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O+G > Postnatal > Flashcards

Postnatal Flashcards

1
Q

What is PPH?

A

Blood loss after delivery of baby + placenta.

Primary - within 24 hours of birth
Secondary - 24 hours - 12 weeks after

500ml after vaginal or 1000ml after CS. Minor <1L, Major >1L, mod 1-2L, severe >2L.

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2
Q

Causes of PPH?

A

4 T’s:
Tone: uterine atomy, soft boggy uterus + ineffective contractions (normally compress BVs). Uterine overdistension (multiple gest, polyhydramnios). Uterine fatigue (prolonged labour), full bladder, preterm labour, fibroids/Ca, anaesthetics esp halothane, Mg sulfate, nifedipine.

Trauma: perineal tear, trauma, surgical incision (section, episiotomy).

Tissue: retained placenta fragments, placenta accrete, XS traction on UC

Thrombin: impaired clotting, VWD, DIC, related to obstetric complication eg eclampsia, placenta previa.

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3
Q

RFs for PPH?

A

prev PPH, obesity, PE, placenta accrete/previa, GA, XS oxytocin, ↑age, emergency CS ritodrine (β adrenergic receptor agonist for tocolysis).

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4
Q

Features of PPH?

A

XS bleeding

↑HR, ↓BP, pulse pressure, O2 sat, haematocrit, delayed CRT.

Shock signs usually appear when haem advanced due to normally ↑pregnancy blood volume

Soft boggy uterus

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5
Q

Prevention of PPH?

A

treat anaemia via blood transfusion

empty bladder before labour

active Tx of 3rd stage.

Tranexamic acid during CS in 3rd stage for high risk

Group + cross match 4 units.

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6
Q

Investigation of secondary PPH?

A

Retained products of conception or infection i.e. endometriosis

Investigations: USS – see products, endocervical + high vaginal swabs for infection

Management: surgical evacuation of RPOC, Abx of infection

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7
Q

Management of PPH?

A

2 large bore cannulas

Warmed IV fluids + bloods

Syntometrine: when head + ant shoulder delivered, otherwise can cause shoulder dystocia

Mechanical: rub uterus through abdo > stim contractions. Catheter ↓bladder distension

Syntocinon: oxytocin 10U, slow injection, followed by continuous infusion (40 units in 500mls)

Ergometrine: IV/IM, stim smooth muscle contractions. CI in HTN. 500micrograms

Carboprost: IM prostaglandin analogue, stim uterine contraction. Caution in asthma.

Misoprostol: sublingual prostaglandin analogue. Stimulate uterine contraction.

Tranexamic acid: antifibrotic, ↓bleeds

IU balloon tamponade: press against bleeding

B-lynch suture: suture around uterus + compress

Hysterectomy: last resort, save woman’s life
Interventional radiology: uterine artery embolism

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8
Q

What is shoulder dystocia?

A

Ant shoulder of baby stuck behind pubis symphysis after head delivered

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9
Q

RFs for shoulder dystocia?

A

fetal macrosomia (maternal DM)

↑maternal BMI

prolonged labour

IOL

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10
Q

Features of shoulder dystocia?

A

Difficulties delivering face + head

Failure of restitution: head remains faced down, doesn’t turn sideways

Turtleneck: head delivered but retracts back into vagina.

Fetal hypoxia: CP
Brachial plexus injury + Erb’s palsy
Perineal tears
PPH

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11
Q

Management of shoulder dystocia?

A

Stop pushing

McRobert’s: work in 90% bring knees to abdo, lift pubic symphysis out of way, pressure on ant shoulder on suprapubic

Episiotomy: allows other manoeuvres

Robins: reach into vagina, pressure on post aspect of baby’s ant shoulder.

Wood screw: rotate baby, top shoulder pushed forward + bottom backwards to move baby 180°

Zavaneli’s: usually LT consequences for baby. Pushing baby’s head back into vagina so baby can be delivered CS.

Cleidotomy: fracture fetal clavicle

Symphysiotomy: cutting pubic symphysis

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12
Q

What is Sheehan’s syndrome?

A

postpartum pituitary necrosis secondary to a postpartum haemorrhage

Pit ↑ size in gestation

↑no of lactotrophs

↑blood demand w/o ↑blood supply.

PPH

pit infarct

necrosis. Pit gland scars + shrinks.

Only ant pit: TSH, FSH ACTH, LH, GH PRL

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13
Q

Symptoms of Sheehan’s syndrome?

A

↓lactation: PRL

Amenorrhea: ↓LH + FSH. Infertility, loss of libido.

Adrenal insuff + crisis: ↓ cortisol + ACTH. Tiredness, postural hypotension.

Hypothyroidism

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14
Q

Investigations for Sheehan’s syndrome?

A

MRI: pit ring sign (halo around empty sella)

Pit hormone levels

Obstetric history

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15
Q

Management of Sheehan’s syndrome

A

Replacement of missing hormones

GC replacement (emergent) if adrenal insufficiency

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16
Q

Causes of puerperal pyrexia and sepsis?

A

Fever>38, within 6wks PP.

Endometritis: most common.
>
RF prolonged labour, PROM, CS retained placental/fetal tissue, IUD. GBS, ureaplasma urealyticum, peptostrem, chlamydia, gonorrhoea

UTI: e coli, proteus, klebsiella

Genital tract: e coli, GAS, staph, clostridium welchii

Mastitis

DVT, ovarian vein thrombophlebitis

17
Q

Features of puerperal pyrexia and sepsis?

A

Pyrexia

Sustained ↑HR + RR

Abdo/CP

D/V

Uterine or renal angle pain + tenderness

Woman unwell or seems unduly anxious or distressed

Dyspareunia. Dysuria

Purulent + foul smelling lochia.

18
Q

Investigations for puerperal pyrexia and sepsis?

A

Wound + high vaginal swabs

Blood cultures

FBC

Urine microscopy + cultures

Throat swabs + sputum cultures

CXR, pelvic USS

19
Q

Management of puerperal pyrexia and sepsis?

A

Not unwell: ice packs for pain, rest, fluid intake, oral Abx broad spectrum

Clinically unwell: admission, clindamycin + gentamicin until afebrile for >24hrs. Analgesics (not NSAIDs > impede ability of polymorphs to fight infection)

Removal of retained tissue

20
Q

What are baby blues?

A

3-7 days following birth

60-70% of women

Particularly 1st time mothers

Due to: hormonal changes, sleep deprivation, fatigue, overwhelming responsibility

Features - Mood swings, low mood, anxiety, Irritability, Tearfulness

Management - Self-limiting, Resolve within 2 wks, Self-limiting

21
Q

What is post-natal depression?

A

Start within a month, peak around 3mnths
Lasts >2wks
10% of women

Sx:
Low mood, low energy
Anhedonia
Inadequacy, unable to cope, feeling guilty, irritable wanting to cry
Obsessive + irrational thoughts 
Loss of appetite
Difficulty sleeping/ concentrating.

Hostile/ indiff to partner/ baby.
Thoughts about harming self/ baby

22
Q

Diagnosis and management of post-natal depression?

A

Edinburgh PND scale: 10 item questionnaire indicates how mother felt over prev wk. >13.

Mild: self-help, follow up GP.

Mod: SSRI (sertraline + paroxetine), CBT

Severe: specialist in pt mother + baby unit

23
Q

What is puerperal psychosis?

A

Few wks after birth
0.2% of women
25-50% recurrence
Begins abruptly

Sx:
Delusions 
Hallucinations 
Depression 
Mania
Confusion
Severe moods swings 
Thought disorder
24
Q

Diagnosis and management of puerperal psychosis?

A

Urgent assessment

Admission to mother + baby unit 
CBT
Antidepressants 
Antipsychotics 
Mood stabilisers
ECT.
25
Q

What is breast engorgement?

A

Breasts become overly full - feel hard, tight and painful

1st few days after born

Milk accumulation in breast tissue, vascular congestion

can be due to newborn not feeding as much as perhaps they need to

26
Q

Sx of breast engorgement?

A

Firm, tender breast

↑vascular markings

Pain, typically worse just before feed.

Milk tends to not flow well from engorged breast, infant find it hard to attach + suckle

Can cause:
Blocked milk duct
Mastitis
Difficulties BF

27
Q

Management of breast engorgement?

A

Freq feedings, good latch to ensure empty breast

Pumping

Warm shower/ compress before feeding (enhances let down)

Cool compress after feed

NSAID.

28
Q

Summary of sore, cracked nipples?

A

Cause: improper latch/ position

Pain, blister/bleb on nipple if pores plugged

Prevent: good BF technique

Cool/warm compress
Apply expressed milk to nipple.

29
Q

What is mastitis?

A

an inflammation of breast tissue that sometimes involves an infection

Infective 30% (s aureus), non infective 70% (poor positioning, inadequate milk removal, milk stasis, back pressure, leaks into interstitial tissue > inflam.

30
Q

Sx of mastitis?

A

Usually unilat

Localised warmth, tenderness/pain

Oedema

Erythema

Firmness

Acute onset flu like Sx

Complications - Breast abscess that may require incision + drainage.

31
Q

Management of mastitis?

A

Prevention: good hygiene.

Continue breastfeeding

NSAIDs

Flucox 10-14 days: systemically unwell, nipple fissure, Sx don’t improve after 12-24 hrs of effective milk removal, if cultures indicate infection.

32
Q

Summary of yeast infection of breast?

A

Candida albicans, Hx of infant oral/diaper/ maternal vaginal candida infection,

Infant plaques in oral
Mother: pain, red/sore cracked nipples

Prevention: good hygiene, avoid XS moisture by keeping breasts dry between feeds

Mother: miconazole cream after feeding.
Infant: nystatin solution swabbed into oral mucosa after feed.

33
Q

What is Raynaud’s disease of the nipple?

A

blood vessels in the nipples are affected, causing pain during, immediately after, or between breastfeeds.

Blanching of nipple may be followed by cyanosis +/or erythema

Nipple pain resolves when nipples return to normal colour

Tx:
Advise minimising exposure to cold, use heat packs following BF, avoid caffeine, stop smoking.
if persist, refer to specialist for trial of nifedipine.

O+G (8 decks)

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