OBgyn Week 11

1. OBgyn Week 11 Post Partum Concerns, Breastfeeding, Breast Health

2. Post Partum Complications • Postpartum hemorrhage • Defined as blood loss over 500ml (about 2 cups) • 5% of births end up in a hemorrhage • Maternal hemorrhage accounts for 25% of maternal deaths perinatally • Bleeding to death can occur in 7 minutes • Most likely occurs immediately post-partum but it can happen later • Early pp hemorrhage occurs in first 24 hours • Late pp hemorrhage occurs within 1-6 days; usually dt retained fragments; more likely to be complicated by DIC

3. Hemorrhage • Can be due to retained tissue Signs/ symptoms of retained secundines: (products of conception that are not the baby) • Abdominal tenderness • Slight non-involution (return to prePG state) of the uterus • Post-partum involution refers to the gradual return of the reproductive organs back to their non-pregnant state • Fever or temperature over 99.4 degrees F

4. Hemorrhage • Risk factors for hemorrhage

5. Hemorrhage • Characteristics of hemorrhage: • Can gush or be slow trickle bleed • Non-visible: clots inside uterus • Bright red blood or pulsating: artery rupturedSurgery required. • Some women can tolerate blood loss better than others; depends on: • Quantity of blood loss • Hgb levels – higher levels = less shock • Self awareness– psychological factors • Blood volume • Body weight

6. Hemorrhage • Hemorrhage may be stopped by achieving uterine contractions/ clamping down. These will help expel all contents: • Nipple stimulation • Uterine massage/ bimanual compression • Methergine: causes large uterine contraction • Pitocin: usually used to stimulate labor, causes contractions • O2 administration and Trendelenburg position (on back with feet above heart level) help prevent shock / shut-down of rest of body

7. Shock • Shock • CV system fails to provide sufficient circulation, tissues eventually suffer from a lack of oxygen • Compensatory mechanism designed to keep brain well oxygenated during CV insufficiency • Brain remains oxygenated by: • Peripheral vasoconstricion of circulation so blood is pulled to internal vital organs • Increased HR to increase blood to brain • Increased respirations to maximize oxygen in blood

8. Types of Shock • Hypovolemic: decreased blood volume due to internal or external hemorrhage; main type in deliveries • May also be dt dehydration (sweating, diarrhea, vomiting) • Cardiogenic: heart failure • Neurogenic/vasogenic: decreased vascular tone leads to anaphylactic shock (over release of histamine) which leads to vasorelaxation of parasympathetic NS • Sepsis, blood poisoning, bee sting, etc. • Psychogenic: fainting dt vasorelaxation then vasoconstriction

9. Shock S/SX • Shock signs/ symptoms • Restlessness • Anxiety • “Spaciness” • Foreboding feeling • Rapid, shallow respiratory rate • Increased HR but weak and thready • Skin cool, clammy pale • Nausea/ vomiting, pupils dilated • Change in BP of 10mm Hg from normal, or systolic < 80

10. Shock Tx • To treat shock, stop hemorrhage • May require ER • Many western and Chinese herbs can help with shock and hemorrhage • Trendelenburg position to increase brain O2 • Acupuncture (from Dr. Fritz) • Sp 10, Lr 1, Sp1, Sp 6, CV4, Sp 9, moxa • Dizziness after delivery: CV 7, GV 20, Sp 6 • Shock: CV 24, K 1, Pc 5, Pc 6, Pc 7, Lu 9, ST 36

11. PP Complications - Hematoma • Hematoma • Rupture of blood vessel causing extravasation of blood into tissue – pools between tissue layers. Enough of this can cause shock. Can be painful as well as tissues are stretched. • Predisposing factors: • Prolonged second stage – in birth canal for longer • Excessive use of perineal stretching • Instrumentation – forceps i.e. • Macrosomia – large baby

12. Hematoma • Hemotoma signs/ symptoms • Swelling, bruising • Signs of shock: increased pulse, hypotension • As much as 1500cc can accumulate in broad ligament hematoma • Displacement of uterus • Pain • Hematoma management: • Apply pressure • Stop bleeding– mb necessary to open and ligate vessel • Prevent infection

13. PP Complications - thromboses • Thrombosis: presence of a thrombus (blood clot still attached at the site of its formation) in a blood vessel • 5X more likely in the pregnant and parturient patient • In the parturient patient high risk of pulmonary embolism (embolus is the same as a thrombus but it’s been dislodged); still a major cause of maternal death (parturient = in labor)

14. Thromboses • Thrombosis predisposing factors: • Caesarian section – many clotting factors used • > 35 yo (increased age) • High parity • Obesity • Smoking (esp combined w/oral contraceptives) • Immobility • Trauma to legs

15. Thromboses • Thrombosis signs/ symptoms • Superficial thrombophlebitis: tenderness, very hard, feel a lump, red, and warm • Deep vein thrombosis: pain swelling, + Homan’s sign (lay ‘em down, raise the knee, quickly dorsiflex the foot = pain then that’s a positive Homan’s sign) • Diagnosed with ultrasound, venography

16. PP Complications - Emboli • Pulmonary embolism signs/ symptoms • Severe chest pain – causes necrosis in the fx’d part of lung • Dyspnea – esp SOB. Compromises O2 xchg. • Shock sx • Slight hemoptysis • Mb asymptomatic if clot large enough; death may occur without warning. Seems counter-intuitive. • Collapse • Cyanosis • Hypotension (look for dizziness)

17. Emboli • Amniotic fluid embolism • Definition: amniotic fluid entering maternal circulation. May cause obstruction of pulmonary vessel but seems to more often cause anaphylaxis • Predisposing factors: • Precipitous labor • Multiparity • Excessive use of oxytocic drugs or prostaglandins • Uterine trauma: rupture, Caesarian, catheter insertion

18. Emboli • Amniotic fluid embolism signs/ symptomsSame sx as other embolism • Dyspnea • Rapid, shallow respirations • Pulmonary edema • Tachycardia • Hypotension • Convulsions • Hemorrhage dt DIC • Mortality rate up to 86% • 25% of deaths occur in first hour

19. PP Complications - Puerperal Fever • Septicemia usu due to strep bacteria • Usu accompanied by fever • Infxn route: traumatized birth canal tissues • Includes infections of genital tract: perineum, vagina, cervix, uterus, adnexae as well as breast infxn and UTI

20. Puerperal Fever • Predisposing factors • PROM • Prolonged labor • Trauma • Intrauterine manipulation • Hemorrhage • Anemia • Malnutrition/ low socioeconomic status • Retained parts

21. Puerperal Fever • Signs/ symptoms • Temperature > 100.4 F po • Chills • Pain • Foul discharge • Body aches • Management • Rest and hydration • Determine source of infection • Simple meals: bone broth • Antibiotics may be necessary, but should be avoided if possible (esp if breast feeding)

22. PP Complications - Depression • Post partum depression • Approximately 10% of new moms experience PPDep • Due to sudden change in hormones (hormones are a main cause of depression) • Mild form: “baby blues: • Mood swings • Anxiety • Sadness • Irritability • Crying • Decreased concentration • Difficulty sleeping

23. PP Depression • Post partum depression: signs and symptoms more intense and longer lasting than “baby blues” (>6 weeks) • Loss of appetite • Insomnia • Intense irritability and anger • Overwhelming fatigue • Loss of interest in sex • Lack of joy in life • Feelings of shame, guilt, or inadequacy • Severe mood swings • Difficulty bonding with baby • Withdrawal from family and friends • Thoughts of harming self or baby

24. Psychosis • Postpartum psychosis • Rare, develops within first two weeks after delivery • Symptoms as with PP Depression, but more severe and also include: • Confusion, disorientation • Hallucinations and delusions • Paranoia • Attempts to harm self and/or baby

25. PP Depression • Etiology: • Rapid drop in estrogen, progesterone, possibly thyroid hormones • Emotional factors: anxiety, sense of identity, loss of control • Sleep deprivation • MOMS SHOULD GET SLEEP WITHIN 6 HOURS OF DELIVERY TO HELP PREVENT PPD • Lifestyle influences: demanding baby or older siblings, financial problems, lack of support

26. PP Depression • PPD Risk factors • May happen after the birth of any child, not just the first • History of depression • PPD after a previous pregnancy • Stressful events in past year • Marital conflicts • Weak support system • Unplanned or unwanted pregnancy • Risk of PP psychosis higher for women who have bipolar disorder

27. PP Depression • Post partum depression • Important to warn new moms about signs and symptoms of PPD, explain not to get embarrassed, that it is important to seek help especially if having difficulty taking care of baby • Seek immediate help if thoughts of wanting to harm self/ baby • If untreated, can last up to a year or longer or may become a chronic depressive disorder • Increases a woman’s risk of future episodes of major depression

28. PP Depression • Treatment may include: • Counseling • Antidepressants – common in biomedicine • Hormone therapy (thyroid; careful with HRT while breastfeeding!), check hormone therapies • Acupuncture, herbal therapy, qi gong • Getting support network involved

29. PP Depression • Prevention • Sleep within 6 hours after delivery • Healthy lifestyle choices that include physical activity (preferably outdoors) and good nutrition • Set realistic expectations • Mommy time • Avoid isolation

30. Post Partum - Resuming Sexual Activity • Pelvic rest is indicated for 6 weeks PP • Immediate risk: air embolism, infection, perineal trauma, thrombus, embolism • Later risks: infection, perineal trauma • If episiotomy/ laceration, pelvic rest recommended for up to 8 weeks • ~1/3rd of women resume sex by 6 weeks • Also, No Tampons!!

31. Resuming Sexual Activity • Resuming sex is often difficult for postpartum moms • Low libido • Decreased interest (normal for a few weeks to months); focus is on baby • Oxytocin in the system can satisfy her, so she doesn’t really want sex. • Decreased enjoyment • Kegels, pelvic weights to increase vaginal tone

32. Dysparunea • DysparuneaAlways a bad sign • 40% women report pain/ discomfort with intercourse at 3 months PP • Evaluate healing of tissue • Evaluate hormonal effect on mucosa • Evaluate for infection

33. Resuming Sexual Activity • Other factors affecting resuming sex • Episiotomy or laceration • Hormonal imbalance • Fatigue • Post partum depression • Complications of labor or postpartum • Breastfeeding: may lower libido initially; high prolactin levels give a greater sense of contentment

34. Breasts • Breast Health • Breastfeeding

35. Breast Exam • Self Exam - starting age 20 • Clinical Exam - ages 20-39, every 1-3 years, usu done same time as Pap exam.Timing depends on results from Pap. • Screening Mammogram - yearly starting age 40 or 50, earlier if high-riskRecently changed to age 50, but there’s a lot of disagreement in the groups who decide these things. And there general guidelines don’t apply if there’s a family hx, etc.

36. Breast Self Exam • May be taught by practitioner during first exam • Do same way, same time each month • Feeling for changes, asymmetry, lumps • Looking for skin changes, discharge, asymmetry • May be done in shower – soap makes it easier • Be sure to examine entire breast, including area towards axilla • Palpation with fingertips plus visual inspection as well • Most breast cancers are detected first by patient

37. Breast Self Exam

38. Breast Self Exam - Visual

39. Breast Changes • Change in size, firmness, tenderness nodularity normal with monthly cycle Nipple discharge should be investigated, esp if one sided, bloody.

40. Clinical Breast Exam • Inspection • Symmetry, contour, skin appearance (peau d’orange) • Palpation • Performed with patient sitting, supine (w/hands under head), or both • Palpate in strips or concentric circles • Don’t forget tail of Spence • Palpate axillary and clavicular nodes • Assess for • Temperature, texture, density, nodularity, tenderness, asymmetry, mass, nipple discharge

41. Breast Imaging Techniques • Mammography • Current standard for screening and diagnosis • Ultrasonography • Used in conjunction with mammography, can distinguish solid from cystic masses • Magnetic resonance imaging • May be useful in certain situations, no radiation • New evidence emerging about benefits of MRI for Dx of DCIS (ductal in situ cancer)

42. Imaging Techniques • Positron emission tomography • Assesses metabolic activity of tumors • Technetium-99m sestamibi • New technology, still being evaluated • Thermography • Not shown to be useful for screening or diagnosis • May be useful in specialized situations

43. Breast Imaging • Mammography and ultrasonography are the most reliable and common imaging techniques for the early detection of breast lesions • Slowly growing breast cancers can be identified by mammography at least 2 years before the mass reaches a size detectable by palpation • ~35-50% of early breast cancers can be discovered only by mammography, and 20% can be detected only by palpation

44. Breast Biopsy • The diagnosis of breast cancer is made by examination of tissue removed by biopsy • Biopsy should be performed on all patients with a dominant or suspicious mass found by PE, and on all suspicious lesions shown by mammography, even with a negative PE • Mammography is not a substitute for biopsy • Typically, biopsy is performed by needle or excision techniques

47. Benign Breast Conditions • Fibrocystic change • Most common lesion of the breast • Covers a spectrum of clinical signs, symptoms, and histologic change • Common in 35-55 year old women • Estrogen is thought to promote clinical symptoms • Cysts arise from breast lobules • Rare after menopause, common during perimenopause

48. Fibrocystic Change • Clinical findings • Pain and tenderness, often premenstrual • Occasionally painless • Fluctuation in size, rapid appearance and disappearance common • Cyclic breast pain most common symptom • Usually multiple and bilateral • DDX • If a dominant mass is palpated, carcinoma must be ruled out with mammography, ultrasonography, and biopsy if appropriate

49. Tx of Fibrocystic Change • Conventional treatment • Supportive bra night and day • Bromocriptine – 2.5 mg BID X 3-6 months • Danazol – 100-200 mg BID • Tamoxifen • Analgesic agents - NSAIDS • Diuretics • Progestogen

50. Tx of Fibrocystic Change • Naturopathic treatment • Strategies • Decrease inflammatory activity in breast • Reduce relative estrogen excess and sensitivity to estrogen – consume soy and other phytoestrogens as they binds with the estrogen receptors and reduces production internally…unless px has estrogen sensitive/induced tumors.** • Provide diuretic activity