Puerperium/Postnatal

Question 1

What is the definition of postpartum haemorrhage (PPH)?

Answer 1

• Blood loss of > 500 mL from genital tract

- From delivery of foetus up until 12 weeks postpartum

Question 2

What is the definition of…

a) Primary PPH
b) Secondary PPH
c) Minor PPH
d) Major PPH

Answer 2

a) From birth of baby up to 24 hours after delivery
b) Between 24 hours after delivery and 12 weeks postpartum
c) Between 500ml and 1000ml blood loss
d) >1000ml blood loss

Question 3

What are the causes of primary PPH?

Answer 3

Remember the 4 T’S!

1) Tone (uterine atony = most common cause)
2) Tissue (retained placental tissue)
3) Trauma (e.g. perineal tear, episiotomy)
4) Thrombin (inherited coagulopathy, e.g. von Willebrand’s, haemophilia OR acquired coagulopathy e.g. DIC/HELLP)

Question 4

Describe the immediate and definitive management of primary PPH

Answer 4

Immediate:

• ABCDE approach
• Two large bore cannulae and bloods (FBC, U&E, LFT, cross match, coagulation)
• Activate major haemorrhage protocol, if necessary

Definitive: depends on cause…

TONE:

• Bimanual compression
• Pharmacological (1st line = syntocinon (oxytocin), 2nd line = ergometrine)
• Surgical (in order: intrauterine balloon tamponade, B-lynch suture, uterine artery ligation, hysterectomy)

TISSUE:

• Syntocinon (oxytocin)
• Manual removal under anaesthetic
• Prophylactic antibiotics

TRAUMA:

• If perineal tear/episiotomy, repair
• If uterine rupture, repair or hysterectomy

THROMBIN:
- Correct coagulation abnormalities with blood products (liaise with haematology)

Question 5

Describe the prevention of primary PPH

Answer 5

Active management of the 3rd stage of labour (syntocinon/oxytocin) significantly reduces risk of primary PPH

Question 6

What is Sheehan’s syndrome? Describe its pathophysiology

Answer 6

Sheehan’s syndrome (also known as postpartum hypopituitarism) is a reduction in the function of the pituitary gland following ischaemic necrosis, due to hypovolaemic shock following birth (i.e. PPH)

Question 7

What are the clinical features of Sheehan’s syndrome?

Answer 7

• Difficulty breastfeeding
• Amenorrhoea
• Weight gain and feeling cold all the time (due to hypothyroidism)
• Hair loss

Question 8

What are the symptoms of postpartum thyroiditis?

Answer 8

• Weight gain
• Constipation
• Fatigue
• Cold intolerance

Question 9

1) Describe the investigation of postpartum thyroiditis

2) How is the diagnosis made?

Answer 9

1) Thyroid function tests

2) Postpartum thyroiditis is diagnosed based on the following 3 criteria:
- Patient is within 12 months of giving birth
- Clinical features of hypothyroidism
- TFTs support diagnosis

Question 10

Describe the management of postpartum thyroiditis

Answer 10

Levothyroxine

Question 11

Which tool is used to screen for postnatal depression?

Answer 11

Edinburgh scale

Question 12

What are the clinical features of mastitis?

Answer 12

• Signs of inflammation of the breast (redness, pain, swelling)
• Fever

Question 13

Describe the management of mastitis

Answer 13

• Conservative measures first (continue breastfeeding, analgesia/warm compresses)
• If symptoms persist, flucloxacillin for 10-14 days

Question 14

If left untreated, mastitis may develop into a…

Answer 14

Breast abscess

Question 15

In a case of postpartum depression, which antidepressant is most appropriate to initiate in a breastfeeding woman?

Answer 15

Sertraline or paroxetine