Self-assessment questions: The puerperium I I

Question A

Al) A lactating mother present 10 days after delivery of her first child with mastitis of her right breast.

a) Which is the most common infecting organism? b) How will you treat the problem? c) Can breast feeding continue? d) If treatment is inadequate, what complication will

occur? e) How should this complication be treated? A2) A primiparous patient is found to have a broken

down episiotomy wound on her perineum 10 days after normal vaginal delivery.

a) When is resuturing the treatment of choice? b) If conservative therapy is instituted, how long will

healing take?

c) What antibiotic therapy should be used? d) What are the complications of conservative

therapy? e) How are these best treated? A3) A 35-year-old patient collapses, shocked, 3 h

after the spontaneous vaginal delivery of her second child, without excessive revealed vaginal bleeding.

a) What are the differential diagnoses? b) What is your immediate management? c) What is the prognosis? d) What other diagnoses would have been entertained

if the collapse had occurred immediately after delivery?

Question B

Bl) In the puerperium the incidence of deep venous thrombosis is:

a) Reduced by the decreasing concentration of clot- ting factors VII and X in maternal blood.

b) Increased with age. c) Increased with parity. d) Increased after forceps delivery. e) Increased in women who are breast feeding. B2) By the seventh day after a spontaneous vaginal

delivery: a) The placental site in the uterus has been covered

with new endometrium. b) The haemoglobin concentration has stabilised. c) Bacteria are no longer present within the uterine

cavity. e) Cardiac output falls to pre-pregnant levels. e) Total serum triiodothyronine concentration has

returned to the pre-pregnant level. B3) Human breast milk: a) Contains more lactose than cow’s milk. b) Contains maternal immunoglobulins. c) Reduces iron absorption from the neonatal gut. d) Contains a higher protein concentration than col-

ostrum. e) Contains substances that reduce the likelihood of

susceptible infants developing asthma. B4) Secondary post partum haemorrhage: a) Usually occurs in the fourth week after delivery. b) Is associated with retained products of conception

in only 10% of cases.

c) Is frequently associated with pelvic infection. d) May be a complication of submucous leiomyomata

(fibroids). e) Are usually severe enough to warrant blood trans-

fusion. B5) Puerperal depression: a) Occurs after 3% of pregnancies. b) Is commoner in women with a history of previous

psychiatric problems. c) Is related to social class. d) Usually presents in the first 2 weeks after delivery. e) Usually requires hospitalisation. B6) In the puerperium: a) Lactation prevents ovulation until after the first

menstrual period. b) Lactation is inhibited by depo-progestogen

injections. c) IUCD insertion should be delayed until the postna-

tal visit in most cases. d) The cap is not suitable as a form of contraception

in the first 6 weeks after delivery. e) Sterilization is best performed 2 days after delivery. B7) The following drugs should not be be given to

breast feeding women because of the stated effects on the neonate:

a) Iodides: hypothyroidism. b) Lithium: hypotonia. c) Warfarin: haemorrhage. d) Cyproterone acetate: virilization. d) Vegetable laxative: diarrhoea.

Current Obstetrics and Gynoecohgy (1992) 2, 60-62 0 1992 Langman Group UK Ltd 60

SELF-ASSESSMENT QUESTIONS: THE PUERPERIUM 61

Answer A

Al) Mastitis is an infection of breast tissue that occurs in association with breast feeding, usually following a cracked nipple. Staph. aureu.r is the commonest infecting organism. To treat this problem the breast is rested and milk is expressed and discarded. Although a swab from the nipple and some milk is sent for culture and sensitivity investigations, antibiotic therapy should begin immediately.

The affected breast should be rested until the mastitis had settled. The unaffected breast can continue to be used and once the affected breast has returned to normal that too can be used for further breast feeding. If treatment is inadequate a breast abscess may develop, although this is extremely uncommon. Antibiotics are of no use in treating a breast abscess. Once the area has become fluctuant it should be incised under general anaesthetic and drained.

A21 4

b)

c)

4

4

A3) a)

Occasionally, if the wound is completely broken down and very clean it can be resutured. In many cases, however, breakdown is only partial. The wound is usually heavily contaminated with bacteria and attempts at resuture often fail because of sepsis. Healing by secondary inten- tion is often more successful. Healing by secondary intention takes a long time, often several months. Antibiotic therapy is not indicated. Local anti- sepsis is all that is required. Medium to long-term complications include failure of healing or formation of tender scars, causing superficial dyspareunia. Healing failure will eventually require resutur- ing, although some patients may prefer to defer this until after a subsequent pregnancy. Tender scarred areas can be removed under general anaesthetic and the introitus refashioned.

Haemorrhage into the abdomen (ruptured uterus), the broad ligament or paravaginally. Pulmonary embolus. Eclampsia. Cardiac arrest. Endotoxic shock.

b) Immediate management is concerned with: (i) Maintaining cardiac output.

CVP or pulmonary capillary wedge pressure is essential. Liberal transfusion. Treat left ventricular dysfunction.

(ii) Maintain respiration. Monitor blood gases. Intubate and ventilate if necessary.

(iii)Establish the cause of the problem and elim- inate it if possible. Stopping haemorrhage. Lower blood pressure in eclamptics.

(iv)Replace clotting factors if a coagulopathy develops.

(v) Maintain urine output to prevent renal corti- cal or tubular necrosis.

c) The prognosis depends upon the cause. Approximately 20% of maternal deaths occur in, or shortly after, the third stage of labour. Pulmonary embolism and cardiac arrest have the same prognosis as in non-pregnant patients. Eclampsia is more dangerous postpartum than antepartum because of failure of recognition. Haemorrhage carries the best prognosis.

d) Immediately after delivery, in addition to the causes listed above, one has to consider amniotic fluid embolism and uterine inversion. Amniotic fluid embolism can be differentiated from pul- monary embolism by the severe and immediate coagulopathy that occurs. Uterine inversion is often obvious, but if only of a minor degree must be actively sought for.

Bl) a) False. In pregnancy factors VII, VII, IX and X

are all increased and in the puerperium V, VII and X are further increased together with the platelet concentration.

b) True

4 True. The effects of age and parity are indepen- dent of each other, but both increasing age and increasing parity confers an extra risk on a patient such that a 40-year-old grand multipara has 20 times the risk of developing a deep venous thrombosis as a 20-year-old primipara.

d) True. Although the risk after Caesarean section (a tenfold increase) is that which is most com- monly quoted, after forceps delivery the risk is increased threefold over vaginal delivery.

e) False. There is no evidence that breast feeding or bottle feeding increase the risk of deep venous thrombosis. Attempts at suppression of lac- tation with high doses of oestrogens may be associated with an increase in clotting factors and consequent increase in deep venous throm- bosis but this technique of suppression of lac- tation is now rarely used, Bromocriptine being preferred.

W 4

b)

c)

4

e)

False. New endometrium forms from the basal layer and is complete by 3 weeks after delivery. True. Haemoglobin concentration stabilises by day 5. False. Because of the breakdown of normal defence mechanisms, bacteria ascend into the uterus by the fifth day after delivery, but major infection is prevented by a barrier of leucocytes and granulation tissue that forms below the raw placental site. True. Cardiac output returns to normal within 48 h of delivery. True. Thyroxine and thyroid binding globulin concentrations take 6 weeks to return to non-

62 CURRENT OBSTETRICS AND GYNAECOLOGY

pregnant levels, but triiodothyronine is less pro- tein bound and returns to normal by the seventh day.

B3) a) False. Human milk contains 49 g/l and cow’s

milk 68 g/l. b) True. The immunoglobulins may confer passive

immunity to the neonate. c) True. Human breast milk contains lactoferrin

which binds iron, but also inhibits E. coli. d) False. Colostrum contains 210 g/l of protein,

breast milk only 35 g/l (cow’s milk 11 g/l). e) False. Infants are less likely to develop atopic

illnesses such as eczema and asthma if they are breast rather than bottle fed. However, this is probably due to the absence of foreign proteins in human milk.

B4) a) False. Most secondary post partum haemor-

rhages occur in the second week of the puerperium.

b) False. Retained products of conception are pre- sent in at least 35% of cases.

c) True. d) True. Fibroids may cause failure of involution

of the uterus and placental site. e) False. Most cases are mild, only 1 in 10 requir-

ing blood transfusion.

B5) a) False. Puerperal depression occurs after

lo- 15% of pregnancies. b) True. c) False. The development of puerperal depression

is not related to social class, race or other cul- tural factors.

d) False. Puerperal depression usually presents between 6 and 12 weeks after delivery.

e) False. Most cases are of only moderate severity and are treated at home.

B6) a) False. 33% of women ovulate before the first

menstruation after delivery. b) False. Progestogens, oral or by injection, do not

suppress lactation and are safe forms of contra- ception in mothers who wish to breast-feed.

c) True. Expulsion rates are high if the device is inserted early.

d) True. The patient will probably require a larger cap than before the pregnancy.

e) False. When sterilization is performed within days of delivery the incidence of regret is high. Failure rates of 2-3 times interval sterilization have been quoted, although this is probably related to the techniques used in the past.

B7) a) False. Iodides do pass into breast milk, but

cause neonatal goitre and hypothyroidism. b) True. Lithium causes hypotonia, lethargy and

cyanosis. c) False. Warfarin would anticoagulate the neo-

nate, but does not enter breast milk in sufficient quantity to have a clinically important effect.

d) False. Cyproterone acetate should be avoided because of its anti-androgen effect.

e) True. These laxatives enter breast milk and cause neonatal diarrhoea. They are rarely required as essential therapy for the mother and alternatives such as bulk laxatives should be used.

Current

OBSTETRICS & GYNAECOLOGY

Book reviews

Introduction to Clinical Gynaecological Urology by J. R. Sutherst, M. I. Frazer, D. H. Richmond, B. H. Haylen, Butterworth Heinemann, Guildford. 1990. Price: f19.95 ISBN 0 7506143 3

This delightful book on the Cinderella subject of gynaecological urology achieves more than what the authors intended. They have modestly stated that the book is not intended to be comprehensive or embrac- ing. Although it may not be intended, the book is very comprehensive and indeed it embraces the subject matters from anatomy, physiology, embryology, psy- chology and leading on to the description of all recur- rent relevant investigation techniques. The book concludes with a legion of different clinical approaches both conservative and surgical. The theor-

etical and practical aspects are dealt with enthusiasti- cally and with experience. The text is readily assimilated and the book is complemented with clear diagrams and pictures. A valiant attempt was made to produce algorithms for the approach to the next question of appropriate treatment and in particular to failed treatment.

This well constructed book is a must for every post- graduate, both pre- and post-membership and it should be available to every department of urodynam- its. The book would also be a great help to every health-care professional who has any dealings with voiding disorders.

GM FILSHIE

Currem Obsrerrics and Gymecology (1992) 2, 62 0 1992 Longman Group UK Ltd