WH: puerperium + Postnatal Flashcards
What is puerperium ? how long ?
the period of about six weeks after childbirth during which the mother’s reproductive organs return to their original non-pregnant condition
What happens in the days after delivery ? what care provided ? (5)
- Analgesia
- Help with breast or bottle feeding
- VTE risk assessment
- Anti-D for rhesus -ve patients (if baby positive)
- Routine baby check
What topics are discussed at the 6 week post natal check ? what does this coincide with ? (5)
usually same time as NIPE (6 week)
- General wellbeing
- Mood + depression
- Bleeding + menstruation
- Contraception
- Breast feeding
What is lochia ? describe
mix of blood, endo tissue + mucus
- normal in puerperium
what menstrual device should be avoided for lochia
tampons due to infection risk
How can Brest feeding affecting menstruation ?
can cause lactational amenorrhoea
how long after giving birth will bottle feeding women have menstural periods ?
from 3 weeks onwards
when does fertility return after childbirth ? (days)
21 days (don’t need contraception before then but then do)
how effective is lactational amenorrhoea ? what is required for it to be effective ?
98% effective
- If fully breastfeeding + fully amenorrhoea
which hormonal contractions are safe during breast feeding ? which should be avoided and for how long ?
- Safe: POP + progesterone implant are safe during breast feeding
- COCP should be avoided (for 6 weeks)
When is the copper coil + mirena safe after birth ?
<48 hrs
or
more than 4 weeks after birth
(not in between)
What is post party endometritis ? usually caused by ?
it is inflammation of the endometrium (lining of the uterus)
- Usually caused by infection
why is there in increased risk of endometritis in the PPP ?
due to the infection risk in labour + delivery
After what kind of delivery is endometritis most common ? what is done to try to prevent this ?
CS
- prophylactic Abx given during CS
endometritis presentation ? (4) when ?
shortly after birth till several weeks post partum
- foul smelling discharge of lochia
- Lower abdo/pelvic pain
- Fever
- Signs of sepsis
endometritis investigations ? what other differential is important to exclude ?
- Vaginal swabs
- Urine culture + sensitivities
- US: to exclude retained products of conception
post partum endometritis management ?
oral Abx: broad spectrum
What is retained products of conception ? what 2 types of tissue ?
it is when pregnancy related tissue (placental or fetal membranes) remains in the uterusdur
which events could lead to retained products of conception ? (3)
- Delivery
- Miscarriage
- TOP
significant RF for retained products of conception ?
placenta accreta
retained products of conception presentation ?
- Vaginal bleeding
- Abnormal vaginal discharge
- Lower abdo/pelvic pain
- Fever (if infection)
how is retained products of conception diagnosed ?
US
Retained products of conception management ?
- Surgical removal: evacuation of retained products of conception (ERPC) under GA
Complications of retained products of conception management (surgical) ? (2)
evacuation of retained products of conception (ERPC)
- endometritis
- Ashermanns syndrom e
what is ashermanns syndrome ?
adhesion form with uterus => stick structures together that should be stuck => infertility
Why is anaemia common is the PPP ?
common due to the acute blood loss during labour + delivery
When would you do an FBC for suspected anaemia in the postpartum period ?
- PPH
- CS
- Antenatal anaemia
- If symptomatic
post partum anaemia management ?
Depends on level of deficiceny
- Ferrous sulphate, iron transfusion, blood transfusion
SE of ferrous sulphate ?
- N&V
- Constipation
- Dark poo
what are the 3 mood disorders present in the postnatal period ?
- baby blues
- Postnatal depression
- Puerpral psychosis
What is baby blues ? when ? how common ?
low mood in the first week after birth
- majority of women (>50%)
- especially 1st time mothers
what is baby blues presentation ? (5) symptoms severity and how long do they last ?
- Mood swings
- Low mood
- anxiety
- Irritabily
- Tearfullness
(symptoms usually mild and resolve within 2 weeks)
what causes baby blues ?
- Hormonal changes
- Recovery from birth
- Fatigue + sleep deprivation
- Establishing feeding
What is postnatal depression ? how common ? When ?
depressive episode within first 12 months post partum
- 1/10 women with peak at 3 months after birth
classic triad of postnatal depression presentation ? how long do symptoms last ?
- Low mood
- Anhedonia
- Low energy (Lethargy)
(symptoms last at least 2 weeks)
What antidepressant is appropriate in breast feeding women (2) type ?
- sertraline
- paroxetine
(SSRI)
How is post natal depression treated ? (4)
(similar to regular depression)
- additional help
- SSRI (if moderate)
- CBT
- Edinburgh postnatal depression scale
what screening tool can be used for post partum depression ? what number indicated depression ?
Edinburgh post batal depression scale
>10 => post natal depression
how common is puerperal psychosis ? how soon after birth ?
rare but severe
- 1/1000
- a few weeks after birth
how does puerperal psychosis present ? (6)
- Delusions
- Hallucinations
- Depression
- Mania
- Confusion
- Though disorder
How is puerperal psychosis managed ? (5)
urgent assessment + input from specialist NH services
- Spot early to avoid harm to mum or baby
- Mother + baby unit: they can remain together and continue to bond
- CBT
- ECT
- Meds (antidepressant, antipsychotics, mood stabilisers)
puerperal psychosis RF ?
- Previous MH condition (BP, schizophrenia, OCD, eating disorder)
- If had prev PP psychosis (=> 50% chance again with next)
- Can occur if no prev psychiatric disorder
What preparation can be done during pregnancy if mother has preexisitng MH condition ?
- consider SSRI use
- Maintain good social network
how can antenatal SSRI use effect the neonate ?
neonatal abstinence syndrome
- Irritability
- Poor feeding
What is lactational mastitis ?
It is inflammation of beast tissue
- Common complication of breast feeding (+/- infection)
What 2 things could cause lactational mastitis ?
- Obstruction
- Infection
how would obstruction cause mastitis ? and how can this be prevented ?
obstruction in the ducts + the accumulation of milk => mastitis
- Regularly expressing milk can preven this form occurring
how does infection cause mastitis ? which causative organism ?
- bacteria (s.aures) enters nipple => back track to ducts => infection + inflammation
lactational mastitis presentation ? (5)
unilateral
- treat pain/tenderness
- Localaised errythema
- Local warmth + infammation
- Nipple discharge
- Fever
Lactational mastitis management ?
- If due to duct blockage: conservative, continue breathing feeding, express milk, breast massage
- Infection: sample of milk sent to lab for culture + sensitivity, Abx (flucloxaillin)
what happens if mastitis is not adequately treated ? management of this ?
can develop breast abscess => required incision + drainage
complication of mastitis after Abx treatment ?
after Abx course => candidal infection of nipple => recurrent mastitis
how does candidial infection of nipple present ?
mum: bilateral sore nipples, nipple tenderness + itching, cracked/flakey areolar
Baby: with parches in mouth + tongue, or condidial nappy rash
candidiasis infection management ?
treatment required for both mother + baby
- topical micronazole (to breast and affected area on baby)
What is Sheehans syndrome ? complication of what ?
it is a rare complication of PPH
- drop in circulating blood vol => avascular necrosis of pituitary => ischaemia of cells in pituitary => cell death
why does Sheehans only affect AP ? explain
blood supply
- AP gets blood form low pressure system (vulnerable to rapid drops in BP)
- PP has different food blood supply form various arteries
what homones does AP secrete ? (6)
- TSH
- ACTH
- FSH
- LH
- GH
- Prolactin
what hormones does posterior pituitary produce ? how is this affected in sheehan’s
- Oxytocin
- ADH
its not affected by Sheehan’s
Sheehas presentation ? say what causes each one ?
sign + symptoms of decreased AP hormones
- reduced lactation (due to low prolactin)
- Amenorrhoea (due to low FSH + LH)
- Adrenal insufficiency (low ACTh => low cortisol)
- Hypothyroidism (due to low TSH)
Sheehans management ?
long term replacement of the missing hormones
- Oestrogen + progesterone, Hydrocortisone, levothyroxine, GH
What is post partum thyroiditis ?
condition where there are changes to thyroid function within 12 months of delivery affecting women wihtough Hx of thyroid disease
- over time third function returns to normal and Px will be asympotmattic
stages to post partum thyoiditis ?
usually
- thyrotoxicosis (first 3 months)
- hypothyroidism (3-6 months after birth)
- function begins to return to normal
thyrotoxicosis Sx ? (6)
hyperthyroidism
- anxiety/irritabilty
- sweating + heat intolorance
- tachycardia
- weight loss
- fatigue
- frequent loose stools
hypothyroidism Sx ? (7)
- weight gain
- fatigue
- dry skin
- hard loss
- low mood
- heavy periods
- constipation
what would be seen on TFT for thyrotoxicosis and hypothyroidism ?
thyrotoxicosis: high T3, high T4, low TSH
hypothyroidism: low T3, low T4, high TSH
post partum thyroiditis Mx ? (3)
- thyrotoxicosis: symptomatic control (propanolol)
- hypo: levothyroxine
annual monitoring (TFT)
