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Year 4 Obstetrics and Gynaecology > Postnatal Care > Flashcards

Postnatal Care Flashcards

1
Q

After how long should postpartum hair loss resolve?

A

Six weeks

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2
Q

Most common cause of PPH

A

The most common cause of PPH by far is uterine atony: failure of sufficient uterine contractions

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3
Q

Examples of drugs that are safe during breastfeeding

A

antibiotics: penicillins, cephalosporins, trimethoprim

endocrine: glucocorticoids (avoid high doses), levothyroxine*

epilepsy: sodium valproate, carbamazepine

asthma: salbutamol, theophyllines

psychiatric drugs: tricyclic antidepressants, antipsychotics**(excluding clozapine)

hypertension: beta-blockers, hydralazine

anticoagulants: warfarin, heparin

digoxin

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4
Q

Drugs which should be avoided during breast feeding?

A

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

psychiatric drugs: lithium, benzodiazepines

aspirin

carbimazole

methotrexate

sulfonylureas

cytotoxic drugs

amiodarone

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5
Q

SSRIs of choice in breastfeeding women?

A

Sertraline or paroxetine are the SSRIs of choice in breastfeeding women

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6
Q

What is lochia?

A

The bleeding that presents for the first 2 weeks following giving birth, whether this is by vaginal birth or caesarian section

Passage vaginal discharge containing blood, mucous, and uterine tissue which can continue for 6 weeks following childbirth

Lochia typically takes the course of fresh bleeding, which undergoes colour changes before finally stopping.

The patient can be reassured and advice should be given to her regarding lochia. Specifically, she should be told that if this begins to smell badly, its volume increases or it doesn’t stop, she should seek medical help.

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7
Q

Antibiotic of choice to treat UTI in breastfeeding women?

A

Trimethoprim in breastfeeding is considered safe to use

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8
Q

Management of second degree perineal tares

A

Second degree perineal tears may be repaired on the ward by a suitably experienced midwife or clinician

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9
Q

PPH vs MOH

A

PPH>500ml
MOH>1500ml

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10
Q

What is a galactocele?

A

Galactocele typically occurs in women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct. A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

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11
Q

Postpartum Hb cut off for iron supplementation

A

postpartum Hb less than 100 g/l

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12
Q

What should be suspected in patients with continuous dribbling incontinence after prolonged labour and from a country with poor obstetric services?

A

Vesicovaginal fistulae - presents with continuous dribbling incontinence
Perform urinary dye studies
A dye stains the urine and hence identifies the presence of a fistula.

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13
Q

Diabetic therapy when breastfeeding?

A

Sulfonylureas (gliclazide) should be avoided when breastfeeding due to the theoretical risk of neonatal hypoglycaemia.

Exenatide, liraglutide, and sitagliptin should be avoided when breastfeeding.

Metformin is safe to use when breastfeeding.

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14
Q

After what period of time would continued lochia warrant further investigation with ultrasound?

A

6 weeks

Continue vaginal discharge beyond this time is an indication for ultrasound to investigate the possibility of retained products of conception.

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15
Q

What is puerperium

A

Puerperium is the period of approximately six weeks after childbirth during which time the woman’s reproductive organs return to normal.

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16
Q

What haemoglobin cut-off should be used in order to commence treatment in the post partum period?

A

100

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17
Q

Screening tool for post natal depression?

A

The Edinburgh Scale is a screening tool for postnatal depression

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18
Q

What is low birth weight defined as

A

Low birth weight is defined as a birth weight of less than 2500g.

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19
Q

Over what weight is macrosomia

A

4.5kg

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20
Q

Postpartum anticoagulation following VTE in pregnancy

A

When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery. An individual risk assessment is performed before stopping anticoagulation, with advice from a haematologist if necessary.

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21
Q

Postnatal care in women with diabetes

A

Diabetes improves immediately after birth. Women with gestational diabetes can stop their diabetic medications immediately after birth. They need follow up to test their fasting glucose after at least six weeks.

Women with existing diabetes should lower their insulin doses and be wary of hypoglycaemia in the postnatal period. The insulin sensitivity will increase after birth and with breastfeeding.

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22
Q

What will women receive immediately in the post natal period?

A

Analgesia as required
Help establishing breast or bottle-feeding
Venous thromboembolism risk assessment
Monitoring for postpartum haemorrhage
Monitoring for sepsis
Monitoring blood pressure (after pre-eclampsia)
Monitoring recovery after a caesarean or perineal tear
Full blood count check (after bleeding, caesarean or antenatal anaemia)
Anti-D for rhesus D negative women (depending on the baby’s blood group)
Routine baby check

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23
Q

After the initial post natal period what do midwives discuss with mothers in follow up appointments

A

General wellbeing
Mood and depression
Bleeding and menstruation
Urinary incontinence and pelvic floor exercises
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Vaccines (e.g. MMR)

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24
Q

When do GPS offer a routine post natal check

A

At 6 weeks

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25
Q

What is covered at the six week post natal check

A

General wellbeing
Mood and depression
Bleeding and menstruation
Scar healing after episiotomy or caesarean
Contraception
Breastfeeding
Fasting blood glucose (after gestational diabetes)
Blood pressure (after hypertension or pre-eclampsia)
Urine dipstick for protein (after pre-eclampsia)

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26
Q

Why do women bleed more whilst breastfeeding

A

Breastfeeding releases oxytocin, which can cause the uterus contract, leading to slightly more bleeding during episodes of breastfeeding. This is normal.

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27
Q

Menstruation after delivery

A

Women who are breastfeeding may not have a return to regular menstrual periods for six months or longer (unless they stop breastfeeding). The absence of periods related to breastfeeding is called lactational amenorrhoea.

Bottle-feeding women will begin having menstrual periods from 3 weeks onwards. This is unpredictable, and periods can be delayed or irregular at first.

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28
Q

Contraception after childbirth

A

Fertility is not considered to return until 21 days after giving birth, and contraception is not required up to this point. The risk of pregnancy is very low before 21 days. After 21 days women are considered fertile, and will need contraception (including condoms for seven days when starting the combined pill or two days for progestogen-only contraception).

Lactational amenorrhea is over 98% effective as contraception for up to 6 months after birth. Women must be fully breastfeeding and amenorrhoeic (no periods).

The progestogen-only pill and implant are considered safe in breastfeeding and can be started at any time after birth.

The combined contraceptive pill should be avoided in breastfeeding (UKMEC 4 before six weeks postpartum, UKMEC 2 after six weeks).

A copper coil or intrauterine system (e.g. Mirena) can be inserted either within 48 hours of birth or more than four weeks after birth (UKMEC 1), but not inserted between 48 hours and four weeks of delivery (UKMEC 3).

Remember that the combined pill should not be started before six weeks after childbirth in women that are breastfeeding. The progesterone-only pill or implant can be started any time after birth.

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29
Q

What is post partum endometritis

A

Endometritis refers to inflammation of the endometrium, usually caused by infection.
It can occur in the postpartum period, as infection is introduced during or after labour and delivery. The process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.

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30
Q

What increases the risk of postpartum endometritis and how can the risk be reduced?

A

Endometritis occurs more commonly after caesarean section compared with vaginal delivery.
Prophylactic antibiotics are given during a caesarean to reduce the risk of infection.

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31
Q

Which organisms cause endometritis

A

Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea.

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32
Q

Presentation of postpartum endometritis

A

Postpartum endometritis can present from shortly after birth to several weeks postpartum. It can present with:

Foul-smelling discharge or lochia
Bleeding that gets heavier or does not improve with time
Lower abdominal or pelvic pain
Fever
Sepsis

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33
Q

Diagnosis and management of postpartum endometritis

A

Investigations to help establish the diagnosis include:

Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities

Ultrasound may be considered to rule out retained products of conception (although it is not used to diagnose endometritis).

Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics (according to local guidelines). A combination of clindamycin and gentamicin is often recommended. Blood tests will show signs of infection (e.g. raised WBC and CRP).

Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics. A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.

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34
Q

What are retained products of conception

A

Retained products of conception refers to when pregnancy-related tissue (e.g. placental tissue or fetal membranes) remain in the uterus after delivery. It can also occur after miscarriage or termination of pregnancy.

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35
Q

What condition in pregnancy is a major risk factor for retained products of conception

A

Placenta accreta is a significant risk factor for retained products of conception.

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36
Q

How does retained products of conception present

A

Retained products of conception may be present in patients without any suggestive symptoms. It may present with:

Vaginal bleeding that gets heavier or does not improve with time
Abnormal vaginal discharge
Lower abdominal or pelvic pain
Fever (if infection occurs)

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37
Q

How is retained product of conception diagnosed and managed

A

Ultrasound is the investigation of choice for confirming the diagnosis.

he standard management of postpartum retained products of conception is to remove them surgically.

Evacuation of retained products of conception (ERPC) is a surgical procedure involving a general anaesthetic. The cervix is gradually widened using dilators, and the retained products are manually removed through the cervix using vacuum aspiration and curettage (scraping). The procedure may be referred to as “dilatation and curettage”.

38
Q

Key complications of dilation and curettage

A

Asherman’s syndrome
Endometritis

Asherman’s syndrome is where adhesions (sometimes called synechiae) form within the uterus.

Endometrial curettage (scraping) can damage the basal layer of the endometrium.
This damaged tissue may heal abnormally, creating scar tissue (adhesions) connecting areas of the uterus that are generally not connected. There may be adhesions binding the uterine walls together, or within the endocervix, sealing it shut. This can lead to infertility.

39
Q

What is postpartum anaemia and why might it occur

A

Postpartum anaemia is defined as a haemoglobin of less than 100 g/l in the postpartum period.

Anaemia is common after delivery due to acute blood loss.

Most women lose some blood during delivery. In complicated deliveries, caesarean sections and postpartum haemorrhage, women can lose upwards of 1.5 litres of blood.

It is essential to optimise the treatment of anaemia during pregnancy, so that women have optimal haemoglobin and iron stores before delivery.

40
Q

When is a full blood count the day after delivery indicated?

A

Postpartum haemorrhage over 500ml
Caesarean section
Antenatal anaemia
Symptoms of anaemia

41
Q

Treatment of postpartum anaemia

A

Treatment of anaemia is based on individual factors and preferences alongside local guidelines. As a rough guide (local policies will vary):

Hb under 100 g/l – start oral iron (e.g. ferrous sulphate 200mg three times daily for three months)
Hb under 90 g/l – consider an iron infusion in addition to oral iron (e.g. Monofer, CosmoFer or Ferinject)
Hb under 70 g/l – blood transfusion in addition to oral iron

An iron infusion is also considered in women that:

May have poor adherence or oral treatment
Cannot tolerate oral iron
Fail to respond to oral iron
Cannot absorb oral iron (e.g. inflammatory bowel disease)

42
Q

Iron infusions carry a risk of allergic and anaphylactic reactions. They should be used with particular caution in which patients?

A

patients with a history of allergy or asthma.

It is worth noting that active infection is a contraindication to an iron infusion. Many pathogens “feed” on iron, meaning that intravenous iron can lead to proliferation of the pathogen and worsening infection. It is important to wait until the infection is treated before giving an iron infusion.

43
Q

What is the spectrum of postnatal mental illness

A

Baby blues is seen in the majority of women in the first week or so after birth

Postnatal depression is seen in about one in ten women, with a peak around three months after birth

Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth

44
Q

How do ‘baby blues’ present

A

Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers. It presents with symptoms such as:

Mood swings
Low mood
Anxiety
Irritability
Tearfulness

45
Q

What factors are thought to be responsible for baby blues

A

Significant hormonal changes
Recovery from birth
Fatigue and sleep deprivation
The responsibility of caring for the neonate
Establishing feeding
All the other changes and events around this time

46
Q

How does baby blues differ in severity to other postpartum mental illnesses

A

Symptoms are usually mild, only last a few days and resolve within two weeks of delivery. No treatment is required.

47
Q

How does postnatal depression present

A

Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of:

Low mood
Anhedonia (lack of pleasure in activities)
Low energy

Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed.

48
Q

Treatment of postnatal depression

A

Treatment is similar to depression at other times:

Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy

Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit

49
Q

What tool can be used to screen for post natal depression

A

The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week, as a screening tool for postnatal depression.

There are ten questions, with a total score out of 30 points. A score of 10 or more suggests postnatal depression.

50
Q

What is puerperal psychosis and how does it present

A

Puerperal psychosis is a rare but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:

Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder

51
Q

How is puerperal psychosis managed

A

Women with puerperal psychosis need urgent assessment and input from specialist mental health services.

Treatment is directed by specialist services, and may involve:

Admission to the mother and baby unit
Cognitive behavioural therapy
Medications (antidepressants, antipsychotics or mood stabilisers)
Electroconvulsive therapy (ECT)

52
Q

How are women at high risk of postpartum mental illness prepared during pregnancy

A

Women that have existing mental health concerns before or during pregnancy are referred to perinatal mental health services for advice and specialist input. This includes decisions and ongoing management of psychiatric medications, such as SSRIs, antipsychotics and lithium. A plan is put in place for after delivery to ensure they are followed up closely with help from midwives, health visitors, GPs, family and friends, so that treatment and additional support can be put in place early if required.

SSRI antidepressants taken during pregnancy can lead to neonatal abstinence syndrome (also known as neonatal adaptation syndrome). It presents in the first few days after birth with symptoms such as irritability and poor feeding. Neonates are monitored for this after delivery. Supportive management is usually all that is required.

53
Q

What is mastitis and why might it occur

A

Mastitis refers to inflammation of breast tissue, and is a common complication of breastfeeding. It can occur with or without associated infection.

Mastitis can be caused by obstruction in the ducts and accumulation of milk. Regularly expressing breast milk can help prevent this occurring.

Mastitis can also be caused by infection. Bacteria can enter at the nipple and back-track into the ducts, causing infection and inflammation. The most common bacteria is staph aureus.

54
Q

How does mastitis present

A

Mastitis presents with:

Breast pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Local warmth and inflammation
Nipple discharge
Fever

55
Q

Management of mastitis

A

Where mastitis is caused by blockage of the ducts, management is conservative, with continued breastfeeding, expressing milk and breast massage. Heat packs, warm showers and simple analgesia can help symptoms.

When conservative management is not effective, or infection is suspect (e.g. the woman is febrile), antibiotics should be started.

Flucloxacillin is first line, or erythromycin if allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.

Women should be encouraged to continue breastfeeding, even when infection is suspected. It will not harm the baby and will help to clear the mastitis by encouraging flow. Where breastfeeding is difficult, or there is milk left after feeding, they can express milk to empty the breast.

56
Q

Potential complication of mastitis

A

A rare complication if not adequately treated, is a breast abscess. This may need surgical incision and drainage.

57
Q

What is candidal infection of the nipple, and what is it associated with

A

Candidal infection of the nipple can occur, often after a course of antibiotics. This can lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection. It is associated with oral thrush and candidal nappy rash in the infant.

58
Q

How does Candida infection of the nipple present

A

Sore nipples bilaterally, particularly after feeding
Nipple tenderness and itching
Cracked, flaky or shiny areola
Symptoms in the baby, such as white patches in the mouth and on the tongue, or candidal nappy rash

59
Q

Management of Candida of the nipple

A

Both the mother and baby need treatment, or it will reoccur. Treatment is with:

Topical miconazole 2% after each breastfeed
Treatment for the baby (e.g. miconazole gel or nystatin)

60
Q

What is post partum thyroiditis

A

Postpartum thyroiditis is a condition where there are changes in thyroid function within 12 months of delivery, affecting women without a history of thyroid disease. It can involve thyrotoxicosis (hyperthyroidism), hypothyroidism, or both.

Over time the thyroid function returns to normal, and the patient will become asymptomatic again. A small portion of women will remain hypothyroid and need long-term thyroid hormone replacement.

61
Q

Pathophysiology of post partum thyroiditis

A

The cause of postpartum thyroiditis is not clear.

The leading theory is that pregnancy has an immunosuppressant effect on the mother’s body, to prevent her from rejecting the fetus.

Once delivery has occurred, there can be an exaggerated rebound effect, with increased immune system activity and expression of antibodies.

This may include antibodies that affect the thyroid gland, for example, thyroid peroxidase antibodies.

These antibodies cause inflammation of the thyroid gland, leading to over or under activity.

62
Q

Typical pattern of postpartum thyroiditis

A

There is a typical pattern of postpartum thyroiditis. Not all women will follow this pattern. There are three stages:

Thyrotoxicosis (usually in the first three months)
Hypothyroid (usually from 3 – 6 months)
Thyroid function gradually returns to normal (usually within one year)

63
Q

Signs and symptoms of thyrotoxicosis

A

Anxiety and irritability
Sweating and heat intolerance
Tachycardia
Weight loss
Fatigue
Frequent loose stools

64
Q

Signs and symptoms of hypothyroidism

A

Weight gain
Fatigue
Dry skin
Coarse hair and hair loss
Low mood
Fluid retention (oedema, pleural effusions, ascites)
Heavy or irregular periods
Constipation

65
Q

Deranged TFTs post partum

A

In thyrotoxicosis, you expect raised T3 and T4 and suppressed TSH.

In hypothyroidism, you expect low T3 and T4 and raised TSH.

66
Q

Management of Postpartum Thyroiditis

A

There should be a low threshold for testing thyroid function in women presenting with suggestive symptoms, particularly postnatal depression. Thyroid function tests are performed 6 – 8 weeks after delivery.

Patients with abnormal thyroid function tests in the postpartum period require referral to an endocrinologist for specialist management. Typical treatment is with:

Thyrotoxicosis: symptomatic control, such as propranolol (a non-selective beta-blocker)
Hypothyroidism: levothyroxine

Symptoms and thyroid function tests are monitored, and treatment is altered or stopped as the condition changes and improves.

Women with postpartum thyroiditis require annual monitoring of thyroid function tests, even after the condition has resolved. Monitoring is to identify those that go on to develop long-term hypothyroidism.

67
Q

What is Sheenans syndrome

A

Sheehan’s syndrome is a rare complication of post-partum haemorrhage, where the drop in circulating blood volume leads to avascular necrosis of the pituitary gland.

Low blood pressure and reduced perfusion of the pituitary gland leads to ischaemia in the cells of the pituitary, and cell death.

Sheehan’s syndrome only affects the anterior pituitary gland. Therefore, hormones produced by the posterior pituitary are spared.

68
Q

Why does Sheenans syndrome only affect the AP

A

The anterior pituitary gets its blood supply from a low-pressure system called the hypothalamo-hypophyseal portal system. This system is susceptible to rapid drops in blood pressure.

The posterior pituitary gets a good blood supply from various arteries, and is therefore not susceptible to ischaemia when there is a drop in blood pressure.

69
Q

Which hormones are affected by Sheenans syndrome

A

The anterior pituitary releases:

Thyroid-stimulating hormone (TSH)
Adrenocorticotropic hormone (ACTH)
Follicle-stimulating hormone (FSH)
Luteinising hormone (LH)
Growth hormone (GH)
Prolactin

The posterior pituitary releases (not affected by Sheehan’s syndrome):

Oxytocin
Antidiuretic hormone (ADH)

70
Q

How does Sheenans syndrome present

A

Sheehan’s syndrome causes a lack of the hormones produced by the anterior pituitary, leading to signs and symptoms of:

Reduced lactation (lack of prolactin)
Amenorrhea (lack of LH and FSH)
Adrenal insufficiency and adrenal crisis, caused by low cortisol (lack of ACTH)
Hypothyroidism with low thyroid hormones (lack of TSH)

71
Q

How is Sheenans syndrome managed

A

Sheehan’s syndrome will be managed under the guidance of a specialist endocrinologist. It will involve replacement for the missing hormones:

Oestrogen and progesterone as hormone replacement therapy for the female sex hormones (until menopause)
Hydrocortisone for adrenal insufficiency
Levothyroxine for hypothyroidism
Growth hormone

72
Q

What might be given to suppress lactation following still birth

A

Dopamine agonists (e.g. cabergoline) can be used to suppress lactation after stillbirth.

73
Q

When should a breastfed baby be feffered to midwidfe led breastfeeding clinic if weight has been lost

A

If a breastfed baby loses > 10% of birth weight in the first week of life then referral to a midwife-led breastfeeding clinic may be appropriate

74
Q

How long do WHO reccomended breastfeeding

A

The world health organisation recommend exclusive breastfeeding for the first 6 months of life.

75
Q

Advantages of breast feeding

A

Breast milk contains antibodies that can help protect the neonate against infection. Breastfeeding has been linked to reduced infections in the neonatal period, better cognitive development, lower risk of certain conditions later in life and a reduced risk of sudden infant death syndrome.

Body composition appears to be slightly different between breast and bottle-fed babies and children and adolescents that were breastfed appear to have less obesity.

There is evidence that breastfeeding can reduce breast cancer and ovarian cancer risk in the mother.

76
Q

How much should neonates be fed

A

On formula feed, babies should receive around 150ml of milk per kg of body weight. Preterm and underweight babies may require larger volumes. This is split between feeds every 2-3 hours initially, then to 4 hours and longer between feeds. Eventually babies and infants transition to feeding on demand (when they are hungry).

Volumes are gradually increased in the first week of life as tolerated. For example:

60mls/kg/day on day 1
90mls/kg/day on day 2
120mls/kg/day on day 3
150mls/kg/day on day 4 and onwards

77
Q

Initial weight loss in babies

A

It is acceptable for breast fed babies to loose up to 10% and formula fed babies to loose up to 5% of their body weight by day 5 of life. They should be back at their birth weight by day 10. If they loose more weight than this or do not regain their birth weight by two weeks, they need admission to hospital and assessment for possible causes.

The most common cause of excessive weight loss or not regaining weight is dehydration due to under feeding, even when they do not clinically look dehydrated. The most reliable sign of dehydration in babies is weight loss.

78
Q

How to wean a baby

A

Weaning refers to the gradual transition from milk to normal food. Weaning usually starts around 6 months of age. It starts with pureed foods that are easy to palate, swallow and digest, for example pureed fruit and “baby rice”.

Over 6 months this will progress towards a healthy diet resembling an older child, supplemented with milk and snacks to 1 year of age.

79
Q

How often is postnatal mental health support available

A

1 year PP, being extended to 2 years

80
Q

Leading cause of maternal death in the UK following 1 year after the end of pregnancy

A

Suicide

81
Q

How many women will experience a perinatal mental health problem

A

1 in 5

82
Q

Main disorders of perinatal mental health

A

Perinatal depression
Perinatal Anxiety
Perinatal OCD
Tokophobia (fear of childbirth)
PTS
Bipolar disorder
Schizophrenia
Postpartum psychosis
Personality disorders

83
Q

Perinatal community mental health team referal criteria

A

Minimum age is 16+
Previous puerperal psychosis
Bipolar affective disorder
Schizo-affective disorder
Previous depression resulting in hospital admission
Moderate/severe depression
Moderate/severe anxiety
OCD
Personality disorder
Family history of bipolar
Red flags

84
Q

Perinatal mental health - red flags for urgent referal

A

Significant change or new symptoms

New thoughts or acts of violence, self harm

Persistent expressions of incompetency as a mother or estrangement from the infant

Multiple referrals

85
Q

Appropriate referrals to IAPT

A

Depression
Social phobia
GAD
Panic disorder +/- agoraphobia
Mild OCD
Specific phobia
PTSD - single trauma events
Health anxiety
Long term health conditions impacting mental health
Loss including miscarriage, abortions or still births

86
Q

Clinical features of post partum depression

A

In keeping with any depressive disorder, postpartum depression presents with a lowering of mood, reduced enjoyment in activities and lowering of energy levels.

Biological symptoms of depression such as poor appetite and poor sleep may also be present, but it is important to distinguish between sleep that is disrupted because of the baby waking and sleep that is poor for other reasons.

In postpartum depression there may also be associated concerns from the mother about bonding with her baby, caring for her baby, or even harming herself or her baby in extreme circumstances.

Unlike “baby blues”, which present in the first two weeks after birth and resolve spontaneously, postpartum depression rarely resolves spontaneously and should be treated to prevent long-term depressive disorder.

87
Q

Clinical features of post partum psychosis

A

Women with a previous history of severe mental illness, such as schizophrenia or bipolar affective disorder, those with a family history of postpartum psychosis, or those who have experienced postpartum psychosis themselves before are considered to be high risk for postpartum psychosis and should be monitored by a specialist perinatal mental health team.

In some cases the risk of harm to baby or mother can be high and so a referral to a specialist mother and baby inpatient mental health unit is often warranted. This is particularly important in cases where the mother is experiencing command hallucinations (which may instruct her to harm herself or the baby), has thoughts of self-harm or suicide, or has delusional beliefs about the baby’s role or identity (which may lead to harm of the baby).

88
Q

Management of post partum psychosis

A

Postpartum psychosis is managed with antipsychotics and sometimes mood stabilisers. These need to be prescribed with the consideration of breastfeeding if the mother is doing so.

89
Q

What is post partum psychosis?

A

Postpartum psychosis is a rare but severe mental health problem that usually develops in the first two weeks after birth.

The woman may experience paranoia, delusions, hallucinations, mania, depression or confusion.

An important differential diagnosis is postpartum depression with psychotic symptoms and this usually presents with a more insidious onset of low mood, tearfulness and anxiety.

If psychotic symptoms are present, delusions are often mood-congruent.

90
Q

Recurrence rate of post partum psychosis

A

25-50%

91
Q

What mode of delivery is most likely to cause problems in the neonate when the mother has ITP and why

A

Immune thrombocytopenia (ITP) is an autoimmune condition that can occasionally complicate pregnancies, especially if there is placental passage of maternal antiplatelet antibodies.

The high pressure exerted by the vacuum during a ventouse delivery can cause bleeding in the neonate.

Year 4 Obstetrics and Gynaecology (10 decks)

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