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Postpartum Flashcards

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1
Q

Definition of a primary and secondary PPH?

When is a PPH major?

A 
Primary= Blood loss >500mls within 24 hours of delivery
Secondary= Between 24hrs to 6 weeks 
Major= >1000mls loss
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2
Q

What are the 4 T’s of PPH

A

Tone
Tissue
Trauma
Thrombin

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3
Q

Antenatal RF for PPH

A

Previous PPH/Retained products, High BMI, Para>4, APH, Uterine overdistension, Uterine abnormalities, Mat age >35

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4
Q

Intrapartum RF for Iol

A

IoL, Prolonged, oxytocin, C-section, Precipitate labour, Operative delivery

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5
Q

Causes of a hypotonic PPH

A 
Overdistension- TWINS
Prolonged, Induction
Infection
Multiple pregnancy
Retained tissue 
Rarely placental abruption
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6
Q

Tissue causes of PPH

A

Retained placenta

Abnormal placental sight- Praevia, Accreta

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7
Q

Trauma causes of PPH

A

Uterine inversion/Rupture

Genital tract trauma e.g tears

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8
Q

Thrombin causes of PPH

A

Coag disorders

Abruption, Sepsis, AI, Liver disease

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9
Q

How do you manage a tissue induced PPH

A

Manual removal +/- GA/Spinal

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10
Q

How does a PPH B/C retained products present?

A

Pain, Bleeding, Offensive Lochia, Boggy poorly contracted uterus
May be infected

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11
Q

Management of a Hypotonic PPH

A

Compression ?Tranexamic acid IV 0.5-1g
IV Syntocinon bolus 10 units + IV Ergometrine 500mcg bolus
IM Carboprost (Prostaglandin) +/- Intramyometrial carboprost
Rectal Misprostol
Anaesthesia and IU Baloon Tamponade or Laparotomy

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12
Q

Eclampsia Management

A

Magnesium Sulphate 4g IV 5-10 mins-> 1g/hr

Delivery baby

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13
Q

How long should you continue magnesium sulphate in eclampsia?

A

Continue until 24 hour post-seizure/delivery

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14
Q

Do prophylactic anti-convulsants help in eclampsia? What is the best method of prevention?

A

No

Best way is to control BP

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15
Q

Causes of secondary PPH

A

Retained products, Endometritis, Infection

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16
Q

Management of secondary PPH

A

24 hours Abx and USS and evacuation

Tranexamic acid 1g stat IV

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17
Q

Most common cause of post-natal septic shock

A

Staph A

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18
Q

Abx for management septic shock

A

Cefotaxime, Metronidazole, Gentamicin

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19
Q

Presentation of amniotic fluid embolus

A

Collapse and unaccountable bleeding, DIC

Dx of exclusion

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20
Q

Management of an amniotic fluid embolus

A

Supportive, Early ITU transfer for inotropic and renal support, Correct clotting, Expert help

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21
Q

Presentation of a uterine rupture

A 
Fresh vaginal bleeding
Haematuria 
Fetal distress
Constant severe abdo pain which breaks through epidural 
Shock
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22
Q

Management of a uterine rupture

A

A->E
IV access
resus
Immediate laparotomy to salvage baby, repair damage +/- Hysterectomy

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23
Q

Risk factors for uterine rupture

A

Previous C-Section
Multips
Uterine stimulants

RARE IF PRIMIPS

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24
Q

What is Colostrum?

A

20weeks + gestation
Thick yellow lactation
Good for gut maturation and immunity of baby
Decreases following birth

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25
Breast feeding benefits to mother
Helps uterine involution Lactational amenorrhoea Decreased breast cancer, ovarian cancer and OP
26
Benefits of breast feeding to infant
Decreased GI illness, Decreased UTIs, Decreased chest infections, Decreased Atopy, Decreased Leukaemia
27
Problems with breast feeding
``` Inadequate milk supply Breast engorgement Mastitis Breast abscess Cracked nipples ```
28
Advice for breastfeeding mothers with mastitis
Continue breastfeeding Analgesia Consider oral Flucloxicillin
29
Which BBVs can be transmitted through breastmilk? | What about if the mum has chickenpox?
HIV Breast lesion +ve= HBV, HSV Rubella can be but transmission of maternal Ab helps (Encourage if Chicken pox)
30
Difference in symptoms between galactocele and breast abscess
Galactocele will be painless and no infective signs
31
Key drugs CI in breast feeding
Amiodarone, Lithium, Methotrexate, Tetracylcines, Chloramphenicol
32
When is contraception required in post-partum?
After Day 21 | N.B If started after this use additional contraception like Condoms
33
Rules of POP post-partum
Anytime post partum
34
Rules for COCP post-partum
Breast feeding and <6 weeks post partum= ABSOLUTE CI (decreases production) UKMEC 2 if 6/52-6/12 Not breastfeeding= ?D21
35
Rules of IUDs,IUS post-partum
Within 48 hours or post-4 weeks
36
What is lactational amenorrhoea?
Effective contraception 98% of the time must be amenorrhoeic and <6 months post-partum and baby must be getting >85% of milk from breast
37
What are the baby blues? When do they resolve?
3 days postpartum Brief MILD emotional instability Resolves spontaneously in 10 days
38
What is Post-natal depression? What do you treat it with?
Peaks 3 months postpartum Key features of depression + Specific parenting worries ``` Mild-mod= Self help, counselling Sev= 1) CBT 2) Sertraline, Paroxetine ```
39
What can antidepressants do to breast milk?
Decrease excretion
40
What is puerperal psychosis?
Rapid onset and presentation within 2 weeks Early non-specific signs with windows of normality Then Psychotic symptoms and rapidly changing mood Need urgent assessment and admission
41
What is florid psychosis?
Rapid onset (hours) Lability of mood Mania, confusion, delusions of control, ramblind, distractibility Pscyh emergency
42
What is lochia and what should happen to it?
Vaginal discharge- Bloody, Uterine tissue, Mucus | Should stop before 6 weeks (USS if not)
43
When should involution be complete by?
2/52 postpartum
44
Presentation of endometritis?
Day 2-10 post natally Offensive vaginal discharge with lochia getting heavier Signs of infection, uterine enlargement with soft boddy tender uterus, abdo pain
45
Investigations for ?endometritis
FBC, CRP, Cultures HVS USS useless as uterine distension means clot looks like placenta
46
Management of ? Endometritis
Admit for IV Abx- admit any puerperal pyrexia! | Clindamycin and gent until >24hrs apyrexial
47
When do you give iron tablets or transfusion for Postpartum anaemia?
80-100g/l- Tablets <80-?Transfusion or IV iron If there is >500ml blood loss always do FBC
48
What is Sheehan's syndrome
Post-partum hypopituitarism caused by ischaemic necrosis of the pituitary gland after blood loss = Amenorrhoea, milk production decreased, Hypothyroidism
49
Risk factors for GBS
Prematurity, Prolonged RoM, Previous sibling with GBS, Maternal pyrexia
50
How do you test for GBS?
ONLY IF HIGH RISK HVS 35-37 weeks or 3-5 weeks prior to EDD
51
Is there universal screening for GBS?
No | Only those at risk
52
Transmission risk of GBS in +ve in previous pregnancy
50%
53
If GBS +ve in previous pregnancy what should you do?
Maternal IV Abx prophylaxis | Testing at 36 weeks +/- Abx in late pregnancy
54
What are the indications for IV Benzylpenicillin during/near labour
Preterm labour | Intrapartum pyrexia
55
Action if there is maternal colonisation with GBS (1 minor RF)
Hospital for 24 hours and regular obs
56
What do you do if someone has >2 minor RF for GBS or 1 red flag
Benzyl +Gent + Septic screen
57
Abx of choice for GBS
Benzylpenicillin
58
What is Ashermann's syndrome
Intrauterine adhesions that prevent the endometrium responding to oestrogen Amenorrhoea
59
What is fibronectin? When is it CI?
Probability of labour in the next 2 weeks | CI: Bleeding, semen in last 24 hours as F+ve
60
Indications for at least 6 weeks post-partum LMWH
Any previous VTE Antenatal LMWH High risk thrombophilia Low risk thrombpophila and FHx
61
Indications for at least 10 days post-natal LMWH
``` C-section Readmission BMI>40 >3 Day admission Any puerperium surgical procedure except perianal repair Medical comorbidities =/More than 2 low risk factors ```
62
minor indications for LMWH, =/>2 of which would require 10 days LMWH
Smoker, >35, BMI>30, p>3, Elective C-section, Gross varicose veins, current systemic infection, Immovility, Current pre-eclampsia, Multiple preg, Preterm, Stillbirth, prolonged
63
What do you do about LMWH if <2 minor indications
Encourage early mobilisation and avoid dehydration

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