Puerperium Flashcards
What is puerperium?
period between delivery and 42d after birth
constitutes multifactorial changes to maternal body
Why is puerperium important?
biggest causes of maternal death fall within this period:
- sepsis
- VTE
- pre-eclampsia/eclampsia
- haemorrhage
What is the most common direct cause of maternal death from pregnancy?
VTE
What is the major cause of indirect maternal death?
cardiovascular disease (from ageing and other co-morbidities)
What are the main reasons for patient complains in postnatal care?
- understaffed
- poor staff attitude/lack of interest
- lack of info/access to care
What is the purpose of post-natal care?
- 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
What are the immediate hormonal changes postnatally?
placental hormones fall very quickly: E2, P, hPL, cortisol
- uterine involution
- CVS changes
- coagulation changes
- metabolic changes
What does UTERINE INVOLUTION postnatally involve?
- autolysis by D10
- postnatal bleeding (lochia) stops
- menstruation is resumed as HPO axis in reinstated
What CVS CHANGES occur postnatally for the mother?
- CO reduces to normal
- TPR increases to normal
- BP returns to normal baseline
normalised by 2wks postnatally
What is LOCHIA?
- vaginal discharge after birth
- contains blood, mucus and uterine tissue
- typically continues for 4-6 wks after childbirth
What COAGULATION changes occur postnatally for the mother?
- fibrinolysis back to normal within 30’
- pro-coagulant state remains (due to increases clotting factors increased)
What METABOLIC changes occur postnatally for the mother?
- INS resistance goes immediately
How is lactation promoted in the mother postnatally?
Breast development: E2, P, hPL, PRL
Development of:
- Glandular tissue
- supporting stroma
Pre-labour: high E2 inhibits PRL activity
What hormonal changes promote lactation POST-DELIVERY?
- reduced E2 = no PRL inhibition
- increased PRL activity -> mild secretion in glandular cells
- suckling: oxytocin release -> milk ejection reflex
What is colostrum?
- produced in the first 48h after birth
Contains:
- IgA (provides neonatal immunity for neonatal period)
- lysozyme and macrophages
- moderate carb, fat and protein content
When does milk production in the mother occur?
- milk comes in ~3-4d after birth
Milk contains:
- increased carb, fat and protein content
- lactose
- lactalbumin/casein
What is the function of lactalbumin in breast milk?
- important role in milk production
- produced in the epithelia of mammary glands
- helps to convert maternal glucose -> lactose (via lactose synthase)
What are the PROS of breast feeding?
- easy, free and convenient
- promotes bonding
- reduced atopy
- reduced infections (esp. GI tract)
- reduced breast Ca
- mild contraceptive
- promotes weight loss
What are the CONS of breastfeeding?
- 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
What lactational problems may occur?
- failure of lactation RARE
- cracked nipples and pain COMMON
- acute mastitis (usually after cracked nipple)
- Breast abscess (complication of untreated mastitis)
What is acute mastitis?
- 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
How is a breast abscess managed?
- maintain feeding/expressing if possible
- flucloxacillin
- may need incision and drainage (I+D)
What are the puerperal abnormalities?
- haemorrhagic (PPH)
- VTE
- lactational
- puerperal pyrexia
- psychological
What is postpartum haemorrhage?
= 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
What are the main causes of SECONDARY PPH?
retained placental products + subsequent infection
What is the maternal morbidity caused by PPH?
- anaemia
- trauma
What are the main causes of PRIMARY PPH?
4 T’s, Mx in brackets
- TONE (treat cause)
- TISSUE (replace volume)
- TRAUMA (replace O2 carrying capacity + fluid rescus.)
- THROMBIN (replace clotting factors
What is the main cause of ‘impaired tone’ in primary PPH?
uterine atony: muscles fail to contract after birth and reduction in placental hormones
resulting in haemorrhage
What is the risk of PPH caused by thrombin abnormalities?
DIC= disseminated intravascular coagulopathy
caused by spontaneous loss of clotting factors due to increased bleeding and loss of balance in clotting cascade/fibrinolysis
What is the management of secondary PPH?
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)
Why is VTE a major health concern for maternal mortality?
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
What are the main risk factors for VTE in postnatal period?
- obesity
- older age
- intercurrent illness e.g. infection
- immobility
- LSCS
- FHx of VTE
- known thrombophilia
What prophylaxis can be used for puerperal VTE?
- TED stockings
- subcut heparin
- early mobilisation
- adequate hydration
- Education
What is the management for puerperal VTE?
formal anticoagulation
heparin and warfarin
What is puerperal pyrexia?
- multiple causes
- most common is infective
- need to examine women head to toe
- and consider what is most likely
What are the common infective causes of puerperal pyrexia?
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
What are the non-infective causes of puerperal pyrexia?
- physiological (first 24-48hr, <38C)
- VTE
- always check legs/chest for DVT/PE
What is the sepsis 6 protocol?
3in, 3out
3in: fluids, oxygen, Abx
3out: urine, blood cultures, lactate
What are the main types of puerperal psychological disorders?
- baby blues
- postnatal depression (PND)
- puerperal psychosis
[considerable overlap]
What are the ‘Baby Blues’?
- very common (60-70%)
- occurs in first 3-4d
- weepy, labile and helpless
- support and reassurance needed for most
- short-lived and self-limiting
What is ‘postnatal depression (PND)?’
- 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
What are the risk factors for puerperal psychological disorders?
- 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
What is the main Mx for puerperal psychological disorders?
- support and counselling
- anti-depressants
- hospitalisation
What is puerperal psychosis?
- rare but severe
- occurs in first 2 wks
- severe psychotic episodes
- delusions and hallucinations
- bipolar is a major risk factor
- serious suicide/infanticide risk
What is the Mx for puerperal psychosis?
URGENT PSYCH HELP
- mother-baby units
- usually self limiting with good outcome
