Postpartum Complications

Question 1

What is a Galactocele?

Answer 1

A build up of milk creates a cystic lesion in the breast. The lesion can be differentiated from an abscess by the fact that a galactocele is usually painless, with no local or systemic signs of infection.

Question 2

Galactocele typically occurs in

Answer 2

women who have recently stopped breastfeeding and is due to occlusion of a lactiferous duct.

Question 3

Breast feeding: suppressing lactation

Techniques

Answer 3

stop the lactation reflex i.e. stop suckling/expressing
supportive measures: well-supported bra and analgesia
cabergoline is the medication of choice if required

Question 4

nipple pain: may be caused by

Answer 4

poor latch

Question 5

frequent feeding in a breastfed infant is a sign of low milk supply

Answer 5

false

frequent feeding in a breastfed infant is not alone a sign of low milk supply

Question 6

blocked duct (‘milk bleb’) sx

Answer 6

nipple pain when breastfeeding

Question 7

blocked duct (‘milk bleb’) mx

Answer 7

Breastfeeding should continue. Advice should be sought regarding the positioning of the baby. Breast massage may also be tried

Question 8

treatment for nipple candidiasis whilst breastfeeding

Answer 8

should involve miconazole cream for the mother and nystatin suspension for the baby

Question 9

Mastitis affects around 1 in 10 breastfeeding women.

Answer 9

true

Question 10

Mastitis antibiotic indications

Answer 10

systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection

Question 11

Mastitis antibiotics

Answer 11

first-line antibiotic is flucloxacillin for 10-14 days

Breastfeeding or expressing should continue during treatment.

Question 12

If left untreated, mastitis may develop into a breast abscess.

Answer 12

True

This generally requires incision and drainage.

Question 13

Breast engorgement is one of the causes of breast pain in breastfeeding women.

Answer 13

true

Question 14

Breast engorgement usually occurs

Answer 14

in the first few days after the infant is born

Question 15

Breast engorgement usually affects both breasts

Answer 15

true

Question 16

sx breast engorgement?

Answer 16

The pain or discomfort is typically worse just before a feed.

Milk tends to not flow well from an engorged breast and the infant may find it difficult to attach and suckle.

Fever may be present but usually settles within 24 hours.

The breasts may appear red.

Question 17

what help relieve the discomfort of engorgement.

Answer 17

Although it may initially be painful, hand expression of milk

Question 18

Raynaud’s disease of the nipple sx

Answer 18

Pain is often intermittent and present during and immediately after feeding.

Blanching of the nipple may be followed by cyanosis and/or erythema.

Nipple pain resolves when nipples return to normal colour.

Question 19

Raynaud’s disease of the nipple mx

Answer 19

advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking.
If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).

Question 20

Around 1 in 10 breastfed babies lose more than the ‘cut-off’ threshold in the first week of life.

Answer 20

true

Question 21

What is the ‘cut-off’ threshold for poor infant weight gain

Answer 21

loss 10% in first week

Question 22

ix baby lose more than the ‘cut-off’ threshold in the first week of life.

Answer 22

prompt consideration of the above breastfeeding problems.
The infant should also be examined to look for any underlying problems. NICE recommends an ‘expert’ review of feeding if this occurs (e.g. midwife-led breastfeeding clinics) and monitoring of weight until weight gain is satisfactory

Question 23

The following drugs CAN be given to mothers who are breastfeeding:

Answer 23

antibiotics: penicillins, cephalosporins, trimethoprim
endocrine: glucocorticoids (avoid high doses), levothyroxine
epilepsy: sodium valproate, carbamazepine
asthma: salbutamol, theophyllines

psychiatric drugs: tricyclic antidepressants, antipsychotics

hypertension: beta-blockers, hydralazine
anticoagulants: warfarin, heparin
digoxin

Question 24

Which antibiotics should be avoided in breastfeeding

Answer 24

ciprofloxacin, tetracycline, chloramphenicol, sulphonamides

Question 25

Which psychiatric drugs should be avoided in breastfeeding

Answer 25

lithium, benzodiazepines

Question 26

Which cardiovascular drugs should be avoided in breastfeeding

Answer 26

amiodarone | aspirin

Question 27

Which endocrine drugs should be avoided in breastfeeding

Answer 27

carbimazole | sulfonylureas

Question 28

Which rheumatoid drugs should be avoided in breastfeeding

Answer 28

methotrexate

Question 29

cytotoxic drugs should be avoided in breastfeeding

Answer 29

true

Question 30

The Edinburgh Postnatal Depression Scale may be used to screen for depression:

Answer 30

10-item questionnaire, with a maximum score of 30 indicates how the mother has felt over the previous week score > 13 indicates a 'depressive illness of varying severity' sensitivity and specificity > 90% includes a question about self-harm

Question 31

Outline post-partum mental health problems & epidemiology for the following: 'Baby-blues' Postnatal depression Puerperal psychosis

Answer 31

'Baby-blues' - Seen in around 60-70% of women Postnatal depression - Affects around 10% of women Puerperal psychosis - Affects approximately 0.2% of women

Question 32

Onset of 'Baby-blues'

Answer 32

Typically seen 3-7 days following birth and is more common in primips

Question 33

Onset of Postnatal depression

Answer 33

Most cases start within a month and typically peaks at 3 months

Question 34

Onset of Puerperal psychosis

Answer 34

Onset usually within the first 2-3 weeks following birth

Question 35

Baby blues sx?

Answer 35

Mothers are characteristically anxious, tearful and irritable

Question 36

Baby blues mx?

Answer 36

Reassurance and support, the health visitor has a key role

Question 37

Postnatal depression mx?

Answer 37

As with the baby blues reassurance and support are important Cognitive behavioural therapy may be beneficial. Certain SSRIs

Question 38

Postnatal depression mx - which SSRIs?

Answer 38

sertraline and paroxetine may be used if symptoms are severe

Question 39

SSRIs are not secreted in the breast milk

Answer 39

false | whilst they are secreted in breast milk it is not thought to be harmful to the infant

Question 40

Puerperal psychosis There is around a 25-50% risk of recurrence following future pregnancies

Answer 40

true

Question 41

Postnatal depression mx - paroxetine is recommended by SIGN because

Answer 41

low milk/plasma ratio

Question 42

Postnatal depression mx - fluoxetine

Answer 42

best avoided due to a long half-life

Question 43

Post-partum thyroiditis - Three stages

Answer 43

1. Thyrotoxicosis 2. Hypothyroidism 3. Normal thyroid function (but high recurrence rate in future pregnancies)

Question 44

Post-partum thyroiditis antibodies?

Answer 44

Thyroid peroxidase antibodies are found in 90% of patients

Question 45

Post-partum thyroiditis mx

Answer 45

the thyrotoxic phase is not usually treated with anti-thyroid drugs as the thyroid is not overactive. Propranolol is typically used for symptom control the hypothyroid phase is usually treated with thyroxine

Question 46

Postpartum haemorrhage (PPH) is defined as

Answer 46

blood loss of > 500mls and may be primary or secondary

Question 47

Primary PPH | occurs within

Answer 47

24 hours

Question 48

most common cause of PPH

Answer 48

``` uterine atony (90% of cases) Other causes include genital trauma and clotting factors ```

Question 49

Risk factors for primary PPH include

Answer 49

``` previous PPH prolonged labour pre-eclampsia increased maternal age polyhydramnios emergency Caesarean section placenta praevia, placenta accreta macrosomia ritodrine (a beta-2 adrenergic receptor agonist used for tocolysis) ```

Question 50

PPH mx - medical

Answer 50

ABC including two peripheral cannulae, 14 gauge IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms IM carboprost if medical options failure to control the bleeding then surgical options will need to be urgently considered

Question 51

PPH mx - surgical

Answer 51

intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Question 52

Secondary PPH | occurs when

Answer 52

between 24 hours - 12 weeks

Question 53

Secondary PPH | occurs due to?

Answer 53

retained placental tissue or endometritis

Question 54

Puerperal pyrexia may be defined as

Answer 54

a temperature of > 38ºC in the first 14 days following delivery.

Question 55

Puerperal pyrexia causes

Answer 55

``` endometritis: most common cause urinary tract infection wound infections (perineal tears + caesarean section) mastitis venous thromboembolism ```

Question 56

Puerperal pyrexia mx

Answer 56

if endometritis is suspected the patient should be referred to hospital for intravenous antibiotics (clindamycin and gentamicin until afebrile for greater than 24 hours)