BUILDING A HEALTHY COMMUNITY Office-based Postpartum Care Dr. Kristine Whitehead, M.D., C.C.F.P....

BUILDING A HEALTHY COMMUNITYBUILDING A HEALTHY COMMUNITY

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Office-based Postpartum Care

• Dr. Kristine Whitehead, M.D., C.C.F.P.• Assistant professor Family Medicine• Somerset West Community Health Centre• March 2011



From the Hospital

• MMR, Rhogam

• Influenza vaccine prn

• D/C meds: ibuprofen, acetaminophen, colace

• Health Dept. follow-up

• Hearing test

• Newborn screening, serum bili



48 Hour Visit

• 1. Baby - Feeding assessment: newborn passport

• NB weight, d/c weight, output• Jaundice• Ensure hearing test and BW done prior to d/c

• 2. Mom



Case #1

• Baby boy L., parents studying, from China

• Exclusively breastfed

• Bili on discharge normal

• Moderate jaundice in office day 4

• Adequate weight gain/output

• Increased jaundice day 6



Con’t

• A4 bili day 6 330 umol/L

• CHEO bili 315 umol/L on day 7

• Looks well

• Feeding well, adequate weight gain

• Repeat bili day 17 = 246



Guidelines for intensive phototherapy

• Available on every NB chart

• Usually graphed by RN

• Available on intranet

• 2 categories: risk factors for kernicterus vs. risk factors for severe jaundice



Risk factors for kernicterus

• Acidosis, asphyxia, respiratory distress, lethargy, temperature instability, sepsis

• Isoimmune hemolytic disease, G6PD deficiency



Risk factors for severe jaundice

• African, Mediterranean, Middle Eastern, Native, East Asian

• Bruising, poor feeding, jaundice within 24 hours, sibling with phototherapy, diabetic mom



Investigations

• Bilirubin

• CBC

• Coombs’ test

• G6PD screen

• Reticulocyte count



Maternal Assessment

• Breasts/nipples eg. pain

• Bladder, bowels

• Perineum

• Lochia

• Fever

• Supports



Case #2

• 33 y.o G1P1

• Presenting in urgent appt. spot 72 hours PP

• Bilat red, swollen, painful breasts

• T = 37.7 C



Engorgement

• Early or late

• Firm, enlarged, tender, warm

• Edema, tissue swelling, accumulated milk

• Max. 1-7 days

• “Milk fever”

• Treatment



Mastitis

• Hard, red, tender, swollen area of breast

• Unilateral, febrile

• 1-3% lactating women

• Staph, strep, E. coli

• Treatment



6 Week PP Visit

• MOHLTC/OMA form – hx and PE weight?

• Consider varicella

• Return to work/childcare

• Mood

• Birth spacing/contraception/folic acid

• ? Pap ? cultures



Case #3

• 35 y.o. G3P3 8 weeks PP

• Multiple concerns: stress incontinence, painful intercourse, contraceptive questions, persisting spotting, varicose veins, hair loss



Incontinence• J Obstet Gynaecol Can 2009 4 months PP SVD: 23%

stress incontinence, 12% urge incontinence, 29% any incontinence, 4% fecal incontinence

• Related to maternal age (> 30 yrs.) and forceps• Birth weight, parity, episiotomy, length of second stage?• Incidence and severity decrease over first year• C-section protective(?) (appx. 30% incidence)• Effect of pregnancy vs. effect of childbirth • No identified risk factors for fecal incontinence • Kegel’s, PT



Sexual function

• Libido

• Vaginal dryness

• Dyspareunia

• Contraception



Libido• 47-57% report decreased interest 3 months PP

(UpToDate)• Causes: fatigue, concern over injury, pain, ?

breastfeeding, PPD,relationship issues• Int. Urogynecol J Pelvic Floor Dysfunct 2005:

150 primips• Resumption of intercourse: 6 weeks (57%), 12

weeks (82%), 24 weeks (90%)• Orgasmic function unchanged



Dyspareunia• More likely with episiotomy, forceps, ? ?

breastfeeding• Greater incidence in primips• Greater incidence with higher order perineal

trauma, granulation tissue• Lesser incidence with continuous technique vs.

interrupted (Cochrane Database Syst. Rev. 2007) – up to 10 days

• Treatment



Fertility

• Non-lactating: avg. menstruation returns on day 55-60, ovulation by day 40-50

• Lactating: avg. menstruation returns 8-15 months, ovulation 30-40 weeks

• Variables: pattern of breastfeeding eg. intensity and pattern of suckling

• Obstet Gynecol Surv 1994



Contraception

• LAM

• Hormonal contraception

• Condoms

• IUD – perf risk with insertion

• Depo-provera

• Sterilization



LAM

• Absolute requirements:

• baby under 6 months

• no menses

• baby is exclusively breastfed

• baby is breastfeeding at least every 4 hours during the day and at least every 6 hours at night

• 98% effective



Hormonal Contraception• Contraception,1984: “Effects of hormonal

contraceptives on milk volume and infant growth. WHO Special Programme of Research, Development and Research Training in Human Reproduction Task Force on oral contraceptives”

• 30 mcg ethinyl estradiol and 150 mcg levonorgestrel vs. 75 mcg dinorgestrel

• N ~ 300



Cont’d• Followed at 9, 12, 16, 20 and 24 weeks

• Double-blind to pills

• Milk volume determined by pump expression

• Controls were no contraception, non-hormonal methods, depo-provera in Thailand



Cont’d• Combined OCP – 41.9% decline in milk

volume vs. 12.0% with minipill vs. 6.1%

• Equal complementary feeding and withdrawals due to inadequate milk supply

• Quantity of complementary feeds not provided

• No significant differences in infant growth



Contraception 2003• Hormonal contraception during lactation,

systematic review of randomized controlled trials• Cochrane Database Syst Review 2003• “limited evidence, poor quality, insufficient to

establish effect of hormonal contraception on milk quality and quantity”

• Inadequate evidence to make recommendations• Randomized controlled trial of adequate size

“urgently” needed



Case #4

• 38 y.o G3T1P0A2L1

• Exclusively breastfeeding, 2 months PP

• Would like to have at least 1 more child

• When should they “start trying”?



Birth Spacing - fetal

• Optimum interval is 18-23 months• Interpreg interval < 6 months: increased

PT birth (1.4 pooled adjusted odds ratio), low birth weight (1.61), SGA (1.26)

• Increased risk also for > 59 months

• JAMA 2006 Birth spacing and risk of adverse perinatal outcomes: a meta-analysis



Birth spacing - maternal

• Interval < 5 months: higher risk maternal death (odds ratio 2.54), T3 bleeding (1.73), PROM (1.72), puerperal endometritis (1.33), anemia (1.30)

• Interval > 59 months: increased pre-eclampsia (1.83), eclampsia (1.80)

• BMJ 2000 Maternal morbidity and mortality associated with interpregnancy interval:cross-sectional study



Case # 5

• 30 y.o G2P2

• 8 months PP, persisting fatigue

• Weaning, planning to return to work

• DDx



PP Depression

• Often unrecognized

• Prevalence around 5%

• Distinguish from postpartum blues

• Edinburgh Postnatal Depression Scale

• Health department

• Perinatal Mental Health Program

• MOMS



PP Thyroiditis

• Transient hyperthyroidism alone

• Transient hypothyroidism alone

• Transient hyper, then hypo then recovery

• Prevalence appx. 7%, 25% with IDDM

• Biochemical vs. clinical

• Symptoms usually mild



PP Thyroiditis

• TSH, T3 and T4

• Anti-thyroid peroxidase antibodies

• Distinguish from Graves’

• Treatment

• Recurrence, monitoring

• May occur after TA or SA



Hypothyroidism in Pregnancy

• T4 needs increase during pregnancy : weight gain, T4 to baby, decreased iodine absorption due to iron vit

• TSH 4-6 weeks after conception, at least once each trimester, 4-6 weeks after dose change

• Decrease dose PP, check TSH 4-6 weeks



Case # 6

• 38 y.o. G2P2, BMI = 34

• Diet-controlled gestational diabetes

• Follow-up



Gestational Diabetes

• CDA 2008• 75 g OGTT between 6 weeks and 6 months• Diet, exercise counselling• Ongoing surveillance eg. prior to conception• 1/3-2/3 will have GDM in subsequent preg• Lifetime incidence: 9 months (3.7%), 15 months

(4.9%), 5 year (13.3%), 9 years (18.9%)



Case #7

• 35 y.o. G3P3 leg/groin/back pain PPD#3, slightly feverish

• Advised NSAID, morphine

• On-call PPD#5 : unable to get out of bed: sent to hospital: XR and US

• FU phone call PPD#8: barely able to walk, husband carrying her up the stairs



MSK• 1. Symphysis pubis disruption/Pelvic

girdle syndrome: pain, tenderness, swelling• Radiates to legs, hips, back• Worse with weight-bearing• Conservative treatment

• 2. Coccydynia – conservative treatment

• 3. DeQuervain’s tenosynovitis- abductor pollicis longus

• 4. Back pain



Case # 8

• 35 y.o G1P1 PPD#4

• Induced for severe PIH with proteinuria

• Labetolol 200 mg tid

• FU and management

• SOGC Clinical practice guideline 2008



• Close monitoring of BP at least 1 week, BW, UA for protein

• Consider taper and d/c meds

• Avoid NSAIDs

• Ok for breastfeeding: labetalol, methyldopa, nifedipine, captopril/enalopril

• Birth spacing : > 2 yrs, < 10 yrs

• Weight, diet, exercise



Pre-eclampsia Prognosis

• Resolution within days to weeks PP, consider essential HTN if persists 12 weeks

• Recurrence risk varies with severity and time of onset (25-65% vs. 5-7%)

• Long-term maternal risks: hypertension (RR3.7), ischemic heart disease (RR 2.16), stroke (RR1.81), venous thromboembolism (RR1.81)

• Graded relationship between severity of preeclampsia and risk of future cardiac disease



Additional Concerns

• Persisting spotting

• Varicose veins

• Telogen effleuvium

• Weaning

• Colic, sleep, regurg, rashes



Questions

BUILDING A HEALTHY COMMUNITY Office-based Postpartum Care Dr. Kristine Whitehead, M.D., C.C.F.P....

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