/expressing if possible
  • flucloxacillin
  • may need incision and drainage (I+D)
23
Q

What are the puerperal abnormalities?

A
  • haemorrhagic (PPH)
  • VTE
  • lactational
  • puerperal pyrexia
  • psychological
24
Q

What is postpartum haemorrhage?

A

= blood loss > 500ml from genital tract

5% cases are underestimated

classified into:

  • PRIMARY: first 24h
  • SECONDARY: 24h-42d
  • TERTIARY: >42d

causes significant maternal morbidity and mortality

25
Q

What are the main causes of SECONDARY PPH?

A

retained placental products + subsequent infection

26
Q

What is the maternal morbidity caused by PPH?

A
  • anaemia

- trauma

27
Q

What are the main causes of PRIMARY PPH?

A

4 T’s, Mx in brackets

  • TONE (treat cause)
  • TISSUE (replace volume)
  • TRAUMA (replace O2 carrying capacity + fluid rescus.)
  • THROMBIN (replace clotting factors
28
Q

What is the main cause of ‘impaired tone’ in primary PPH?

A

uterine atony: muscles fail to contract after birth and reduction in placental hormones
resulting in haemorrhage

29
Q

What is the risk of PPH caused by thrombin abnormalities?

A

DIC= disseminated intravascular coagulopathy

caused by spontaneous loss of clotting factors due to increased bleeding and loss of balance in clotting cascade/fibrinolysis

30
Q

What is the management of secondary PPH?

A

cause is usually endometritis and retained products of conception (RPOC)

Presentation: excessive lochia, pain, fever

Mx: Abx, analgesia
if not improvement after 48hr: then evacuation of retained products of conception (ERCP)

31
Q

Why is VTE a major health concern for maternal mortality?

A

MAJOR CAUSE of MATERNAL MORTALITY

Pro-coagulant state continues throughout puerperium

highest risk @ 10-14days

most occur postpartum and there are many risk factors at play

Mx: reduce Virchow’s triad for clot formation

32
Q

What are the main risk factors for VTE in postnatal period?

A
  • obesity
  • older age
  • intercurrent illness e.g. infection
  • immobility
  • LSCS
  • FHx of VTE
  • known thrombophilia
33
Q

What prophylaxis can be used for puerperal VTE?

A
  • TED stockings
  • subcut heparin
  • early mobilisation
  • adequate hydration
  • Education
34
Q

What is the management for puerperal VTE?

A

formal anticoagulation

heparin and warfarin

35
Q

What is puerperal pyrexia?

A
  • multiple causes
  • most common is infective
  • need to examine women head to toe
  • and consider what is most likely
36
Q

What are the common infective causes of puerperal pyrexia?

A

GENITAL TRACT
endometritis/perineum

PELVIS
peritonitis (ascending infection)

UTI
esp. if catheterised

WOUND INFECTION
LSCS operative delivery

RESPIRATORY
esp. from general anaesthetic

BREAST
mastitis/abscess

OTHER
e.g. cannula sites, epidural sites or concurrent infection
Iatrogenic sources

Cause will depend on the type and Mx of delivery the woman has had

37
Q

What are the non-infective causes of puerperal pyrexia?

A
  • physiological (first 24-48hr, <38C)
  • VTE
  • always check legs/chest for DVT/PE
38
Q

What is the sepsis 6 protocol?

A

3in, 3out

3in: fluids, oxygen, Abx
3out: urine, blood cultures, lactate

39
Q

What are the main types of puerperal psychological disorders?

A
  • baby blues
  • postnatal depression (PND)
  • puerperal psychosis

[considerable overlap]

40
Q

What are the ‘Baby Blues’?

A
  • very common (60-70%)
  • occurs in first 3-4d
  • weepy, labile and helpless
  • support and reassurance needed for most
  • short-lived and self-limiting
41
Q

What is ‘postnatal depression (PND)?’

A
  • affects 10% (underestimated)
  • occurs from 4wks onwards
  • spectrum between mild mood disorder -> severe clinical depression
  • most cases have other risk factors e.g. previous PND
42
Q

What are the risk factors for puerperal psychological disorders?

A
  • previous psych history
  • FHx psych disorders
  • previous PND
  • EtOH/drug abuse
  • lack of social and family support
  • poor/no relationship
  • financial concerns
  • poor outcome (maternal/neonatal)
  • ambivalence (mixed feelings) towards pregnancy
43
Q

What is the main Mx for puerperal psychological disorders?

A
  • support and counselling
  • anti-depressants
  • hospitalisation
44
Q

What is puerperal psychosis?

A
  • rare but severe
  • occurs in first 2 wks
  • severe psychotic episodes
  • delusions and hallucinations
  • bipolar is a major risk factor
  • serious suicide/infanticide risk
45
Q

What is the Mx for puerperal psychosis?

A

URGENT PSYCH HELP

  • mother-baby units
  • usually self limiting with good outcome

Life Cycle (29 decks)

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