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CFB > WCS20 Puerperium And Related Problems > Flashcards

WCS20 Puerperium And Related Problems Flashcards

1
Q

Puerperium

A

Period during which maternal body returns to non-pregnant state after delivery
- ***6 week period after delivery (of placenta)
- ~70% describe >=1 physical problems within first 12 months postpartum

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2
Q

Normal physiological changes in puerperium

A
  1. Genital tract: **Involution of uterus, **Lochia (vaginal discharge after giving birth, containing blood, mucus, and uterine tissue)
  2. Breasts + Hormones
  3. Perineum, urinary (including pelvic floor and bladder function), bowel
  4. CVS, haematological
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3
Q

Red flag conditions

A
  1. ***Postpartum haemorrhage
    - sudden + profuse blood loss / persistent increased blood loss
    - faintness, dizziness
    - palpitations, tachycardia
  2. Infection
    - fever, shivering, abdominal pain, offensive vaginal loss (fluid loss from the vagina)
  3. ***Pre-eclampsia / Eclampsia
    - headaches with >=1 following symptoms within first 72 hours
    —> visual disturbances
    —> N+V
  4. ***Thromboembolism
    - unilateral calf pain, redness, swelling
    - SOB / chest pain
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4
Q

Involution of uterus

A

***1 Finger breadth per day

**Day 1: Umbilical level
Day 10-14: Not palpable abdominally
**Internal cervical os closed by week 2
***6 weeks: Non-pregnant size

Involution usually faster in breastfeeding

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5
Q

Lochia (惡露)

A

Shedding of ***decidua (uterine lining)
- Decidua parietalis
- Decidua basalis
- Decidua capsularis

Contents:
- Decidua
- Erythrocytes
- WBC
- Epithelial cells
- Bacteria

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6
Q

Clinical appearance of Lochia

A

Day 1-4: Red
Day 4-8: Brown
Day 9 onwards: Serous-like discharge, occasionally brownish spotting

Mean duration:
- **24-36 days (ranging from 2-90 days)
- beyond **6 weeks is unusual (up to 1/3)

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7
Q

Abnormal genital tract physiological changes in puerperium

A
  1. Subinvolution of uterus
  2. Abnormal lochia
    - **Persistent red
    - **    Excessive (aka ***Secondary postpartum haemorrhage)
    - Foul smelling (infection)

—> Signs of Retained products of Gestation (RPOG) / Endometritis

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8
Q

***Management of subinvolution

A

Lochia normal:
- Observe

Lochia foul:
- ***Antibiotics after swabs for culture

Lochia excessive (PPH):
- Condition stable
—> USG no RPOG (products of gestation): Antibiotics
—> USG RPOG: Antibiotics + ***Evacuation of uterus

  • Condition unstable
    —> ***Resuscitation + Antibiotics + Evacuation of uterus
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9
Q

Postpartum haemorrhage

A

Primary
- loss of blood estimated **>500 mL
- from genital tract
- within **24 hours of delivery

Secondary
- poorly defined
- any significant bleeding from genital tract **24 hours after delivery till **6 weeks

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10
Q

Causes of Secondary PPH / Persistent Lochia

A

Common causes:
1. **Retained product of gestation (RPOG)
2. **Infection (Endometritis)
3. **Return of menses (usually return **6 weeks postpartum)
4. **Genital tract tears
5. **Gestational trophoblastic disease, AV malformation (rare)

Rare causes:
1. New pregnancy
2. Coagulopathy
3. Uterine AV malformations
4. Gestational trophoblastic disease
5. Undiagnosed carcinoma of cervix
6. Pseudoaneurysm of uterine artery
7. Hypoestrogenism
8. Dehiscence of Caesarean scar

A temporary increase in bleeding may be ***menses! —> bleeding should stop within a few days

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11
Q

History taking for Secondary PPH / Persistent Lochia

A
  1. Review delivery record for any risk factors for RPOG / Postpartum endometritis
  2. Whether placenta has been sent for histology (to ***rule out Gestational trophoblastic disease)
  3. Any medications that may predispose to uterine bleeding e.g. Chinese herbs, Anticoagulants
  4. Symptoms of uterine ***infection e.g. abdominal pain, fever, foul-smelling vaginal discharge
  5. Any sexual intercourse after delivery and contraception
  6. Latest cervical smear result
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12
Q

Physical examination for Secondary PPH / Persistent Lochia

A
  1. ***Pallor
    - anaemia
  2. ***Abdominal tenderness
    - infection
  3. Cervical lesion / Abnormal vaginal discharge on speculum examination
  4. ***Cervical excitation tenderness
  5. ***Uterine size
  6. ***Cervical os status (open / closed)
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13
Q

Investigations for Secondary PPH / Persistent Lochia

A
  1. CBC
  2. USG for ***RPOG
  3. Urine pregnancy test (take blood for ***hCG if positive)
  4. High vaginal swab / endocervical swab if suspect infection

Flow chart:
6 weeks postpartum
—> Vaginal bleeding in decreasing trend + scanty + normal physical exam
—> Review in 2 weeks
—> Persistent bleeding
—> Investigations
—> Review in 2 weeks

—> Moderate bleeding / Increased bleeding
—> Investigations
—> Review in 2 weeks

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14
Q

Return of ovulation

A

Ovulation suppressed by high prolactin level after delivery
—> ovulation resume after prolactin return to non-pregnant level

  • Seldom occurs before 3 weeks after delivery (unless prolactin release suppressed by drugs)
  • Median time: **6 weeks after delivery in non-breastfeeding women, **Longer in breastfeeding women
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15
Q

Ovulation suppression during lactation

A

Suckling ↑ sensitivity to estrogen feedback
—> ↓ Pulsatile GnRH release
—> ↓ FSH, LH
—> No ovulation

but 10% women have ovulatory cycles while breast feeding

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16
Q

Return of menstruation after delivery

A

2 weeks after ovulation (i.e. 6+2 = 8 weeks)

Non-lactating women
- 1st menstruation ~45-94 days (6.5-13.5 weeks)

Lactating women
- remained amenorrheic (***6 months - 13 months)

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17
Q

Clinical implications of Amenorrhea / Bleeding

A

Bleeding
- Increased vaginal bleeding within 5 weeks of delivery is unlikely to be due to return of menstruation

Amenorrhea
- need not be investigated until 6 months after delivery / weaning in lactating mother

Contraception: needed before return of menstruation (∵ may still have ovulation)

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18
Q

Puerperal pyrexia

A
  • Presence of fever in a mother ***>=38oC in puerperium / first 14 days after giving birth
  • Most common cause of maternal mortality before introduction of antibiotics

Predisposing factors:
Antepartum:
1. Anaemia
2. Long duration of membranes rupture
3. Poorly controlled DM
4. Use of immunosuppressants

Intrapartum:
1. Long duration of labour
2. Instrumentation during labour
3. Trauma (e.g. episiotomy, tears, C/S)
4. Haematoma
5. Bacterial contamination during vaginal examination

Causes (**Genital vs **Non-genital):
Genital:
1. Infection
- **Endometritis
- **RPOG
2. ***Wound infection
- Episiotomy / Caesarean / Drip site

Non-genital:
1. **Breast engorgement / Mastitis / Abscess
2. **Venous thromboembolism
3. **URTI / pneumonia - anaesthesia-related
4. Skin wound infection
5. **UTI
6. GE

Investigations (Aim to identify most likely diagnosis / source of infection):
1. CBC
2. **Blood cultures
3. **MSU
4. **High vaginal + endocervical swab
5. **Wound swabs
6. CXR (for suspected chest infection)
7. USG pelvis (if Endometritis + RPOG suspected)
8. USG doppler of lower limb, CT Pulmonary angiogram (for suspected DVT / PE)

Management:
1. General
- **Analgesics + **Antipyretics
- ***Wound care + dressing (if wound infection)
- NSAID (for breast engorgement)
- Ice pack (for perineal pain / mastitis)
- Watch out for signs of severe sepsis: Tachycardia, Tachypnea, Hypoxia, Hypotension, Oliguria

  1. ***Empirical antibiotic (for infection)
  2. Anticoagulant (LMW heparin) (for venous thromboembolism)
  3. Surgical
    - Suction evacuation for RPOG
    - Drainage of vulvovaginal haematoma
    - Drainage of breast abscess
19
Q

Endometritis (Uterine infection)

A

Predisposing factors:
1. **C-section
2. **Intrapartum chorioamnionitis
3. ***Prolonged labour
4. Multiple pelvic examination during labour
5. Internal fetal monitoring

S/S:
1. Fever
2. **Foul, profuse, bloody discharge
3. **Secondary PPH
4. **Subinvolution of uterus
5. **Tender bulky uterus on abdominal examination

20
Q

Perineal wound infection

A

Infection of episiotomy wound / repaired lacerations

S/S:
1. Painful perineum
2. ***Breakdown of wound

21
Q

Postpartum UTI

A
  • 2-4% women

Causes:
1. Hypotonic bladder from over-distension during labour —> stasis + reflux of urine
2. Catheterisation
3. Birth trauma

S/S:
1. **Frequency
2. **Dysuria
3. ***Urgency
4. Urinary retention

Common organisms:
1. E. coli
2. Proteus
3. Klebsiella

22
Q

Breast engorgement

A
  • Breast become engorged between 2-4th day
  • 15% develop fever from breast engorgement
  • may be as high as ***39oC

S/S:
1. Painful + Hard breast
2. ***NO associated signs of infection (erythema, induration)

Treatment:
- Continue breastfeeding to relieve engorgement

23
Q

Mastitis

A
  • Obstruction of milk drainage from one section of breast
  • May get infected (Staph. aureus)

S/S:
1. Swollen, red, painful area of breast
2. Fever
3. Tachycardia

Treatment:
- Continue to breastfeed to relieve obstruction
- Antibiotics

24
Q

C/S Wound infection

A
  • Incidence ~6%

Risk factors:
1. Obesity
2. DM (esp. poorly controlled)
3. Poor haemostasis at surgery with subsequent haematoma formation

Treatment:
- Routine prophylactic antibiotics for C/S reduce wound infection
—> ***Cefazolin

25
Q

Respiratory complications

A
  • Less common (almost ALL women are those delivered by C/S (often after GA, uncommon after spinal anaesthesia))
  • Usually within 24 hours of delivery

Causes:
1. Atelectesis
2. Aspiration
3. Bacterial pneumonia

26
Q

Venous thromboembolism

A
  • Main cause of maternal death
  • Incidence: 1-2 in 1000 pregnancies
  • Can occur at ***any point in pregnancy
  • ***Higher in puerperium
  • Pregnancy a risk factor for VTE —> **Venous stasis in lower limb + **Changes in coagulation system

S/S:
1. **Low grade fever, Tachycardia (can be subtle) +/- Desaturation
- Require high level of suspicion
2. **S/S of DVT, PE

Treatment:
- Commenced while waiting for diagnostic tests

27
Q

Other postnatal problems

A
  1. Pain
    - After-pains due to uterine contraction
    - Perineal pain
    - Treatment: Paracetamol, NSAID
  2. Bladder problems
    - Urinary retention: following instrumental delivery / extensive tears, pain + deems can cause voiding difficulties and retention
    - Treatment:
    —> Pain relief + reassurance
    —> Catheterisation may be required
  3. Bowel problems
    - Constipation may continue
    - Pain + fear of wound disruption can exacerbate problem
    - Treatment:
    —> Increase intake of fibre and fluids
    —> Stool softeners
  4. Symphysis pubis discomfort
    - Severe pubic + groin pain exacerbated by weight bearing
    - Usually resolve by 6-8 weeks
    - Treatment: Rest, belt, weight-bearing assistance, analgesics
28
Q

Summary of puerperal problems

A
  1. PPH
  2. Puerperal pyrexia
  3. Urinary retention / incontinence
  4. Mental health problems
  5. Pain
    - After-pains due to uterine contraction
    - Perineal pain
    - Treatment: Paracetamol, NSAID
  6. Bowel problems
    - Constipation may continue
    - Pain + fear of wound disruption can exacerbate problem
    - Treatment:
    —> Increase intake of fibre and fluids
    —> Stool softeners
  7. Symphysis pubis discomfort
    - Severe pubic + groin pain exacerbated by weight bearing
    - Usually resolve by 6-8 weeks
    - Treatment: Rest, belt, weight-bearing assistance, analgesics
29
Q

Perineum in the puerperium

A

Perineum may be torn during delivery / episiotomy to facilitate delivery
- some muscles fibres may be damaged even if look intact
- complicated by pain
- infection may complicate injuries
- long term complications: ***Urinary incontinence, Faecal incontinence

30
Q

Pelvic floor and Bladder function

A
  1. Bladder may be over-distended during labour and become ***atonic
    —> incomplete emptying
  2. Pelvic floor muscles stretched + ***innervation partially damaged during vaginal delivery
  3. Descend of uterus + bladder neck
  4. ***Stress incontinence
31
Q

Urinary retention

A

Causes:
- Pain / Edema due to instrumental delivery, excessive tears —> Voiding difficulties + Retention

Symptoms:
1. Unable to void (complete retention)
2. Void small volume frequently (incomplete retention / UTI)
3. Incontinence (***overflow incontinence)

Signs:
1. **Uterine fundus too high / **deviated
2. ***Bladder palpable
3. Note any vulval / vaginal haematoma if co-existing complaint of painful swollen vulva

Check ***residual urine after voiding by
1. Catherisation
2. USG estimation

32
Q

Management of urinary retention

A

Exclude **UTI and treat if UTI (save Catheter specimen of urine —> **Urine culture and sensitivity)

Encourage voiding by:
1. Toilet / Commode instead of bedpan
2. Running **warm tap water over perineum
3. Adequate **pain relief for perineal pain
4. ***Suprapubic pressure
5. Double voiding

Catheterisation of bladder:
- **Indwelling catheter usually required when retained volume **>500mL
- keep for ***48 hours

33
Q

Management of stress incontinence

A
  1. Pelvic floor physiotherapy
  2. Consider surgical repair (strengthening of pelvic floor and elevate bladder neck)
    - if physiotherapy not effective
    - only used more than 6 months after delivery and woman does not want more children
  3. Refer patient to urogynaecology clinic
34
Q

Bowel function in puerperium

A
  1. Constipation due to perineal pain
  2. Haemorrhoids common (∵ ↑ intraabdominal pressure during pregnancy —> aggravated during delivery)
  3. Pelvic floor weakening —> Damage to anal sphincter —> Faecal incontinence
35
Q

Mental health problem in puerperium

A

Leading cause of maternal deaths overall 1 year after delivery (more likely through violent methods e.g. hanging / JFH)

Psychological changes in puerperium:
Positive feelings:
1. Satisfaction
2. Increased closeness to partner
3. Increased closeness to her own mother
4. Gradual falling in love with baby
5. Feeling of protectiveness towards baby
6. Changes in relationship with marital partner: now “mother and father” and not just “husband and wife”

Negative feelings:
1. Dissatisfaction, disappoint / distress over delivery process
2. Anxiety about baby
3. Rejection / Ambivalence about baby
4. Jealousy about baby being centre of attention
5. Fears of harming baby
6. Physical discomfort + anxiety about physical damage during birth
7. Overwhelming responsibility
8. Resentment at loss of freedom
9. Reactivation of poor relationship with own mother leading to anxiety about repetition through generations

Psychological aspects of puerperium:
1. Change in family structure and relationship due to arrival of new member
2. Additional responsibilities
3. Change in role of mother
- wife to mother
- working woman to housewife
- loss of freedom
4. Change in role of father

Need for support:
- Newborns are entirely dependent
- Physiological changes in puerperium is rapid —> can cause discomfort
- Burden of child care aggravate fatigue from labour / delivery
- Anxiety caused by inexperience + perceived vulnerability of newborn
- Coming to terms with new role

Poor social support
—> difficulties in mother-infant relationship

Consequences:
- Maternal morbidity / mortality
- Adverse infant outcomes —> Child protection (***CCDS (Comprehensive Child Development Service))

Psychiatric problems in puerperium
1. **Puerperal blues
- Common mood change in 50% mothers during puerperium
- **Day 4/5 to 10
- **lasting transient half day to 2/3 days
- **resolve spontaneously within 10 days
- tearful, labile mood, irritable
- if symptoms ***> 1 week, need to exclude depression
- resolve faster with protected sleep + rest
- respond to support + reassurance

Causes:
- Hormonal factors + Psychosocial factors

Hormonal factors:
- Progesterone + Estrogen were higher in women with postnatal blues (but cortisol levels were similar)
- Prolactin levels may also be higher (may correlate with anxiety / depression)

Psychosocial factors:
- Anxiety in pregnancy
- Experiencing pregnancy as unpleasant
- Fear of childbirth and pre-existing anxious / pessimistic personality

  1. **Postpartum depression (PND)
    - 10%
    - within 6 months of delivery
    - non-psychotic illness occurring in first postnatal year
    - symptoms ~ depression during other periods
    - NICE guideline: if persistent of puerperal blues for **    10-14 days after birth —> assessed for PND
  2. Puerperal psychosis
  3. Other pre-existing mental health problem
    - Relapse of Bipolar affective disorder more likely to occur following childbirth
    - Sleep loss may be a contributor to development of manic episodes
    - Risk of infanticide + suicide
36
Q

How to distinguish between Puerperal blues and PND

A

Blues:
- **transient, at most a few **days
- no suicidal thoughts
- little guilt feeling
- no loss of self esteem
- no psychomotor retardation
- resolve spontaneously within 10 days, respond to support + reassurance

Depression:
- ***> 1 week
- suicidal thought in severe cases
- guilt feeling, fear of harm
- loss of self esteem
- psychomotor retardation
- mild / moderate respond to counselling, severe require antidepressants + psychotherapy, may need psychologist, social worker input

37
Q

Postpartum depression

A

Why important?
- Common
- Suffering of mother
- Affect family
- Affect child development
- Severe cases: suicide, infanticide

Blocks to effective detection and management of PND:
Medical profession:
- Low index of suspicion
- Attribute symptoms to fatigue

Patient and family:
- Attribute symptoms to fatigue
- Afraid of stigmatisation
- Do not seek help

Help not readily available:
- Social support
- Medical help

Risk of PND
Reduced risk:
- planned pregnancy
- supportive partner and family
- well adjusted at work and at home
- female relative / experienced helper for postpartum care and support

Increased risk:
- unplanned pregnancy
- poor family and marital relationship
- poorly adjusted
- socially isolated
- previous history of depression
- other life events occurring during pregnancy

38
Q

Screening and Diagnosis for PND

A

Screening:
1. Whooley questions
- Bothered by feeling down, depressed, hopeless in past month?
- Bothered by little interest / pleasure in doing things in past month
- Something with which you would like help?

  1. Edinburgh postnatal depression scale (EPDS)
    - 10-item, self-rated questionnaire
    - Cut-off score **>12 (overall PPV 57%, NPV 99%)
    - **    Screening only, NOT for diagnosis

Diagnosis:
**DSM-5
- Within 4 weeks of delivery
- >=5 depressive symptoms present for >=2 weeks
- Symptoms may go **unnoticed in initial period —> patient may only present even 1 year after delivery

39
Q

History taking in PND

A
  1. Whooley questions
  2. ***Edinburgh postnatal depression scale (EPDS)
  3. Risk factors for mood problems
    - **History of mental health problems (esp. previous postpartum mood problems)
    - **    Obstetric complications
    - **Poor baby outcome
    - **    Family history of BAD / Postpartum psychosis
    - **Sleep deprivation
    - **    Increased environmental stress
    - ***Lack of partner support
  4. Red flags
    - **Psychosis + Suicide
    - Recent / rapidly changing significant alterations in mental state
    - Emergence of new symptoms (e.g. psychotic symptoms, severe anxiety in relation to infant’s welfare)
    - Psychotic symptoms that involve infant
    - **    Thoughts / Acts of violent self-harm / suicide
    - New / persistent / non-reassurable ideas + expression of these ideas, where the woman believes she is incompetent / inadequate as a mother / feels estranged from her infant
    - Pervasive guilt / hopelessness
    - Deterioration in function as a consequence of symptoms (e.g. self-care, care of infant, avoidant of infant)
    - Not eating
    - Severe insomnia
    - Psychomotor retardation
  5. ***Suicidal assessment
    - Any suicide thoughts
    - Duration (Long / Fleeting)
    - Any action plan
40
Q

Management of PND

A
  1. Early recognition of perinatal mood problems
  2. Screening for PND prior to discharge
  3. Psychosocial + Psychological intervention
    - education of condition
    - peer support
    - non-directive counselling
    - cognitive behaviour therapy
    - interpersonal psychotherapy
    - ECT (if severe cases)
  4. Pharmacological
    - SSRI
  5. **Indications for referral to psychiatric services
    - **    Symptoms of psychosis, severe anxiety, severe depression
    - **Suicidality
    - **    Self-neglect
    - ***Harm to others
    - Significant interference with daily functioning
    - History of bipolar disorder / schizophrenia
    - Previous serious postpartum mental illness (e.g. Puerperal psychosis)
    - Patients on complex psychotropic medication regimen
  6. Multidisciplinary
    - Obstetricians
    - Midwives
    - Psychiatrists
    - Psychiatric nurses
    - Clinical psychologists
    - Primary care physicians
41
Q

Postpartum psychosis

A
  • Rare (0.05-0.1%)
  • Presenting acutely in first 2-4 weeks postpartum
  • 50% develop postpartum psychosis with no risk factor
  • Onset within 2 weeks of delivery
  • > 50% day 1-3
  • Sudden onset and rapid deterioration
  • ***Risk of infanticide + suicide

Symptoms:
- Symptoms resembling mania with delusions, hallucinations, agitation, confusion
- Psychotic
- Loss of insight
- ***Visual hallucination (common)

Prophylaxis:
- **Lithium
- **Antipsychotic (Typical / Atypical)

Usually respond well to treatment

Good short term prognosis

42
Q

Other rarer abnormalities during puerperium

A
  1. Perineal / Vaginal haematoma
  2. DVT
  3. Faecal incontinence
  4. Urinary fistula
  5. Sheehan syndrome
43
Q

Other things to note

A
  1. Rh -ve mother
    - **Anti-D Ig to non-sensitising women within **72 hours following delivery of an Rh +ve baby
  2. Rubella Ab -ve mother
    - vaccination and contraception for ***1 month
  3. Cervical screening
  4. Contraception
44
Q

Summary

A
  1. Subinvolution of uterus
  2. Lochia
  3. Postpartum haemorrhage
    - Secondary PPH / Persistent Lochia
  4. Return of ovulation
    - Amenorrhea
    - Lactation
    - Bleeding
  5. Puerperal pyrexia
  6. Pelvic floor and Bladder function
    - Urinary retention
    - Constipation
    - Stress incontinence
  7. Mental health problems
    - Puerperal blues
    - PND
    - Postpartum psychosis

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