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uWISE 13. Postpartum Care
Terms in this set (10)
What is PPH?
Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. It is important to detect excessive bleeding quickly and determine an etiology and initiate the appropriate treatment as excessive bleeding may result in hypovolemia, with associated hypotension, tachycardia or oliguria. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery
What is Sheehan Syndrome?
Sheehan Syndrome is a rare occurrence. When a patient experiences a significant blood loss, this can result in anterior pituitary necrosis, which may lead to loss of gonadotropin, thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) production, as they are all produced by the anterior pituitary. Signs and symptoms of Sheehan syndrome may include slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension and amenorrhea. Sheehan's syndrome frequently goes unnoticed for many years after the inciting delivery. Treatment includes estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones.
.A 21-year-old G1P0 woman delivered a 4000 gram infant by a low-forceps delivery after a protracted labor course that included a three-hour second stage. Her prenatal course was notable for development of anemia, poor weight gain and maternal obesity. Following the delivery, the patient was noted to have a vaginal sulcus laceration and a third-degree perineal laceration, which required extensive repair. Her hematocrit was noted to be 30% on postpartum day one. Which of the following factors places this patient at greatest risk for developing a puerperal infection?
Endometritis in the postpartum period is most closely related to the mode of delivery. Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status.
What is the most common cause of postpartum fever?
The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Endometritis appearing in a postpartum period is most closely related to the mode of delivery and occurs after vaginal delivery in approximately 2 percent of patients and after Cesarean delivery in about 10 to 15 percent. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status. Uterine fundal tenderness is commonly observed in patients with endometritis.
What organisms cause postpartum endometritis?
Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.
What is postpartum depression?
Postpartum depression is a common condition estimated to affect approximately 10-15% of women and often begins within two weeks to six months after delivery. Signs and symptoms of depression which last for less than two weeks are called postpartum blues; it occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited. This patient does not have signs/symptoms of anxiety disorder or bipolar disorder.
How does one differentiate postpartum blues vs. depression?
In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and manifest ambivalence toward her infant. Anhedonia is an inability to experience pleasure from normally pleasurable life events such as eating, exercise, and social or sexual interaction.
A 30-year-old G1P1 woman who underwent an urgent vacuum extraction of a baby girl two months ago is experiencing persistent depressive symptoms suggestive of postpartum depression. She is recently divorced and has no immediate family or close friends. She works as a mechanic in a local garage and is planning on going back to school. She contemplated terminating the pregnancy but ultimately decided to have the baby despite no support from her ex-husband. She has a history of depression in the past but has not required any medications for the last three years. Which of the following is her most significant risk factor for postpartum depression?
The most significant risk factor for developing postpartum depression is the patient's prior history of depression. Other risk factors for postpartum depression include marital conflict, lack of perceived social support from family and friends, having contemplated terminating the current pregnancy, stressful life events in the previous twelve months, and a sick leave in the past twelve months related to hyperemesis, uterine irritability or psychiatric disorder.
A 17-year-old G1P1 female delivered a term infant two days ago. She is not interested in breastfeeding and she asks for something to suppress lactation. Which of the following is the safest method of lactation suppression in this patient?
Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement. Bromocriptine, in particular, is associated with hypertension, stroke and seizures. The safest method to suppress lactation is breast binding, ice packs and analgesics. The patient should avoid breast stimulation or other means of milk expression, so that the natural inhibition of prolactin secretion will result in breast involution.
What cancer does breastfeeding decrease the risk for?
Human milk is recognized by the American Academy of Pediatrics as an optimal feeding for all infants. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months after birth. Physicians can influence a patient's feeding choice, and prenatal education is important in the initiation and maintenance of breastfeeding. Nationally representative surveys have noted that women were more likely to initiate breastfeeding if their physicians or nurses encouraged it. Benefits to the mother include increased uterine contraction due to oxytocin release during milk let down and decreased blood loss. Breastfeeding is associated with a decreased incidence of ovarian cancer. Some studies have reported a decreased incidence of breast cancer. Breastfeeding has not been shown to decrease the risk for developing coronary artery disease, cervical dysplasia and cervical cancer or colon cancer in the mother. Breast milk is a major source of Immunoglobulin A which is associated with a decrease of newborn's gastrointestinal infections.
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