Puerperium and Lactation Flashcards by Denisse Tiangco

Going back to pregnant state

Involution

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Reappearance of rugae in birth canal

3rd week

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Vaginal epithelium proliferates in

4-6 weeks postpartum

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Uterus puerperi changes

Calibers of vessels become smaller
External os lacerated
Opening readily admits 2 fingers

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Cervix forms at end of

2 weeks

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Postpartum, the uterus can be palpated readily just

slightly below the umbilicus

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The myometrium deconstructs (goes back to normal nonpregnant state) after

2 days

Heavy immediatelty post partum
1 week pp - 500
2 weeks pp - 300
4 weeks pp - 100

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Not sloughed off because not reactive to hormones so the basalis now divides itself into

Superficial - necrotic

Basal - intact and source of new endometrium

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Endometrium is not adherent to the entire cavity, only one point in the endometrial cavitt wherein placenta is attached.

All other parts wherein the placenta was not attached will involute or go back rapidly except

on placental side

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Afterpains

Pimirparous - tonically contracted
Multiparous - contracts vigorously at intervals (worsens as baby sucks)

Pain should be decreased by the 3rd day (if there ks pain after 3rd day, you have to reassess)

Persistent pain - after 3rd day; infection

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Decidua sloughing off

Erythrocytes, shredded decidua, epithelial cells, bacterial

Duration?

Lochia

24-36 days

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Lochia in first few days

Rubra

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Lochia in 3-4 days

Serosa

pale

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Lochia white or yellow white, 10th day

Mixture of leukocytes and reduced fluid content

Alba

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Placental site involution

6 weeks to complete extrusion
After delivery, palm sized

end of 2nd week - 3-4cm in size

Duration: 24-36 days

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Placental site regenerates by a new endometrial proliferation

There is sloughing off of infarcted and necrotic tissue followed by remodelling

Exoliation

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Proper timing of placental involution does not happen

Subinvolution

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Signs of subinvolution

Prolonged lochia
Excessive uterine bleeding
Uterus Larger and softer than usual

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Subinvolution Tx

Ergonovine/Methylergonovine

Azithromycin/Doxycycline

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Late postpartum hemorrhage

1 day-12 weeks after delivery

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Retained products of conception Dx

UTZ

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Most common cause of late postpartum hemorrhage

Retained products of conception

Tx: Suction curettage

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Urinary tract puerperium

1 day postpartum - hyperfiltration (inc urination)
2 weeks - urinary tract returns to its non-pregnant state
2-8 weeks - dilated ureters return to non-pregnant state

The degree of bladder trauma depends on length of labor: atony, fluids or urine cannot be expelled

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Muscles of rectus abdominis become atonic

Separation of rectus abdominis muscle this much

Diastasis recti

>2.7 cm

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Hematologic changes puerperium

H and H fluctuate Increased plasma fibrinogen in first week Increased sedimentation rate

Pregnancy induced hypervolemia returns to nonpregnant state in

1 week

Cardiac output remains elevated 1-2 days post partum and in the non pregnant state after

10 days

Increased CO puerperially may induce

cardiomyopathy

Systemic vascular changes puerperium

Rise to nonpregnant levels

Increased ECF Na and H20 postpartum lead to

Postpartum diuresis Weight loss of 2-3kg max at 2nd week Surplus weight gain 1.4kg cannot be removed

Puerperal Fever Causes

Fever of 38 or higher Breast engorgement - less in patients who breast feed Urinary tract infection - uncommon due to diuresis, acute pyelonephritis, fever with atelectasis Perineal lacerations Episiotomy Respiratory complications after CS

Most persistent post-partum fever

Genital tract infections of uterus Endometritis, endomyometritis, endoparametritis

Single significant risk factor of uterine infection

Route of delivery | Less in vaginal

Bacteria responsible for Female Genital Infections

``` Aerobes G+ (strep A,B,D) Enterococcus, Staph aureus, Staph epidermidis G- (E coli, Klebsiella, Proteus) Gram variable - Gardnerella ``` Mycoplasma, Chlamydia, Neisseria Anaerobes (Peptostreptococcus, peptococcus) Clostridium, Bacteroides, Fusobacterium, Mobiluncus

Most important criterion of uterine infection

Fever Chills - endotoxemia Abdominal pain Leukocytosis - 15,000-30,000 Vaginal discharge - Foul smelling

Puerperal Infection Tx

Ampicillin + Gentamycin

Perioperative prophylaxis for CS

Single dose Ampicillin or | 1st Gen Cephalosporin

Pelvic infection Post CS Tx Gold standard

Clindamycin + Gentamycin

Separation of fascial layer Occurs on 5th postop day Accompanied by serosanguinous discharge along with abdominal organs

Wound dehiscence If no separation of fascial layer, SSI

Monomicrobial Nec Fasciatis causative agent

GABHS

Parametrial cellulitis following Cesarean delivery and leaves behind a fibrous formation in leaves of the broad ligament Fever persistence >3 days despite IV antimicrobials

Parametrial phlegmon

Septic phlebitis arises from venous routes and may cause thrombosis

Both ovarian venous plexus

Acute febrile illness with associated headache, menta confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, water diarrea, marked hemoconcentration Follows in rapid sequence: renal failure, hepatic failure, disseminated intravascular coagulation, and circulatory collapse

Toxic Shock Syndrome During recovery, rash undergoes desquamation

Most common organism that causes Toxic Shoch Syndrome

Staph areus with exotoxin TSST-1

Small amount of TSST-1 activates 5-30% T cells causing

cytokine storm

Colostrum secretion is from

5 days to 2 weeks Converts to mature milk by 4-6 weeks Mature milk: fat, protein, carbohydrates, minerals, vitamins and hormones Rich in immunologic component More globulins Less sugar and fat

A nursing mother produces milk daily

600 mL

Milk proteins

L lactalbumin B lactoglobulin Casein

Breastmilk contains most vitamins except

``` Vit K Vit D (low 22) ```

Milk serum containing large amounts kf IL-6 Whey:Casein Ratio

Whey 60:40

Not destroyed by gastric acid | Promote growth and maturation of NB intestinal mucosa

Epidermal growth factor

Endocrinology of Lactation

Delivery Decreased progesterone and estrogen Loss of inhibitory influence of progesterone to L-lactalbumin Stimulates lactose synthesis to inc milk lactose Unopposed prolactin stimulation to L-lactalbumin Serotonin secretion to maintain milk production

SSRI SE in breastfeeding

Decreased milk production due to inhibition to serotonin

Hypopituitarism from pituitary ischemia and necrosis secondary to obstetric blood loss Persistent hypotension, tachycardia, hypoglycemia and lactation failure Ave time to diagnosis: 13 years

Sheehan syndrome

Most life threatening complication of Sheehan

Adrenal insufficiency

Latching

Baby mouth wide open Baby chin touches the breast Baby lower lip curled outward Lower portion of the areola is not visible

Hep B

Breastfeeding not contraindicated if Hep B IgG given

Drugs taken multiple dose should be taken after

closest feed

Drugs taken single dose

Just before the longest infant sleep interval (at bedtime)

Absolute CI in breastfeeding

Cyototoxic drugs Inc risk of childhood cancer Cyclophosphamide, cyclosporine, doxorubicin, methotrexate, mycophenolate

Withholding initiation of progestin-containing contraception in the immediate postpartum because progesterone withdrawal is integral to which process?

Breast milk production

Best contraception for breastfeeding mothers?

Progestin

May only be given at least 6 weeks postpartum

DMPA | Combined progesterone and estrogen pills

The major cause of neonatal deaths?

Prematurity

How many newborn deaths occur in first week of life?

75%

Several tags of tissue representing the hymen

Myrtiform caruncle

Most common cause of maternal mastitis

Infant’s nose and throat

Women not breastfeeding usually menstruate within

6-8 weeks

In breastfeeding there is delayed ovulation and menstruation resumes

2-18 months postpartum

For LAM to work,

The baby must be under 6 months Woman must not have had a period Baby must be exclusively breastfed at least every 4 hours at day and every 6 hours at night

For breastfeeding women, these may be initiated any time during puerperium because they do not affect quality or quantity of milk

Progestin-only Depot Medroxyprogesterone Progestin implant

Estrogen-progestin effect on quantity of breast milk

Reduced Withheld until first 4 weeks because of higher thromboembolic risk