5% Leading worldwide cause of maternal death

Maternal Post-Partum Problems Flashcards by Costanza Coronelli

Puerperium

Time from delivery until 6 weeks

Time taken for uterus to involute

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End of puerperium

Most of physiological changes of pregnancy have returned to pre-pregnancy state
However, lactation + psychological strains continue after 6 weeks

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Post Partum Haemorrhage

Excessive bleeding following delivery

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Primary PPH

> 500ml blood loss from genital tract within 24h delivery

Commoner

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Secondary PPH

Abnormal bleeding from genital tract, from 24hr after delivery –> 6 weeks

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PPH Incidence

Leading worldwide cause of maternal death

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PPH Causes

4 Ts
Tone (70%)
Trauma (20%)
Tissue (9%)
Thrombin (1%)

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PPH Predisposing factors

Antepartum haemorrhage in pregnancy
Placenta praevia (15x risk)
Multiple pregnancy
Pre-eclampsia
Nulliparity
Previous PPH
Maternal obesity
Maternal age (increases with age)
Multiparity

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Intrapartum Haemorrhage RFs

Emergency C section
Elective CS
Retained placenta
Episiotomy
Operative vaginal delivery
Labour > 12hrs
>4kg baby
Maternal pyrexia in labour

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Uterine Atony

Most common cause PPH
Initial step- bimanual uterine massage and compression
Oxytocic agents- syntometrine, syntocin, prostaglandins

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Uterotonics

Syntometrine
IVI syntocinon 40 units in 500ml over 4 hours
Misoprostol
Carboprost
Ergometrine

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Surgery PPH

Examination under anaesthetic
Check placenta
Suture tears
Insert intrauterine balloon
Uterine artery embolization

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Hysterectomy PPH

Sooner rather than later

Especially in cases of placenta accrete or uterine rupture

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Secondary PPH causes

Infection- endometritis

Tissue- retained products of conception

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PPH investigations

FBC
Blood culture
High/low vaginal swab
MSU
Ultrasound if RPOC suspected

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Secondary PPH treatment

Broad spectrum IV antibiotics

90% cases treated improve within 48-72 hours

Thromboembolic disease

Main protective psychological change against PPH is increasing clotting factors and reducing anticoagulants
–> BUT predisposes to TED

Thromboembolic disease pre-existing factors

Previous VTE
Thrombophilia
35+
Obesity
Gross varicose veins
Sickle cell
Paraplegia
Inflammatory disorders

Thromboembolic disease Pregnancy related RFs

Surgical procedure
Dehydration
Sepsis
Pre-eclampsia
Excessive blood loss
Prolonged labour
Immobility after delivery

DVT symptoms

Painful swollen leg
Redness/oedema
Pain- left iliac fossa/groin/buttock
Non-specific lower abdo pain

PE symptoms

Chest pain
Breathlessness
Dizziness
Syncope
Hypoxia

Cerebral VT symptoms

Headache

Seizures

Thromboembolic disease management

Early mobilisation
Good hydration
TEDs
LMW heparin prophylaxis
Avoid COCP

Thromboembolic disease treatment

LMWH 1mg/kg
Safe if breastfeeding

Warfarinise

Postpartum "blues"

Tearfulness, reactivity Peaks 3-5 days after delivery Present in 50-80% of women

Perinatal depression

During pregnancy + first postpartum year | 5-25% pregnant women + new mothers

Puerperal psychosis

``` Loss of contact with reality Hallucinations Severe thought disturbance Abnormal behaviour Often no insight Sudden Usually within first 10 days following birth Mania, depressive or atypical psychosis 0.1-0.2% new mothers ```

Mania psychoses

Excited, over-talkative, uninhibited and intensely overactive

Depression psychoses

Differ from postnatal depression in the great severity of their symptoms and the presence of features like confusion, delusions and stupor

Atypical psychoses

Confusion or perplexity, catatonic features, thought disorder, auditory hallucinations and delusions

Pregnancy induced hypertension

Gestational hypertension- late onset hypertension, without proteinuria Pre-eclampsia- hypertension with proteinuria after 20 weeks pregnancy Eclampsia- pre-eclampsia + convulsions

Post natal Pre-eclampsia treatment

Urinary reagent-strip test at postnatal review (6-8 weeks after birth) If proteinuria persists at postnatal review, further review at 3 months to test for kidney function --> referral to kidney specialist

Eclampsia

One or more convulsions in association with pre-eclampsia

Control of Eclampsia fits

``` Loading dose- 4g MgSO4 infused over 20 mins Maintenance dose- 1-2g MgSO4/hr Maintain 24hrs post delivery Pulse Oximetry Therapeutic levels 2-4mmol/litre ```

Cardiac

``` Leading cause of direct maternal deaths Sudden adult death syndrome Aortic dissection Acute coronary syndrome Cardiomyopathy ```

Connective tissue disease

``` Systemic lupus erythematosus (SLE) Antiphospholipid syndrome (APS) ```