OBS - Postnatal Care

Question 1

Routine Postnatal Care

Postnatal Monitoring
Post-Partum Anaemia
Six-Week Postnatal Check

Answer 1

1. ) Postnatal Monitoring - couple days post-delivery
   - monitoring FBC, BP, sepsis, PPH, scar healing
   - analgesia, VTE risk assessment, anti-D for Rh-ves
   - routine baby check, help w/ breast or bottle-feeding

2.) Post-Partum Anaemia - Hb <100g/dL
- FBC is checked 24hrs after delivery in PPH >500ml,
C-section, antenatal anaemia, symptomatic
- Tx: oral iron if Hb <100, consider iron infusion if <90 or can’t have oral iron, blood transfusion if Hb <70
- iron infusion is contraindicated in active infection

3. ) Six-Week Postnatal Check - often offered by GPs
   - six-week newborn baby check
   - general well-being, mood and depression
   - bleeding/menstruation, contraception, breastfeeding
   - BG (post-GDM), BP+urine dip (after pre-eclampsia)
   - scar healing after episiotomy or caesarean

Question 2

Menstruation and Contraception

Lochia
Lactational Amenorrhoea
Contraception After Childbirth

Answer 2

1. ) Lochia - this is normal vaginal discharge after a vaginal delivery that can occur for up to 6 weeks
   - contains a mix of blood, endometrial tissue, mucus
   - initially, dark red colour and over time will turn brown and become lighter in flow and colour
   - more bleeding occurs whilst breastfeeding due to the release of oxytocin causing the uterus to contract
   - avoid tampons due to the increased risk of infection
   - USS after 6 weeks to exclude retained POC
2. ) Lactational Amenorrhoea
   - breastfeeding women may not return to regular periods for 6mths+ (unless they stop breastfeeding)
   - bottle-feeding women will begin having menstrual periods from 3 weeks onwards. This is unpredictable, and periods can be delayed or irregular at first
3. ) Contraception After Childbirth
   - infertile for 21 days so contraception isn’t required
   - lactational amenorrhea is >98% effective for up to 6 months if it’s continuous and they are amenorrhoeic
   - POP and implant are safe in breastfeeding and can be started anytime after birth
   - COCP is contraindicated in the first 3 weeks (6 weeks if breastfeeding) due to increased VTE risk
   - IUS/IUD can only be inserted within 48hrs of birth OR >4wks after birth, it cannot be inserted in between

Cervical Screening
- delayed until 3 months postpartum

Question 3

Postpartum Endometritis

Pathophysiology
Clinical Features
Diagnosis and Management

Answer 3

1. ) Pathophysiology - infection of the endometrium
   - delivery opens the uterus to allow vaginal bacteria to travel upwards and infect the endometrium
   - more common after a C-section
   - bacteria: a variety of g-ve, g+ve, anaerobic bacteria
   - when unrelated to pregnancy, often due to PID
2. ) Clinical Features - can present from shortly after birth to several weeks postpartum, it can present w/:
   - foul-smelling discharge or lochia, bleeding that gets heavier or does not improve with time
   - lower abdo/pelvic pain, fever, sepsis
3. ) Diagnosis and Management
   - urine culture and sensitivities, vaginal swabs (inc chlamydia and gonorrhoea if there are risk factors)
   - USS to help exclude retained products of conception
   - septic patients will require admission,
   - oral abx for non-septic patients: broad-spectrum abx e.g. co-amoxiclav depending on STI risk

Question 4

Retained Products of Conception

What is it?
Clinical Features
Management

Answer 4

1. ) What is it? - when pregnancy-related tissue (e.g. placental tissue or fetal membranes) remains in the uterus after delivery (or after a miscarriage or TOP)
   - placenta accreta is a significant risk factor
2. ) Clinical Features - may present w/o any suggestive symptoms or it may present with:
   - vaginal bleeding that gets heavier or does not improve with time, abnormal vaginal discharge
   - lower abdo/pelvic pain, fever (if infection occurs)
   - a USS is used to confirm the diagnosis
3. ) Management - evacuation of retained products of conception (ERPC), aka ‘dilatation and cutterage’
   - done using a general anaesthetic
   - the cervix is widened using dilators, and the POC are manually removed using aspiration and curettage
   - complications are endometritis and Asherman’s:
   - adhesions (aka synechiae) form within the uterus, abnormally connecting areas of the uterus which can lead to infertility (can seal the endocervix)

Question 5

Depression During Pregnancy

Clinical Features
Referral to Specialist Mental Health Services
Antidepressants in Pregnancy

Answer 5

1. ) Clinical Features - similar to regular depression
   - low mood, low energy and anhedonia + others
   - may have added worries/ruminations about childbirth and caring for the baby, especially w/ lack of support
2. ) Referral to Specialist Mental Health Services
   - made if the patient is severely depressed
   - risk of self-harm, suicide, evidence of self-neglect
   - psychotic sx, manic features or behaviour
   - previous or possible diagnosis of bipolar disorder or any other severe mental illness
   - consider if FH of severe mental illness or suicide
   - need changes in medication
3. ) Antidepressants in Pregnancy - the risks and benefits must be weighed up with the mother
   - ↑risk of miscarriage and premature birth, PPH
   - SSRIs (especially paroxetine) in T1 ↑risk of congenital heart defects, spinal bifida or cleft lift
   - SSRIs in T3 –> persistent newborn pulmonary HTN
   - withdrawal newborn sx for SS/NRIs: jitteriness, poor muscle tone, hypoglycaemia (can cause seizures), difficulty breathing, pulmonary HTN
   - withdrawal newborn sx for TCAs: tachycardia, fever, irritability, sleeplessness, muscle spasms, seizures

Question 6

Postpartum Depression

Baby Blues
Psotpartum Depression
Risk Factors
Management

Answer 6

1. ) Baby Blues - affect >50% of women in the first week or so after birth, particularly first-time mothers
   - sx: low mood, mood swings, anxiety, irritability
   - sx are usually mild, only last a few days and resolve within two weeks of delivery w/ no treatment required
   - health visitor can help with reassurance
2. ) Postpartum Depression - clinical depression seen in 1/10 women, peaking around 3 months postpartum
   - sx should last >2wks before it is diagnosed
   - may have anxiety regarding the infant’s health or ambivalent/negative feeling toward the infant
   - Edinburgh Postnatal Depression Scale is used to aid diagnosis, a score of >10/30 is very indicative
3. ) Risk Factors
   - lack of support, childcare stress, hx of depression
   - low socio-economic background/loss of employment
   - smoking, formula feeding (lack of breastfeeding)
   - use of methyldopa to manage gestational HTN
4. ) Management - urgent referral to specialist mental health services like in depression during pregnancy
   - mild: additional support, self-help, follow up from GP
   - mod: antidepressants, cognitive behavioural therapy
   - severe: need specialist psychiatric services
   - sertraline and paroxetine are the preferred SSRIs whilst breastfeeding, imipramine and nortriptyline are preferred TCAs (doxepin should be avoided)

Question 7

Postpartum Psychosis

Risk Factors
Clinical Features
Management

Answer 7

1. ) Risk Factors
   - personal hx or FH of postpartum psychosis
   - personal hx of bipolar disorder or psychotic illness
   - can develop with no hx of mental health problems
2. ) Clinical Features - can develop rapidly (few hours) and starts within days to weeks of delivery
   - presentation can be very variable:
   - appear confused and distracted, can become quiet and withdrawn or appear agitated and distressed
   - delusions, hallucinations, thought disorders
   - may appear manic, sleep disturbance is common
3. ) Management - urgently refer to mental health unit
   - risk assessment: suicidal ideation, self-harm, self-neglect, harm to baby, ability to care for the baby
   - most require admission to a specialist mother and baby unit or at least a general psychiatric ward
   - Tx: antipsychotics +/- mood stabiliser, consider ECT
   - severe sx can last from 2-12 weeks and it often takes 6-12 months to fully recover
   - risk in next pregnancy is 50% so close monitoring

Question 8

Postpartum Thyroiditis

Pathophysiology
Clinical Features
Management

Answer 8

1. ) Pathophysiology - changes in thyroid function within 12mths of delivery in those w/ no hx of thyroid disease
   - can cause thyrotoxicosis, hypothyroidism, or both
   - due to ↑ antibodies after delivery –> inflammation of the thyroid gland causing over/underactivity
   - there is a typical 3 stage process for most people:
   - 1: thyrotoxicosis (0-3mths), 2: hypothyroid (3-6mths)
   3: thyroid function returns to normal (within 1yr)
2. ) Clinical Features
   - thyrotoxicosis: tachycardia, anxiety, irritability, weight loss, diarrhoea, sweating, heat intolerance, fatigue
   - hypothyroidism: low mood, weight gain, dry skin, coarse hair/hair loss, constipation, fluid retention, heavy/irregular periods, fatigue
   - TFTs will be reflective of the conditions
3. ) Management
   - TFTs are performed 6-8 weeks after delivery
   - thyrotoxicosis: sx control e.g. propranolol
   - hypothyroidism: levothyroxine
   - overtime, the thyroid function returns to normal, and the patient will become asymptomatic again
   - however, will require annual monitoring of TFTs to identify those that develop long-term hypothyroidism

Question 9

Sheehan’s Syndrome

What is it?
Clinical Features
Management

Answer 9

1. ) What is it? - avascular necrosis of the pituitary gland due to a large drop in circulating volume (due to PPH) leading to ↓ perfusion –> ischaemia and cell death
   - only affects the anterior pituitary gland as the hypothalamo-hypophyseal portal system is susceptible to rapid drops in blood pressure
2. ) Clinical Features
   - reduced lactation (↓PRL), amenorrhea (↓LH and FSH)
   - adrenal insufficiency due to low cortisol (↓ACTH)
   - hypothyroidism due to lack of TSH
3. ) Management - by specialist endocrinologists
   - oestrogen and progesterone as HRT for the female sex hormones (until menopause)
   - hydrocortisone for adrenal insufficiency
   - levothyroxine for hypothyroidism
   - growth hormone