Puerperium

Question 1

Causes of maternal death

Answer 1

Haemorrhage by far biggest cause (developing countries)
Sepsis
Thromboembolism
Pre-eclampsia / eclampsia
Indirect causes – Heart disease (1st in UK!!)
Suicide

Question 2

what is the puerperium

Answer 2

Time from delivery to 42-days post-natal.

Question 3

changes that occur in the puerperium

Answer 3

PHYSICAL
ENDOCRINE
IMMUNOLOGICAL
PSYCHOLOGICAL
SOCIAL

Question 4

purpose of postnatal care

Answer 4

Facilitate and reassure normality for mother and baby including bonding and establishing feeding
Identify, investigate and manage abnormality
Consideration during lactation e.g. prescribing
Provide contraceptive advice
Make plans for next time!

Question 5

hormonal control of puerperium

Answer 5

E2/P/HPL/cortisol cause:

• reversal of many changes
• uterine involution- autolysis of endometrial lining, back in pelvis by d10, bleeding stops, resumption of menstruation
• CVS changes
• coag changes: fibrinolysis normal within 30mins, pro-coagulant state remains, CF increased
• metabolic changes: IR goes immediately

Question 6

effect of hormones on breast development

Answer 6

development of glandular tissue and supporting stroma

Question 7

what inhibits PRL before delivery

Answer 7

E2

Question 8

what is contained in the colostrum

Answer 8

• Major source IgA (mucosal type Ig)
• Lysosyme / macrophages
• Mod. CHO / FAT (protein)

Question 9

What is contained in breast milk

Answer 9

Incr. CHO / FAT (protein)
Lactose (glu/galactose)
Lactalbumin / Casein

Question 10

pros of breastfeeding

Answer 10

Easy / Free / Convenient
Promotes bonding
Red. Atopy
Red. Infections esp. GI
Red. Breast cancer Contraceptive
Promotes weight loss

Question 11

cons of breastfeeding

Answer 11

Not easy / convenient
Embarrassing
Painful
Drugs pass thru e.g. anti-thyroid
Perinatal infection e.g. HIV
Non delegable!

Question 12

problems with lactation

Answer 12

Failure of lactation - rare

Cracked nipples and pain - common

Acute Mastitis
Usually following cracked nipple
Staph. Aureus
Presentation - pain / red, hot breast / fever

Question 13

Mx of breast feeding problems

Answer 13

Mx - maintain feeding / expressing / antibiotics (flucloxacillin)
Breast abscess
Sequelae of left / untreated mastitis
Mx - as above BUT needs I+D

Question 14

puerperal abnormalities

Answer 14

Haemorrhagic 
Post partum haemorrhage (PPH)
Thrombo-embolic 
Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE)
Lactational
Puerperal pyrexia
Psychological

Question 15

what is a PPH

Answer 15

Blood loss > 500ml from genital tract

Question 16

3 types of PPH

Answer 16

Primary
first 24 hours

Secondary
>24 hours to 42 days

Tertiary
> 42 days

Question 17

causes of primary PPH

Answer 17

uterine atony / RPOC / trauma to gen. tract

Question 18

causes of secondary PPH

Answer 18

endometritis +/- RPOC`

Question 19

presentation of PPH

Answer 19

Excessive lochia / pain / fever

Question 20

Mx of PPH

Answer 20

Antibiotics
Analgesia
If no improvement 48 hrs: ERPC (Evacuation of retained products of conception)

Question 21

basic causes of PPH

Answer 21

tone
tissue
trauma
thrombin

Question 22

basic management of PPH

Answer 22

remedy cause
replace volume
replace O2 carrying capacity
replace CF

Question 23

RFs for VTE

Answer 23

Obesity
Older
Intercurrent illness e.g. infection / PET
Immobility
Operative delivery – CS
Previous VTE
FH VTE
Known thrombophilia

Question 24

prophylaxis of VTE

Answer 24

TED stockings
S/C heparin
early mobilisation
adequate hydration
EDUCATION, EDUCATION, EDUCATION!!

Question 25

management of VTE

Answer 25

Formal anticoagulation (Heparin and Warfarin)
Imaging to confirm (Leg Dopplers / CTPA)

Question 26

common causes of puerperal pyrexia

Answer 26

Genital tract - endometritis / perineum
Pelvis - peritonitis (ascending infection)   
UTI - esp. catheterized
Wound infection - CS
Respiratory - esp. GA
Breast - mastitis / abscess
Other: 
Venflon sites 
Epidural sites
Concurrent infection 

Non-Infective:
Physiological in first 24-48 hours (<380C)
Thrombo-embolism - DVT / PE
ALWAYS check their LEGS and CHEST!