Post-natal care Flashcards
Lactation begins from 3-4m but full lactation is inhibited during pregnancy, why?
High oestrogen + progesterone inhibit prolactin
How is lactation initiated?
- Secretory activity initiated by prolactin + placental lactogen
- Prolactin stimulates alveolar cells to stimulate synthesis of milk components - after its inhibition by O+P has been removed
- Suckling promotes release of oxytocin from the posterior pituitary - milk ejection reflex as this hormone makes the myoepithelial cells contract to secrete the milk
- Hearing/seeing infant cry can also stimulate this oxytocin effect
What are the benefits of breastfeeding?
- Maternal: free, on-demand, reduced risk of breast cancer/T2DM/ovarian cancer (long periods of bf), lactational amenorrhoea (up to 6m, only if mother amenorrhoeic + child ebf), makes child sleepy as has endocannabinoids, reduces PND
- Infant: contains more protein + immunoglobulins so helps immunity, less atopy esp asthma, lower neonatal NEC/diarrhoea, less SIDS, less risk of future T2DM/obesity, reduced acute infections like otitis media and H influenza
Postnatal depression
A depressive episode within the first year postpartum with a peak in the first 2m
- CF include normal depression sx + negative thoughts about motherhood/coping skills and often combined with anxieties
- For meds SSRIs are 1st line (sertraline or paroxetine as shorter t 1/2), but if mother already established on something like a TCA then can have it – take into account their choice
Baby blues
A low mood about 3-4d after birth that lasts around a week
Reassure + support
Postpartum psychosis
Occurs days-weeks after delivery, onset can be over a few hours.
- RF: h/o PPP in mother/sister/self, BPD/psychotic illness, but may have no h/o MH issues
- CF varied. Confusion, withdrawal, paranoid/grandiose delusions, auditory hallucinations, may be manic, sleep disturbance
- M: most need inpatient care (poss under MHA), usually severity reduces by 12w and full recovery in 6-12m
What factors should be taken into account when prescribing in breastfeeding?
- Age of baby: preterm + younger at higher risk, tho first 3-4d lower risk as limited milk volume produced, at birth renal + hepatic function is immature (develops over 2w)
- Co-morbidities of baby esp renal/hepatic
- Mother meds
- How often mother breastfeeds- influences exposure
- Prescribe lowest effective dose for shortest time possible
What factors are a/w lower transmission into breast milk?
- Must be bioavailable to cause an affect
- High molecular weight e.g. insulin + heparins
- High protein binding e.g. warfarin + NSAIDs
- Low lipid solubility e.g. loratadine
- Lower pH e.g. amoxicillin
Why do certain medications result in a higher dose transmission to the infant?
Some meds get ‘trapped’ in milk because it has a lower pH compared to blood which then changes the active chemical resulting in increasing dose to the infant
E.g. iodine, barbiturates
What vaccines can be given safely in breast-feeding mothers?
All (usually), except yellow fever
Treatment of UTIs in breastfeeding
- Can use amoxicillin, cefalexin or trimethoprim as low conc in breast milk (tho prolonged TMP may reduce folate)
- Nitrofurantoin CI if baby <3m as risk of haemolysis, also avoid in G6PDH and within a month of jaundice
Analgesia in breastfeeding
- Paracetamol: drug of choice, low passage + short half life
- NSAIDs: weak acid + protein bound so low passage, ibuprofen + diclofenac preferred
- Avoid aspirin cos of Reye’s syndrome (tho at anti-platelet doses is considered safe)
- Opioids: best avoided esp <2m as immature hepatic enzyme function. Codeine deffo CI cos of variability in metabolism, dihydrocodeine generally CI as some reported incidents, tramadol generally considered safe if necessary
Treatment of depression in breastfeeding
- SSRI with short half life (sertraline or paroxetine)
- Fluoxetine has highest infant ingestion + longer half life so not recommended but if mother stable on it may be used
- TCAs can be used if mother stable/prefers - imipramine or nortriptyline as least sedating
- Monitor infant for sedation, poor feeding, behavioural change, and adv to BF immediately before taking the drug so longer time for metabolism before next BF, or can substitute with a bottle feed to avoid peak dose (dep on the drug for the timing)
- Avoid MAOIs as no safety data
Contraception in breastfeeding
- COCP: only after 3w of delivery/6w if have VTE RF, may affect production
- POP, implant + injection: known safety + can start at any time
- IUS, IUD: safe but insert within 48h/after 4w cos of uterine perforation risk
- Enzyme inducers like carbamazepine can reduce OCP so consider a LARC; if they want OCP give one containing a higher dose
Treatment of seasonal allergic rhinitis in breastfeeding
- Consider if any needed
- Topical - hardly any absorbed, to further reduce risk close eyes after administering eye drops + press on inside corner of closed eyes. Especially useful for congestion + eye sx
- Oral antihistamines - for rhinorrhoea + sneezing. Non-sedating preferred as they don’t cross the BBB like cetirizine or loratadine. (If deffo need the 1st gen type use chlorphenamine at lowest dose and regularly monitor infant)
