Prescribing postnatal care and the puerperium psychiatry

Question 1

What are 3 main possible problems in pregnancy, related to drugs?

Answer 1

Teratogenicity - organ formation completed at end of first trimester

Miscarriage/death

growth restriction

Question 2

Which conditions are more common in pregnancy?

Answer 2

VTE - body preparing for blood loss in child birth

haemorrhage

Pain

Infection

Hypertension

Question 3

What can we give a woman as VTE prophylaxis/treatment?

Answer 3

Unfractionated heparin (not commonly)

LMWH - tinzaparin

Alteplase may be used only if life threatening (unsure of effects)

Question 4

What CANNOT be given for VTE/treatment? Why is this?

Answer 4

Warfarin

stillbirth
prematurity
haemorrhage
ocular defects.

Fetal warfarin syndrome: nasal hypoplasia
hypoplasia of the extremities developmental delay.

Question 5

How do you manually compress uterus (to stop bleeding)?

Answer 5

2 fingers in vagina

Pressure on fundus to try and contract it down

Question 6

What things can cause postpartum haemorrhage?

Answer 6

Infection
Prone to bleeding
Multip (>4 children)
Trauma: cervical trauma, tear etc.

Question 7

Where should the uterus be palpable following delivery?

Answer 7

below umbilicus

Question 8

When is misoprostol given in gynaecology?

Answer 8

To start a termination pregnancy or if someone is bleeding after miscarriage

Management of miscarriage 800mcg

causes cramping in uterus, helps it to expel anything that’s inside

Cervial softner

Question 9

When is mifepristone given? What dose?

Answer 9

mid-trimester loss/TOP

given to prime cervix before any other treatment

200mg

Question 10

When is methotrexate given?

Answer 10

given in ectopic pregnancy

usually given as one off dose, or given as a second dose

EXTREMELY TOXIC TO PREGNANCY

Question 11

When is tranexamic acid given?

Answer 11

menorrhagia

post-partum haemorrhage

Question 12

What type of drug is tranexamic acid?

Answer 12

anti-fibrinolytic

Question 13

When is mefenamic acid given? What type of drug is it?

Answer 13

period pain

NSAID

Question 14

What type of drug is prostap/gonapeptyle? What does it do? When is it given?

Answer 14

GnRH analogues

Induces a massive drop off of oestrogen (chemical hysterectomy)

Given in endometriosis - treat (or one dose can be used of diagnosis)

Can also be used to shrink fibroids

Question 15

When are progesterones given? (POP, injection, mirena)

Answer 15

All used to suppress ovulation

Can be used as a form of contraception

Question 16

What pain relief can be used in pregnancy?

Answer 16

paracetamol

opiates (can cause neonatal resp. depression, but generally safe codeine/diamorphine)

entonox

Question 17

Why must you avoid NSAIDS in pregnancy?

Answer 17

miscarriage and malformation in 1st trimester

premature closure of the DA in 3rd trimester

Question 18

What can happen if a woman take opioids regularly for a long period of time?

Answer 18

Baby may need further care after birth

Question 19

Why don’t you give trimethoprim in first trimester?

Answer 19

anti-folate

increases risk of neural tube defects
teratogenic

Question 20

Why don’t you use nitrofurantoin in the third trimester?

Answer 20

neonatal haemolysis

Question 21

What ABX would you give to a pregnant woman with a UTI?

Answer 21

penicillins and cephalosporins

Question 22

What ABX should you avoid in pregnancy? why?

Answer 22

co-amoxiclav - necrotising enterocolitis

tetracyclines - brown teeth

trimethoprim in 1st trimester - teratogenic and anti-folate

nitrofurantoin in 3rd trimester - neonatal haemolysis

Question 23

What investigation should you do for a woman who has lost >500mls of blood?

Answer 23

FBC day after delivery?

Question 24

What is endometritis?

Answer 24

infection within uterus

Question 25

After how many days does endometritis occur?

Answer 25

2-10 days

Question 26

Does C-section make endometritis more or less common?

Answer 26

more

Question 27

How might endometritis present?

Answer 27

Offensive vaginal loss ``` Symptoms: Fever, malaise, rigors, tachycardia Headache Abdo pain/suprapubic tenderness/uterine enlargement Offensive lochia Secondary PPH ```

Question 28

What investigations would you do for a women in whom you suspected endometritis?

Answer 28

FBC CRP HVS Blood cultures NOT USS in first instance

Question 29

in which leg will most DVTs occur?

Answer 29

L

Question 30

which investigation for DVT/PE has a higher risk for the mum? which one for the baby?

Answer 30

CTPA - mum V/Q can - baby

Question 31

How long do you generally have to wait before starting/re-starting progesterone pill after childbirth?

Answer 31

6 weeks afterwards

Question 32

What is the main cause of post-natal/post-partum haemorrhage? What are other causes?

Answer 32

Uterine atony Four Ts: tone trauma tissue/infection thrombin

Question 33

How can uterine atony be treated medically?

Answer 33

Uterotonics: Syntoncinon = synthetic oxytocin (bolus 5 units IV, followed by infusion) Syntometrine (3rd stage management): combo of oxytocin 5 units and ergometrine 500mcg (IM bolus) Misoprostol - prostaglandin 800mcg PR Haemabate 250mcg IM

Question 34

What ABX are safe to give a pregnant woman with RTI?

Answer 34

Penicillins | Marcolides

Question 35

What ABX are safe to give a pregnant woman with PPROM?

Answer 35

Erythromycin 250mg QDS PO 10/7 to prevent chorioamnionitis

Question 36

What ABX would you give a woman with chorionamionitis?

Answer 36

``` Cefuroxime 1.5g TDS IV AND Metronidazole 500mg TDS IV ```

Question 37

What ABX would you prescribe a woman with endometritis?

Answer 37

Co-amoxiclav 1.3g iv tds Clindamycin + Metronidazole if penicillin allergic

Question 38

What antihypertensives would you prescribe a pregnant woman?

Answer 38

Labetalol - beta blocker (contraindicated in asthma). Nifedipine - calcium channel blocker (good in black/africa/carribean patients)

Question 39

Why should you NOT use ACEi or ARBs in pregnancy?

Answer 39

fetal renal damage in 2nd and 3rd trimester possible malformation in 1st trimester

Question 40

What anticonvulsant is first line in eclampsia?

Answer 40

MgSO4 iv

Question 41

What are first line anti-epileptics for pregnant women?

Answer 41

Lamotrogine Levieracetam

Question 42

Why shouldn't valproate be used in pregnancy for epilepsy?

Answer 42

Associated with neural tube and development defects

Question 43

What dose of folic acid should be given to pregnant women with epilepsy (or those trying to conceive)? Why?

Answer 43

5mg folic acid Neural tube defect reduction

Question 44

What is puerperium?

Answer 44

6 week period following birth changes that occurred during pregnancy and childbirth revert to non-pregnant state

Question 45

What are some maternal physiological changes that occur during puerperium?

Answer 45

Involution (funds below umbilicus immediately - no longer palpable 2/52) Lochia - blood + necrotic decidua Lactation - due to raised prolactin and oxytocin levels

Question 46

If a woman has a Hb of 80-100g/l after childbirth, how would you treat this?

Answer 46

oral iron

Question 47

If a woman has a Hb of <80g/l and is symptomatic after childbirth, how would you treat this?

Answer 47

blood transfusion

Question 48

If a woman has a Hb that is not low enough to warrant transfusion, but is symptomatic, how would you treat this?

Answer 48

IV iron

Question 49

When does endometritis generally present after birth?

Answer 49

day 2-10

Question 50

When is endometritis more common?

Answer 50

After section

Question 51

How does endometritis present?

Answer 51

Offensive vaginal loss Fever, malaise, rigors, headache Tachycardia abdo pain, suprapubic tenderness/uterine enlargement offensive lochia secondary PPH

Question 52

How would you investigate for endometritis?

Answer 52

FBC CRP HVS Blood cultures NOT USS IN FIRST INSTANCE

Question 53

What is the most common cause of endometritis?

Answer 53

Group A strep

Question 54

What are other causes of endometritis?

Answer 54

Staph Enterococcus E coli anaerobes: cocci

Question 55

How would you treat puerperium endometritis?

Answer 55

Co-amoxiclav Cefuroxime + metronidazole

Question 56

What are common sites of infection after birth?

Answer 56

``` Uterus, vagina etc. Perineum UTI Chest Throat Breast ```

Question 57

What are common puerperium breast problems?

Answer 57

Breast engorgement Mastitis (not always infective, can be due to blocked ducts) Sore/cracked nipples

Question 58

How might thromboembolism present?

Answer 58

unilateral calf pain redness or swelling SOB or chest pain

Question 59

How would you investigate a woman in the puerperium for thromboembolism?

Answer 59

Obs ECG Leg dopplers VQ scan/CTPA

Question 60

How would you manage a woman with thromboembolism during puerperium?

Answer 60

LMWH Warfarin

Question 61

What are the different types of post-natal depression?

Answer 61

Baby blues Postnatal depression (PND) Puerperal psychosis

Question 62

What are some PND symptoms?

Answer 62

``` MOOD CHANGES: FEELING LOW MISERABLE TEARFUL IRRITABLE WITH OTHERS ``` SLEEP DISTURBANCE NO ENERGY POOR APPETITE ANXIETY PANIC ATTACKS FEELING WORTHLESS UNABLE TO COPE SUICIDAL THOUGHTS HARMFUL THOUGHTS possibly to baby

Question 63

What post-natal care is given to women?

Answer 63

Maternal observations Pain relief Observe lochia and involution Observe wounds - perineal and LSCS Ensure passing urine, eating, drinking, stool, flatus VTE assessment, VTE prevention advice HB check Rubella vaccination Anti-D Early neonatal feeding/neonatal care