Postnatal care

Question 1

mastitis

Answer 1

inflammation of breast tissue
common complication of breast-feeding
most common cause: staph-aureus

Question 2

presentation of mastitis

Answer 2

breast pain and tenderness (unilateral) 
erythema in a focal area of breast tissue
local warmth and inflammation 
nipple discharge
fever

Question 3

management of mastitis

Answer 3

Conservative management

• continue breastfeeding, expressing milk & breast massage.
• Heat packs, arm showers and simple analgesia

Infection suspected

• Antibiotics
• 1st line: flucloxacillin or erythromycin (pen. allergic)

Question 4

candida of the nipple

Answer 4

candida infection of the nipple can occur- often after a course of antibiotics.
Can lead to recurrent mastitis, as it causes cracked skin on the nipple that create an entrance for infection.
Associated with oral thrush, candida nappy rash in infant.

Question 5

presentation of candida of nipple

Answer 5

sore nipples bilaterally
nipple tenderness/ itching
cracked, flaky or shiny areola

symptoms in baby

• white patches in mouth and on tongue
• candidal nappy rash

Question 6

candida of nipple treatment

Answer 6

topical miconazole after each breastfeed

Question 7

baby blues

Answer 7

seen in majority of women in first week after birth.
symptoms usually mild and only last few days
resolve with 2 weeks of delivery

Question 8

postnatal depression

Answer 8

peaks around 3 months after birth

symptoms last >2 weeks

Question 9

postnatal depression symptoms

Answer 9

low mood
anhedonia
low energy

Question 10

treatment of postnatal depression

Answer 10

Mild: additional support 7 self-help

Moderate: Antidepressant (SSRIs) and CBT

Question 11

assessment of postnatal depression

Answer 11

Edinburgh postnatal depression scale.

Score of 10 or more suggests postnatal depression

Question 12

puerperal psychosis

Answer 12

rare but severe illness that typically has an onset 2-3 weeks after delivery

Question 13

presentation of puerperal psychosis

Answer 13

full psychotic symptoms 
delusions 
hallucinations 
depression 
mania 
confusion 
thought disorder

Question 14

management of puerperal psychosis

Answer 14

urgent assessment and input from specialist mental health services

• admission to mother & baby unit
• CBT
• medications
• ECT

Question 15

postpartum endometritis

Answer 15

inflammation of the endometrium, usually caused by infection

Question 16

presentation of postpartum endometritis

Answer 16

foul-smelling discharge or loch 
bleeding (gets heavier or does not improve) 
lower abdo/ pelvic pain 
Fever
Sepsis

Question 17

Postpartum endometritis investigations

Answer 17

Vaginal swabs
Urine culture and sensitivities

US: rules our retained products of conception

Question 18

management of postpartum endometritis

Answer 18

Mild
- oral antibiotics: Co-amoxiclav

Septic

• Hospital admission
• Clindamycin + gentamicin

Question 19

postpartum thyroiditis

Answer 19

changes in thyroid function within 12 month of delivery affecting women with no history of thyroid disease.

Question 20

postpartum thyroiditis features

Answer 20

Thyrotoxicosis (hyper)

• anxiety & irritability
• sweating and heat intolerance
• tachycardia
• weight loss
• fatigue
• frequent loose stools

hypothyroidism

• weight gain
• fatigue
• dry skin
• coarse hair and hair loss
• low mood
• fluid retention (oedema, pleural effusions, ascites)
• heavy or irregular periods
• constipation

Question 21

Postpartum thyroiditis: Thyroid function tests

Answer 21

Thyrotoxicosis

• Raised T3 and T4
• Suprressed TSH

hypothyroidism

• Low T3 and T4
• Raised TSSH

Question 22

Management of postpartum thyroiditis

Answer 22

Thyroid function tests performed 6-8 weeks after deliver

THyrotoxicosis
-symptomatic control (propranolol)

hypothyroidism
- levothyroxine

Monitoring: annual thyroid function tests

Question 23

retained products of conception

Answer 23

pregnancy-related tissue remains in the uterus after delivery.
Can also occur after miscarriage or termination of pregnancy

Question 24

presentation of retained products of conception

Answer 24

vaginal bleeding (gets heavier/ does not improve) 
Abnormal vaginal discharge
lower abdo pain or pelvic pain 
fever

Question 25

diagnosis of retained products of conception

Answer 25

ultrasound

Question 26

management of retained products of conception

Answer 26

surgical removal of retained productions - Evacuation of retained products of conception (ERPC) key complications: endometritis and Asherman's syndrome

Question 27

Asherman's Syndrome

Answer 27

Adhesions form within uterus. Endometrial curettage can damage basal layer of endometrium, creating scar tissue connecting areas of the uterus that are not. generally connected. May be adhesions binding uterine walls together, or within endocervix, sealing it shut. Can lead to infertility.

Question 28

Sheehan's syndrome

Answer 28

rare complication of postpartum haemorrhage. Drop in circulating blood volume leads to avascular necrosis of pituitary gland. Leads to ischaemia in cells of the pituitary. Sheehan syndrome only affects anterior pituitary gland.

Question 29

hormones released by anterior pituitary gland (& affected by Sheehans)

Answer 29

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

Question 30

presentation of Sheehan's syndrome

Answer 30

``` result of lack of hormones -reduced lactation (lack of prolactin) -amenorrhoea (lack of LH and FSH) - adrenal insufficiency and adrenal crisis, caused by lack of cortisol (lack of CTH) Hypothyroidism (lack of TSH) ```

Question 31

management of Sheehan's syndrome

Answer 31

Oestrogen and progesterone as HRT Hydrocortisone (adrenal insufficiency) Levothyroxine (hypothyroidism) Growth hormone