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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
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?
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
What are the RF/associations with causing synphysis pubis diastasis?
Associations: * Forceps, * rapid 2nd stage of labour * or severe abduction of thighs during delivery
26
WHAT is the biggest cause of meternal mortality and when is this risk highest?
* **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
What prophylactic measures do we give post-partum women (new mothers) regading VTE/PE?
1. TED stockings, 2. LMWH, 3. early mobilisation, 4. adequate hydration, 5. education
28
What is the Rx for post-partum VTE/PE?
* formal anti-coagulation * with heparin & warfarin
29
What factors/thresholds indicate significant puerperal pyrexia?
* **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
What are the common causes for significant puerperal pyrexia? (2 x \>38o w/i 10d postpartum, exluding 1st 24h)
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
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
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
What is the most likely infective site post-partum causing puerperal pyrexia and how do you Rx it?
endometritis is most likely (endometrial inflammation) Do the sepsis 6 & broad spectrum antibiotcs
33
What are the chest complicatinos assoc. with puerperium?
* atelectasis (partial collapse or incomplete lung inflation) or following GA --\> * aspiration pneumonia (mendelsons syndrome)
34
What is Mendelsons syndrome (of aspiration pneumonia)?
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
A post-partum woman is presenting with cough, purulent sputum and SOB. What investigations and managment should be done?
?pneumonia TF investigate w/ * sputum MC&S * CXR manage: * physiotherapy * abx
36
A post-partum woman is presenting with sore throat, cervical lymphadenopathy. What investigations and managment should be done?
?tonsilitis Ix: throat swab Rx: abx
37
A post-partum woman is presenting with headaches, neck stiffness & had an epidural/spinal during delivery. What investigations and managment should be done?
?meningitis Ix: lumbar puncture Rx: abx
38
A post-partum woman is presenting with dysuria, loin pain and loin tenderness. What investigations and managment should be done?
?pyelonephritis Ix: urine MC&S Rx: abx and increased fluid intake
39
A post-partum woman is presenting with a secondary PPH, she has a tender, bulky uterus. What investigations and managment should be done?
?endometritis or retained placental tissue Ix: clinical diagnosis +/- pelvic USS Rx: abx and/or uterine evacuation
40
A post-partum woman is presenting with pelvic pain/tenderness or calf pain/tenderness. What investigations and managment should be done?
?DVT Ix: doppler/venogram of veins Rx: heparin
41
A post-partum woman is presenting with chest pain and dyspnoea. What investigations and managment should be done?
?PE Ix: CXR, ABG, V/Q perfusion scan [?not CTPA?(IDK maybe do that)], angiogram Rx: heparin
42
A post-partum woman is presenting witha painful engorged breast. What investigations and managment should be done?
?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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