Maternal Post-Partum Problems

Question 1

What is puerperim?

Answer 1

• time from delivery until 6 weeks

- time taken for uterus to involute

Question 2

What does puerperim end?

Answer 2

• most of physiological changes of pregnancy return to pre-pregnancy state
• only lactation and psychological strains continue after 6 weeks

Question 3

What is the most prevalent cause of maternal death?

Answer 3

• cardiac disease

obesity, older age, increased immigrant populations

Question 4

What is post-partum haemorrhage?

Answer 4

• excessive bleeding following delivery
• 5% incidence
• most common cause of maternal deaths

Question 5

What is primary post-partum haemorrhage?

Answer 5

> 500ml blood loss from genital tract within 24 hours of delivery

Question 6

What is secondary post-partum haemorrhage?

Answer 6

Abnormal bleeding from genital tract

From 24 hours after delivery to 6 weeks

Question 7

What are the causes of primary post partum haemorrhage?

Answer 7

Tone (uterus not contracting - 70%)
Tissue (placenta/membranes left behind - 20%)
Trauma (episiotomy/tear which keeps bleeding - 9%)
Thrombin (clotting disorders that need to be corrected - 1%)

Question 8

What are the pre-disposing factors of primary post partum haemorrhage?

Answer 8

Antepartum haemorrhage
Placenta praevia
Multiple pregnancy
Pre-eclampsia
Previous PPH
Maternal obesity
Maternal age
Multiparity

Question 9

What is the significance of uterine atony?

Answer 9

• felt at umbilicus if pregnancy, cricket ball consistency when contracted
• cause of PPH
• uterine fails to contract after birth
• managed by bimanual uterine massage and compression and oxytocic agents if not contracted enough

Question 10

How is primary PPH managed?

Answer 10

• call for help/crash call/ABC/IV canula/oxygen by mask/FBC/transfusion/urea and electrolytes/clotting profile
• uterotonics
• surgery
• uterine artery embolisation

Question 11

What is uterotonics?

Answer 11

• syntometrine (oxytocin synthetic and ergomtrine for vasoconstriction)
• misoprostol (PG E1)
• carboprost (PG F2alpha)

(increase contraction of uterus)

Question 12

How does surgery treat PPH?

Answer 12

• bakri balloon (device used for temporary control and reduction of PHH, inflates keeping uterus contracted stopping bleeding) and continue syntometrine drip
• B-lynch (mechanical compression of atonic uterus using sutures)
• check placenta is fully removed and try to remove some with hands manually if you think it has not
• uterine artery embolisation

Question 13

How can uterine artery embolization be used for PPH?

Answer 13

• catheter to deliver small particles blocking blood supply to uterine body relieving blood loss
• resort to hysterectomy sooner rather than later (especially if placenta accrete where vessels grow too deeply to uterine wall = uterine rupture)

Question 14

What is secondary PPH?

Answer 14

Commonly presents as prolonged/excessive bleeding

Question 15

What are the causes of secondary PPH?

Answer 15

• infection (endometritis)

- tissue (retained products of conception)

Question 16

What is the commonest cause of postnatal morbidity during days 2-10?

Answer 16

Endometritis

Question 17

How is secondary PPH treated?

Answer 17

• broad spectrum IV antibiotics (90% cases)

- RPOC (retained products of conception) -> evacuate after 24 hours of antibiotics

Question 18

What are the 4 key haemorrhage messages?

Answer 18

• anticipate avoid
• early recognition
• prompt effective resuscitation
• control bleeding quickly
• human factors

Question 19

What is the most common direct cause of maternal deaths?

Answer 19

Thromboembolic disease

Question 20

What are pre-existing risk factors of thromboembolic disease?

Answer 20

• previous VTE/gross varicose veins
• thrombophilia (congenital/acquired)
• age over 35 years
• obesity
• paraplegia
• sickle cell disease
• inflammatory conditons

Question 21

What are pregnancy related risk factors of thromboembolic disease?

Answer 21

• surgical procedures
• dehydration
• sepsis
• pre-eclampsia
• excessive blood loss
• prolonged labour
• immobility after delivery

Question 22

What are the symptoms of deep vein thrombosis?

Answer 22

• painful swollen leg
• redness/oedema of leg
• pain in groin/buttock

Question 23

What are the symptoms of pulmonary embolism?

Answer 23

• chest pain (sudden onset)
• breathlessness (sudden onset)
• dizziness/syncope/collapse tachycardia
• hypoxia

Question 24

What are the symptoms of cerebral vein thrombosis?

Answer 24

• headache

- seziures

Question 25

How is thromboembolism managed?

Answer 25

- early mobilisation - good hydration - TEDs - LMW heparin - avoid COCP

Question 26

How is thromboembolism investigated?

Answer 26

- history - examination - tests to exclude other diseases (ABG, CXR, ECG)

Question 27

How is thromboembolism treated?

Answer 27

- LMWH 1mg/kg (safe if breastfeeding) | - warfarin once INR is at normal level, teratogenic, but can give post natally switching from LMWH

Question 28

What are the symptoms of postpartum blues?

Answer 28

- tearfulness/inability/reactivity - predominant mood of happiness - peaks 3-5 days after delivery - unrelated to environmental stressors or psychiatric history

Question 29

What are the symptoms of postpartum/perinatal depression?

Answer 29

- common affliction among women during pregnancy - 5-25% of pregnant women and new mothers - treatment largely same as for clinical depression in general

Question 30

What are the symptoms of postpartum psychosis?

Answer 30

acute mental illness - loss of contact with reality - hallucinations - severe thought disturbance - abnormal behaviour - mania - depression (confusion, delusions, stupor) - atypical psychoses - first 10 days following childbirth

Question 31

What is mania?

Answer 31

excited over-talkative uninhibited intensely overactive

Question 32

What is the 2nd leading cause of direct maternal deaths?

Answer 32

hypertensive disorders

Question 33

What are the types of pregnancy-induced hypertension?

Answer 33

- gestational hypertension - pre-eclampsia - eclampsia

Question 34

What is gestational hypertension?

Answer 34

- late onset without proteinuria

Question 35

How is gestational hypertension managed?

Answer 35

- antenatal antihypertensive treatment continue if 149/99 or over - consider reducing antihypertensive if bp falls below 140/90, reduce if below 130/80

Question 36

What is pre-eclampsia?

Answer 36

hypertension with proteinuria and after 20 weeks of pregnancy - urinary reagent strip test at postnatal review (6-8 weeks after birth) - if persistent further review 3 months after birth (kidney function)

Question 37

What is eclampsia?

Answer 37

Pre-eclampsia and convulsions

Question 38

How are fits controlled?

Answer 38

- loading dose: 8ml MgSO4 over 20 minutes - maintenance dose: (1-2g/hr) - therapeutic levels: 2-4mmol/L

Question 39

What types of cardiac problems are there?

Answer 39

- sudden adult death syndrome - aortic dissection - acute coronary syndrome - cardiomyopathy - other cardiac conditions

Question 40

What are direct and indirect causes of maternal death?

Answer 40

Direct - only due to pregnant state | Indirect - due to other factors than pregnancy

Question 41

What are the intrapartum risk factors of primary PPH?

Answer 41

``` Emergency C section Retained placenta Episiotomy Operative vaginal delivery Labour >12 hours ```