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Obs & Gynae > The Puerperium > Flashcards

The Puerperium Flashcards

1
Q

What is the puerperium?

A

the time from delivery to 6 weeks / 42 days!

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1
Q
A
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2
Q

What changes occur in the puerperium?

A

multifactorial changes:

  • Bio
    • physical
    • endocrine
    • immunological
  • psychological
  • social
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3
Q

Why is the peuerperium important?

A
  • “a woman is most likely to die after her baby is born”
    • –>! its the leading cause of maternal death in the UK
      • Haemorrhage
      • VTE
      • sepsis
      • pre-eclasampsia/eclampsia
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4
Q

What do midwives do for postnatal care?

A

You get 10 days of midwifery care once home:

  • can be every day if needed
    1. to facilitate and reassure normality for mother and baby
      • including bonding and establishing feeding
    2. identify, investigate and manage abnormality
    3. consideration during lactation
      • e.g. prescribing
      • & provide contraceptive advice, if not breastfeeding - have only 30 days until next ovulation!
        • if breastfeeding full time for <6 months contraception isnt needed
    4. make plans for next time
    5. GET DOING PELVIC FLOOD EXERCISES
      • –> PREVENT INCONTINENCE + PROLAPSE
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5
Q

in the puerperium what are the reversal of changes that happen to the placental hormones?

A

they fall very quickly

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6
Q

in the puerperium what are the reversal of changes that happen to the uterus?

A

Uterine involution: –> back in pelvis by 10d

  1. autolysis
    • (the destruction of cells or tissues by their own enzymes),
  2. bleeding stops
    • (can bleed for entire 6wks however),
  3. resumption of menstruation
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7
Q

in the puerperium what are the reversal of changes that happen to the CVS?

A
  • CO
  • TPR
  • BP

back to normal by 2wks (14d)

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8
Q

in the puerperium, what are the reversal of changes that happen to coagulation?

A
  • fibrinolysis normal within 30mins;
  • pro-coagulant state remains however
    • (clotting factors increased)
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9
Q

in the puerperium, what are the reversal of changes that happen to metabolism?

A

insulin resistance goes immediately

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10
Q

What is lochia?

A
  • Lochia is the vaginal discharge after giving birth, containing blood, mucus, and uterine tissue
  • comprised of blood & necrotic decidua
  • if continues after 6wks this do an USS
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11
Q

What are the hormonal changes after delivery regarding breast development and the actions that cause these?

A

breasts contain glandular tissue and supporting stroma

  • there is a post-delivery drop in E2
  • whcich allows active prolactin to stimulate milk production

Suckling is the action that causes prolactin secretion

  • –> milk secretion in glandular cells
  • –> milk ejection reflex
  • –> oxytocin secretion
  • –> aids milk ejection reflex
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12
Q

What are the milk types expected after delivery and at what amount of days?

A
  • Within the 1st 48 hours = colostrum
  • @ day 3-4: milk
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13
Q

What is the difference between colostrum produced w/i 48h and milk produced on day 3-4?

A

Colostrum contains:

  • IgA, lysosyme/macrophages e.g. immune stuff
  • and is moderatre CHO/fat

Milk contains:

  • increased CHO/fat and
  • contains lactose and lactalbumin (milk protein) / casein (slow digesting dairy protein)
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14
Q

What are the pros of breastfeeding?

A

Pro

  1. easy / free / convenient
  2. promotes bonding
  3. reduces atopy
  4. reduces infections especially GI
  5. reduces breast cancer
  6. contraceptive
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15
Q

What are the cons of breastfeeding?

A

cons:

  • not easy / convenient
  • embarassing
  • painful
  • drugs pass through e.g. anti-thyroid
  • perinatal infection e.g. HIV
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16
Q

What lactation abormalities can happen?

A
  • failure of lactation (rare)
  • blood-stained nipple discharge of pregnancy
  • cracked nipples and pain (common)
  • galactocele - sterile milk filled retention cyst
  • acute mastitis
  • breast abscess
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17
Q

What is the presentation of blood-stained nipple discharge of pregnancy?

A

RF: late pregnancy, early breastfeeding

  • typically bilateral
  • due to epithelial proliferation
  • lasts up to 1w
  • is self limiting! = reassure
18
Q

A new mother presents with cracked nipples and pain (this is common) what do you recommend?

A
  • Pain usually settles spontaneously
  • Rx: cracked nipples give local Abx
  • Analgesia
  • cracked nipple gives increased risk of
    • Thrush
    • acute mastitis -> breast abscess
  • TF rest the nipple
19
Q

What is a galactocele and its rx?

A
  • sterile milk-filled retention cyst
  • resolved spontaneously assisted by massage
  • can aspirate or remove surgically
20
Q

a new mother presents to the GP with a painlful, red, hot breast and has a fever.

How do you manage this condition?

A

this is acute mastitis

  • RF: following on from cracked nipple
  • likely infection with S.aureus

Rx: maintain feeding/expressing,

  • give abx - flucloxacillin
21
Q

if actue mastitis remains untreated what can it lead to?

A

can lead to breast abscess

this is the same management of acute mastitis e.g. maintain feeding/expressing but give Abx flucloxacillin

EXCEPT DO INCISION & DRAINAGE of the breast abcess first

22
Q

Is it possible to have eclampsia once the placenta has gone e.g. after labour/delivery?

A

Yes!

50% of eclampsia fits are postnatally!

the puerperium is also the highest risk time for fluid overload

23
Q

Given the high postnatal risk of eclampsia and fluid overload, how do you maintain a new mothers BP and to what levels?

A
  • labetolol or
  • slow release nifedipine
  • to control HTN aiming for BP <150/100, may need HDU
  • often needed for 1-2 wks postnatally
  • do home BP monitoring every 2 days
  • halve the dose of labetolol/SR nifedipine when BP is <140/90
  • if still needing the drug Rx of HTN at 6 weeks postnatally –> specialist assessment needed
24
Q

A new mother has a waddling gait when walking and is experiencing pain, O/E pain is over the pubic region and an interpubic gap is palpable.

What is the rx for this condition?

A

This is

symphysis pubic diastasis

(e.g. spontaneous separation of symphysis pubic –> happens in 1/800 vaginal deliveries)

Rx:

  1. bed rest,
  2. pelvic corset => support and stability
  3. anti-inflammatory agents,
  4. and physiotherapy
25
Q

What are the RF/associations with causing synphysis pubis diastasis?

A

Associations:

  • Forceps,
  • rapid 2nd stage of labour
  • or severe abduction of thighs during delivery
26
Q

WHAT is the biggest cause of meternal mortality and when is this risk highest?

A
  • PE is the biggest cause of maternal mortality
    • [NB Pregnancy-induced hypercoagulability is probably a physiologically adaptive mechanism to prevent post partum hemorrhage]
  • highest risk = 10-14 days post-delivery (e.g. ~2wks)
27
Q

What prophylactic measures do we give post-partum women (new mothers) regading VTE/PE?

A
  1. TED stockings,
  2. LMWH,
  3. early mobilisation,
  4. adequate hydration,
  5. education
28
Q

What is the Rx for post-partum VTE/PE?

A
  • formal anti-coagulation
  • with heparin & warfarin
29
Q

What factors/thresholds indicate significant puerperal pyrexia?

A
  • Temp >38c
  • on any 2 of the first 10 days post-partum (excluding the first 24 hours);
  • pyrexia + tachycardia warrants investigation

NB: Have high index of suspicion for wound infection in C-section patients

30
Q

What are the common causes for significant puerperal pyrexia?

(2 x >38o w/i 10d postpartum, exluding 1st 24h)

A

commonly

  1. infective or
  2. VTE (can cause fever)

examine from head to toe

e.g. as can be multiple possible infective causes endometritis, peritonitis, uti, wound infection, RTI, mastitis, epidural sites

31
Q

When looking for a cause of puerperal pyrexia what should be considered at each of the following sites in the head to toe examination?

  • genital tract
  • pelvis
  • UTI
  • wound
  • respiratory
  • breast
  • other
A

Genital tract - endometritis/perneum

Pelvis - peritonitis (ascending infection)

UTI - especially if catheterised

Wound - perineum or CS scar

Respiratory - especially GA

Breast - mastitis/abscess

Other - venflon sites, epidural sites, concurrent infection e.g. flu

32
Q

What is the most likely infective site post-partum causing puerperal pyrexia and how do you Rx it?

A

endometritis is most likely (endometrial inflammation)

Do the sepsis 6 & broad spectrum antibiotcs

33
Q

What are the chest complicatinos assoc. with puerperium?

A
  • atelectasis (partial collapse or incomplete lung inflation)

or following GA –>

  • aspiration pneumonia (mendelsons syndrome)
34
Q

What is Mendelsons syndrome (of aspiration pneumonia)?

A

a chemical/aspiration pneumonitis caused by aspiration (gastric juices, blood, bile, water) during anaesthesia - esp. during pregnancy

Sy are post GA…

  • spiking temp
  • wheezing
  • SOB!
35
Q

A post-partum woman is presenting with cough, purulent sputum and SOB. What investigations and managment should be done?

A

?pneumonia

TF investigate w/

  • sputum MC&S
  • CXR

manage:

  • physiotherapy
  • abx
36
Q

A post-partum woman is presenting with sore throat, cervical lymphadenopathy. What investigations and managment should be done?

A

?tonsilitis

Ix: throat swab

Rx: abx

37
Q

A post-partum woman is presenting with headaches, neck stiffness & had an epidural/spinal during delivery.

What investigations and managment should be done?

A

?meningitis

Ix: lumbar puncture

Rx: abx

38
Q

A post-partum woman is presenting with dysuria, loin pain and loin tenderness.

What investigations and managment should be done?

A

?pyelonephritis

Ix: urine MC&S

Rx: abx and increased fluid intake

39
Q

A post-partum woman is presenting with a secondary PPH, she has a tender, bulky uterus.

What investigations and managment should be done?

A

?endometritis or retained placental tissue

Ix: clinical diagnosis +/- pelvic USS

Rx: abx and/or uterine evacuation

40
Q

A post-partum woman is presenting with pelvic pain/tenderness or calf pain/tenderness.

What investigations and managment should be done?

A

?DVT

Ix: doppler/venogram of veins

Rx: heparin

41
Q

A post-partum woman is presenting with chest pain and dyspnoea.

What investigations and managment should be done?

A

?PE

Ix: CXR, ABG, V/Q perfusion scan [?not CTPA?(IDK maybe do that)], angiogram

Rx: heparin

42
Q

A post-partum woman is presenting witha painful engorged breast.

What investigations and managment should be done?

A

?mastitis or breast abscess

Ix: clinical exam, MC&S of expressed milk

Rx: express milk, abx, incision and drainage

Obs & Gynae (5 decks)

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