GOSH > Post Partum Problems > Flashcards

Post Partum Problems Flashcards

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1
Q

What is the basic process of involutation after birth?

A

Restoration of the uterus to original shape/size
After placental delivery, uterus contracts and becomes hard, however still palpable below umbilicus.
By six days is at 1/2 navel to symphysis
By 10 days at symphysis and cervical os closes
By six weeks return to normal

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2
Q

What is the normal post-partum discharge?

A

lochia, is a mix of blood, tissue, and mucus from the uterus that gradually changes in color and flow over 4 to 6 weeks. It begins as heavy, bright red discharge with clots, then becomes pinkish-brown, and finally a lighter yellow or white before stopping. The flow should lessen over time, and the discharge should have a smell similar to menstrual blood; a foul odor, greenish color, or heavy bleeding requires medical attention

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3
Q

What post-partum discharge is abnormal?

A

Red lochia >1 week = potential uterine subinvolutation

Malodorous +/- large tissue -> potential infection

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4
Q

What is the initial product of breast feeding?

A

Colostrum for the first 2 days -> thick yellowish
Rich in protein, vitamins, IG and humoral factors -> helps prevent infection in newborn

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5
Q

How has breastfeeding changed by day 3?

A

Breast tenderness and may have fever
Breast milk is more mature, white and abundant

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6
Q

What is the key physiology that triggers breast feeding?

A

Oesotrogen and progesterone drop post delivery -> prolactin begins secretory activity
Oxytocin from post pituitary -> contraction of myoepithelial cells -> eject milk from mamary ducts

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7
Q

What can inhibit the milk ejection reflex during breast feeding?

A

Pain
Anxiety
Breast engorgement
Depression/aletered mood state

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8
Q

What is the key content of breast milk?

A

High in fat (increases over feed duration)
Lactose
Vitamins (particularly VitD)
Micronutrients
Proteins (maternal antibodies IgA for gut and casein)

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9
Q

What triggers the breast feeding reflex?

A

Baby suckling on the breast
Activates mechanoreceptors on the breast to DRG to spinal cord to hypothalamus.
This triggers both prolactin and oxytocin release
Cortisol release during labour can also trigger reflex.
Baby crying can also trigger hypothalamus.
Long term -> full emptying of breast encourages further breast milk production

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10
Q

What causes breast development during pregnancy?

A

Placenta produces -> progesterone and human placental lactogen
Pituiatry gland -> prolactin
Leads to glandular and adipose tissue growth
Alongside areola darkening and growth
Progesterone inhibits expulsion of milk

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11
Q

What is the key content of colostrum?

A

High in protein (immunoglobulins and growth factors)
Low in fat
Coats bowel -> helps pass meconium.

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12
Q

What are the benefits of breast milk in babies?

A

Lower rates of allergies and infection
Reduce obesity
Reduce suddden infant death
Healthier weaigher gain
Better long term outcomes

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13
Q

What are the benefits of breast feeding for the mother?

A

Reduce uterine bleeding
Burns calories
Reduce risk of breast/ovarian/uterine cancer
Reduce osteoporosis, T2DM, heart disease

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14
Q

What is the correct babay latch position for breast feeding?

A

Mouth wide open covering areola
Nipple against soft palate
Tongue against bottom of areola

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15
Q

What weight loss is normal in newborn?

A

Around 10% in first week
Expect to regain this afterwards.

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16
Q

What are the key minor complications after breast feeding?

A

Nipple pain - poor latch
Blocked duct (milk bleb) -> pain when breast feeding, may need help positioning baby or try massaging breast
Nipple candidiasis -> miconazole cream for mother, nystatin suspension for baby.
Breast engorgement -> bilateral pain and discomfort, redness, releaves with feeding, may have fever
Raynauds disease of the nipple

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17
Q

How common is mastitis during breast feeding?
When should it be treated?

A

1 in 10 women
If nipple fissure present, systemically unwell, does not resolve after 24hrs effective milk removal, or culture shows infection

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18
Q

What is the first line treatment for mastitis?

A

Flucloxacillin for 10-14 days
Breastfeeding/expressing should continue

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19
Q

What is a complication of mastitis?

A

Breast abscess
Requires incision and drainage

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20
Q

How to differentiate between mastitis and breast abscess?

A

Mastitis -> diffuse breast pain and tenderness, swelling, redness, warmth, flu like symptoms
Severe may cause nipple discharge, lymphadenopathy.
Abscess -> tender, distinct, potentially mobile mass under skin, fever not improve with antibiotics, more focused area of pain

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21
Q

How quickly do menstrual periods return after birth?

A

6-8weeks if not breastfeeding
Breast feeding -> between 4-24months -> prolactin suppresses FSH on ovaries.

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22
Q

What is it recommended to restart contraception after giving birth?

A

3/4 weeks post partum if not breast feeding
3 months if breast feeding

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23
Q

What contraception can be given straight after birth?

A

Progesterone only pill, implant and injection
Internal and external condoms
IUD/IUS (if within 48hrs or must wait 4 weeks)

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24
Q

What contraceptives can be given 6weeks post birth?

A

Copper coil or intrauterine system
COCP (not when breastfeeding)

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25
How do pregnancy-associated thyroid problems change after birth?
HCG falls in the post partum period HCG mimic TSH As HCG drops thyroid volume regresses at around 12w Thyroid function usually returns to normal 4 w post-partum
26
How does gestational diabetes changes after giving birth?
Placental insulinase + corticotropin-releasing hormone -> reduce insulin sensitivity Risk of higher blood sugar during pregnancy Post-partum above homrones drop Insulin sensitivity normalises within 2-3days (can take longer in obesity)
27
How is the bladder and urinary system affected post-partum?
Immediate -> urinary retention from bladder atony or oedema around urethra During preg -> urter and pelvicalcyeal dilate -> inc risk UTI 0> drop in prog at birth reverses this at 4-8w pp.
28
What happens to the haematological and cardiovascular system post-partum?
Haematocrit drops during delivery -> improves with haemoconcentration post-partum Leucocytosis -> labour stress response -> normalises in 4w Pre-pregnancy cardiac system returns in 4w
29
What care happens initially after giving birth?
Midwife led then health visitor after 2w and 6w post-natal check with GP Often mental health check, analgesia, bleeding, feeding help, monitoring wounds and bloods, contaception, vaccination
30
How often should a women be visited after birth?
All women and babies should remain in hospital for 24hrs Should then have three addition care contacts within the first 6w.
31
What are the key features of the baby blues?
Low mood, overwhelmed Usually between 3-10/14 days post partum Mostly self-resolving Very common
32
What are the key features of post-natal depression?
Usually develops within 6 weeks after giving birth Last for more than 2w Ranges mild to ssevere Affects 1 in 10 women Cause: unknown, antenatal depression, prior/current mental health problems may be a precipitant.
33
What are the key signs/symptoms of post natal depression?
Lack of interest or sense of enjoyment Low mood (upset an tearful) Restless, agitated and irritable Feeling guilty Hostile or indifferent to partner/babay Hopeless/sense of dispair No self-confidence
34
What is the management of mild post-natal depression?
Support networks - family, mid-wife, GP CBT
35
What is the management of moderate post-natal depression?
Conservative measures -> support networks and CBT Alongside anti-depressants: paroextine or sertaline norm recommended.
36
What is the treatment for severe post-natal depression?
As for moderate alongside: Admission - mother and baby units In crisis: CMHT, emergency department
37
Epidemiology of post-partum/puerperal psychosis?
Rare 1 in 1000 mothers Sudden onset within hours/days of birth until 2-3 weeks post partum
38
What are the caues of post-partum/puerperal psychosis?
Largely unknown Personal history Diagnosed with other mental health condition Traumatic pregnancy/birth
39
What are the key signs and symptoms of post-partum/puerperal psychosis?
Paranoia Severe depression Anxious, restless, irritable Psychotic symptoms - hallucinations/delusions Sleeping difficulties Struggling to concentrate Sense of thoughts racing
40
What is the management of post-partum/pueperal psychosis?
Mental health emergency Specialist referall via CMHT, crisis or ED Often admit to mother and baby units, require CBT + medication (antipsychotics, antidepressants or mood stabilisers) ECT
41
What is the NICE definition of a post partum haemorrhage?
Heavy PV bleeding from 24hrs after birth up to 8 weeks post partum
42
What is the difference between a primary and secondary post partum haemorrhage?
Primary -> within 24hrs secondary -> within 12weeks By RCOG definition
43
What are the different categories of PPH?
500-1000ml is minor Over 1liter is major
44
What are the pre-labour risk factors for post partum haemorrhage?
Placenta previa Placental abruption Multiple pregnancy Pre-eclampsia Previous PPH Anaemia Clotting disorders Uterine fibroids
45
What are the labour related risk factors for PPH?
Induction C-section Retained products of conception (including placenta) Instrumental delivery Pyrexia during labour and delivery Baby >4kg Maternal age >40
46
What medication may be given during post partum haemorrhage?
Tranexamic acid
47
What medical management may be used during post partum haemorrhage? Why?
Tranexamic acid -> reduce bleeding Uterotonics -> oxytocin and misoprostol -> stimulate or strengthen uterine contractions
48
What surgical management may be needed for post partum haemorrhage?
Evacuation of any retained products of conception Potential interventional radiology -> uterine artery embolisation, CT angiogram to identify area of active bleeding.
49
What is the pathophysiology of VTE in pregnancy?
Virchows triad Increased venous stasis + vascular damage + hypercoagulability -> increased risk of VTE.
50
What are the maternal risk factors for VTE?
Pregnancy Thrombophilia Advanced maternal age High BMI Smoking Varicose veins Previous VTE Co-morbidities (active cancer, cardia)
51
What are the obstetric risk factors for VTE?
Multiple pregnancies C-section Prolonged labour Instrumental delivery Pre-term birth Stillbirth PPH Pre-eclampsia
52
What transient risk factors can occur during pregnancy that are a risk for VTE?
Long distance travel Surgical procedures IVF Bone fractures Concurrent systemic illness -> pneumonia
53
What treatment is typically used for VTE in pregnancy?
LMWH injections (tinzaparin) Management of underlying cause If known thrombophilia or new haematological conditions referall to haematologist.
54
What antenatal care can be provided for VTE?
High risk -> prophylaxis VTE and referall Intermediate -> consider aprophylaxis Four + risk factors -> prophylaxis from first trimester Three risk factors -> prophylaxis from 28 weeks Lower risk -> mobilisation and avoid dehydration.
55
What risk factors are considered by the RCOG to decide if prophylaxis is needed for a VTE in pregnancy?
Obseity >30 BMI Age >35 Parity greater than = 3 Smoker Gross varicose veins Current pre-eclampsia Immobility -> paraplegia FH of provoked VTE Low-risk thrombophilia Multiple pregnanct IVF?ART 4 or more = from first trimester 3 or more = from 28 weeks
56
What post natal treatment may be given for women with a risk of VTE?
High risk -> 6 weeks LMWH Intermediate risk = 10 days LMWH
57
Define post partum pyrexia
Single reading of 38 degrees or two consecutive 37.5 at least one hour apart from during labour to up to 6 weeks post-partum
58
What are some common causes of post-partum pyrexia?
Endometritis Retained products of conception Mastitis Viral infections Chest/UTI/surgical wound infections etc
59
What is endometritis?
Infectious inflammation fo the endometrium Usually polymicrobial Translocation of normal vaginal flora into uterine cavity during labour/delivery Group A+B strep, E.coli etc
60
What are the risk factors for endometritis?
C-section instrumental delivery Previous STI or pelvic inflammatory disease Diabetes Mellitus
61
What are the key signs/symptoms of endometritis?
Lower abdo pain Foul smelling PV discharge or lochia Fever Maternal sepsis PV bleeding
62
What investigations are done for endometritis?
Abdo/pelvic US Bloods -> FBC (wcc), U&E, CRP Vaginal swabs urine dip and MC&S
63
What is the management for endometritis?
Antibiotics
64
What is the key presentation of reatined products of conception?
Lower abdo pain PV bleeding Malodorous PV discahrge/lochia Identified on pelvic ultrasound
65
What is the management for retained products of conception?
Evacuation of retained products -> curettage of endometrial lining Antibiotics Analgesia
66
What is the ket pathophysiology of mastitis?
Milk stasis -> ductal narrowing and alveolar congestion -> inflammation and infection Disruption of ductal microbiome with imbalance of bacteria Commonly associated with staphylococcus and streptococcus
67
What are the ket risk factors for mastitis?
Smoking Diabetes mellitus
68
What is the key presentation of mastitis?
Breast pain +/- tenderness Focal erythema Local warmth/induated skin Nipple discharge Flu like symptoms
69
What investigations should be done for mastitis?
Clinical examination Breast ultrasound
70
What is the key management for mastitis?
For simple blockage -> continue breast feeding, heat packs, analgesia and warm showers Mild -> also oral antibiotics Mod to severe -> IV antibiotics and surgical incision to drain breast acscess if present
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