Week 4.docx

Care of the Postpartum Patient: Postpartum Care- - Usually done at 6 weeks, but may change to 3 weeks Comprehensive Postpartum Visit: 6-8 weeks Mom: - HPI - Labor and delivery experience- allow the patient to tell the story - Date of delivery - Term or premature - Type of delive...

Care of the Postpartum Patient: Postpartum Care- - Usually done at 6 weeks, but may change to 3 weeks Comprehensive Postpartum Visit: 6-8 weeks Mom: - HPI - Labor and delivery experience- allow the patient to tell the story - Date of delivery - Term or premature - Type of delivery (vaginal c-section) - Interventions: induction of labor including indication, forceps/vacuum, episiotomy or tears - Complications: infection, GDM, preeclampsia, hemorrhage - Recovery bleeding: lochia lasts 4-8 weeks and should have continuous decrease over time; eventually resumption of menses 1. Rubra: dark red/red-brown, days 2-4 2. Serosa: pinkish brown, days 7-22 3. Alba: white to tallow-white, weeks 2-6 incision pain sexual activity: no evidence to suggest timing, may resume by 1 month most resume by 2 months Infant: - Weight - APGAR - Feeding - Circumcision if AMAB - Did the infant spend time in the NICU History - Review and update history need to screen for safety and depression - Meds/allergies; medical/surgical/mental health; reproductive; health maintenance; family hx; social hx - ROS: general HEENT Resp CV Breasts Abdomen Urinary MS/PV Neuro Physical Exam: - Head to toe - GYN: visualization, speculum and bimanual exam - Breast exam: checking for fissures, tenderness, lumps and skin changes - Diagnostic testing if indicated: CBC: prenatal anemia, postpartum hemorrhage, symptomatic and concern for infection TSH: b/c at high risk for thyroiditis 2-hr GTT (preferred), fasting glucose, A1C if they had gestational diabetes Health Promotion/Education: - Maternal attachment: infant feeding; psychological response to birth/parenting - Sleep hygiene - Diet and exercise - Immunizations and routine screenings - Sexual intimacy: contraception and dyspareunia (vaginal dryness) - Return to work, when? Ensure to ask mom because it will depend on work policy **Postpartum Complications:** **Breastfeeding Complications- Mastitis** - More common in the first 3 months of breastfeeding, 2-20% of breastfeeding patients - **Symptoms persist more than 12-24 hrsbacterial infection of parenchyma (usually S. aureus)** - **Risk factors:** breastfeeding difficulties, prior lactational mastitis, stress and fatigue, cracked or fissured nipples, milk stasis/engorgement, breast trauma or restriction, breast pump use, over supply of milk, infrequent feedings Symptoms: 1. Mastitis: unilateral erythema, tenderness, warmth 2. Infective lactational mastitis: firm, red, swollen area of one breast associated with fever \>38.3. Associated symptoms: myalgia, chills, malaise, flu-like symptoms. Physical exam with axillary LAD Differential diagnosis - Severe engorgement: bilateral breasts - Breast abscess: tender, fluctuant area - Plugged duct: no systemic findings - Galactocele: non-tender and no systemic findings (milk filled cyst) - Inflammatory breast cancer: consider if there is no resolution, peau d' orange Treatment: initial management of mastitis for all continue to breastfeed pain management: ibuprofen or Tylenol, cold or warm compresses minimize breast pump usage and avoid nipple shields Antibiotics for infective lactational mastitis: Dicloxacillin 500 mg PO QID or Cephalexin 500 mg PO QID. If pt has MRSA risk or allergy to beta-lactams can treat with Bactrim or Clindamycin (Bactrim is okay in full-term infant at least 1 month old, but avoid in infant with G6PD deficiency) Follow-up in 48-72 hrs if no improvement warrants ultrasound to rule out abscess, consider milk culture if there is no abscess present on ultrasound **Breastfeeding Complications: Breast Abscess** - Complication of mastitis\* - Findings: when mastitis does not improve, fluctuant mass on exam often - Treatment: I and D or needle aspiration - Need to do culture to direct antibiotic therapy - Should continue to breastfeed if infant is able to latch on the unaffected breast - If unable to latch on affected breast pt should hand express or pump milk **Breastfeeding Complications: Nipple Candidiasis** - C. Albicans most common - Symptoms: usually bilateral; burning/stabbing/ or shooting pain in both nipples during and after breastfeeding. Shiny or flaky skin or affected nipple. May have erythema with satellite lesions. - Diagnosis: breast pain out of proportion to physical findings (breast look normal); hx of infant oral or diaper candida infection or maternal VVC; physical exam findings; KOH of skin scrapping or milk culture if available - Treatment: Topical (miconazole or clotrimazole to nipple after each feeding and instruct to remove visible residual medication with olive or coconut oil before feeding) , Infant (nystatin 100,000 units/mL to each side of mouth 4 times a day), Persistent infection (fluconazole 400 mg first day then 200 mg x 14 days) - Check mom for vaginal yeast infection and treat if there - Remember both mom and baby need treatment **Hematologic Complications: Anemia** - Consider with early post partum hemorrhage, anemia of chronic inflammatory disease (lupus, RA) - Symptoms: fatigue, shortness of breath at rest, pale gums - Treatment: iron supplement if Hgb \>7, transfusion if Hgb \35, HTN, preeclampsia/eclampsia, infection, thrombophilia, obesity, smoking - Symptoms: for DVT leg pain, unilateral edema, tenderness, erythema; for PE have chest pain/pressure and SOB - Treatment for DVT: 6 MONTHS of anticoagulation therapy can do heparin or warfarin (safe with breastfeeding), compression stockings, rest until symptoms resolve then gradual increase ambulation **Secondary Postpartum Hemorrhage** - Increased bleeding more than 24 hrs after delivery - Consider uterine atony, retained placenta fragments, infection - If 2-5 days then consider von Willebrand - If you see uterine atony need to massage the fundus HARD and call 911 if in outpatient setting - Symptoms: increased or persistent heavy bleeding more than 1 pad an hour, passing clots size of quarter or larger heavy bleeding after cessation of bleeding hypovolemic shock (shock index tool), ratio of HR to systolic BP, normal is 0.5-0.7 - Management: ultrasound OB/GYN consult hospitalization ergotamine, methylergonovine, prostaglandin analogs **Postpartum Infections: Uterine infection (Endometritis**) - 24 hrs to 2-3 weeks - Risk factors: vacuum/ forceps, shoulder dystocia, C-section, PPH, prolonged ROM, retained placenta, frequent vaginal exams - Symptoms: fever, uterine tenderness and/or midline lower abdominal pain, others: chills, malaise, malodorous, purulent lochia, uterine subinvolution - Treatmenthospitalization for IV antibiotics (clindamycin and gentamicin initially) **Postpartum Infections:** - Incision/laceration perineal infections surgical site infections (3-5%) - Symptoms: pain, erythema, edema at wound edges; Others: low grade fever, dysuria (perineal) - Abdominal wound treatment: debridement, packing - Perineal wound treatment: suture removal, debridement, cleansing - Will give antibiotics for both types **Urinary tract infection:** - Common cause of postpartum morbidity - Symptoms: frequency, urgency, pain - Treatment: antibiotics - Untreated leads to pyelonephritis **Endocrine Complications:** - Thyroiditisusually 1-4 months postpartum hypo or hyper, may be alternating 3 months PP there is an overabundant release of thyroid hormone, lasting 203 months, followed by insufficient release diagnosis: TSH and Free T4; if hyperthyroid do T3 and if hypothyroid do anti-thyroid peroxidase antibodies Treatment: if patient is symptomatic or TSH \>10; for hyperthyroidism treat the symptoms with BB blockers then refer to Endo; hypothyroidism treat with levothyroxine and continue breastfeeding - Diabetes: type 1/type 2: do A1C and continue prepregnancy treatment GDM; 75 gram oral GTT at 6 week pp visit; continue screening every 3 years increased risk of type 2 DM, breastfeeding may prevent development **Cardiac Complications: HTN** - Peaks 3-6 days postpartum - 20% of patients within 6 weeks - Increases risk for stroke - Risk factors: obesity, DM - Follow-up in first 7-10 days (72 hrs if severe) HTN SBP\>140/90 Severe HTN SBP\>160/110 - Prepregnancy HTN: follow up and treat as prepregnancy - Gestational HTN: monitor BP for 12 weeks, if persists diagnosis of chronic HTN - If new onset: need to evaluate for preeclampsia; labs done include CBC w/diff, CMP, urine protein (24-hr or random microalbumin/creatinine ratio) - Treatment: severe HTN need to go to ED non-severe: oral hypertensives the same as during pregnancy; labetalol 100 mg PO BID, Nifedipine ER 30-60 mg PO qday avoid methyldopa bc of risk for PP depression target blood pressure less than 140/90 home monitoring: watch for signs of hypotension as BP returns to normal educate on signs/symptoms of preeclampsia and to avoid NSAIDs **Cardiac Complications: Preeclampsia** - Puerperal preeclampsia24-48 hrs after delivery - Later preeclampsia48 hrs to 4 months postpartum - 1/3^rd^ of cases occur postpartum - Symptoms: headache (most common pp symptom), vision changes, upper abdominal, retrosternal or epigastric pain, altered mental status, new dyspnea or orthopnea - PE: facial edema, visual field deficits, breast sounds, murmurs, extra sounds, liver tenderness, edema, reflexes, mental status - Treatmentto the ER **GU Complications:** - Urinaryvaginal birth complications - Symptoms: stress incontinence (this is not normal); fistula (painless urinary leakage from vagina) - Treatments pelvic floor PT for stress incontinence; referral to GYN for fistula - Pelvic floor therapy can also be helpful during pregnancy to help with delivery\* - Dyspareunia - Symptoms: vaginal dryness and radiating pain - Treatment: lubrication, reassurance, refer to GYN if nerve damage suspected **GI Complications:** - Constipation symptoms: straining, pain, infrequent BM Treatment: diet, fiber supplement, stool softeners - Third- or fourth-degree laceration symptoms: bowel incontinence, fistula, manual disimpaction treatment: refer to GYN - Hemorrhoids symptoms: pain, pruiritis, bleeding treatment: hydrocortisone (topical or suppository), if unresolved refer to colorectal surgeon **Postpartum mood and anxiety disorders**: - Common (5-25%) often reported 2 months PP can occur throughout 1^st^ year - Risk factors: young age, single-parent status, IPV, comorbid illnesses, personal or family history of PMAD - Screen: EPDS (gold standard), PHQ-9 (acceptable alternative) **BABY BLUES:** - Affects 80% of women - But transient and symptoms develop within 2-3 days, peak over next few days, and resolve within 2 weeks of onset - Symptoms: sadness, crying, irritability, anxiety, insomnia, mood swings, fatigue, appetite changes, decreased concentration - Treatment: support, nutrition, exercise **Postpartum Depression:** - Difference between baby blues and PD is that postpartum depression last longer than 2 weeks - Typically in the first 2 months, but consider with any depression in the first year - Symptoms: tearful, irritability or anger, mood swings, fatigue, lack of interest in baby, sleep disturbance, appetite disturbances, guilt/shame, feelings of isolation, hopelessness, loss of pleasure, feelings of harming baby or self - Treatment: first-line is Zuranolone 50 mg PO every night x 14 days; alternatives can do SSRIs sertraline and paroxetine - Can also do CBT or group therapy - Consider mental health consult SSRIs can trigger mani in undiagnosed bipolar **Postpartum Psychosis:** - Can occur anytime in the first year PP - Incidence peaks at 4 weeks PP often presents in the first few days to 10 days after delivery - Has an abrupt onset - Risk factors: history of bipolar disorder or other mental health disorder - Symptoms: hallucinations, delusions, inability to communicate, rapid mood change, paranoia, anxiety, inability to sleep, hyperactivity, disorganized thoughts - Risk for suicide and infanticide - Treatment: immediate referral to impatient mental health treatment **Abnormal Uterine Bleeding and Dysmenorrhea:** **Normal Menses:** - \