Postpartum Problems Extra questions

1. You have just examined Mrs X in the postpartum clinic. She is complaining of breast pain and discomfort. You have established a diagnosis of postpartum mastitis. All of the following are treatment options for her except:

2. The commonest urinary problem occurring in the postpartum period is:

3. A 24-year-old woman presents to delivery suite with a 12 h history of right-sided chest pain and shortness of breath. She is at 7 days’ postnatal having delivered her baby by emergency caesarean section at 34 weeks. Her pregnancy was complicated by severe hypertension and postpartum haemorrhage of 1 L. She has a BMI of 32. Her BP is 130/80 mmHg, pulse is 108 bpm, temperature is 37.2 and oxygen satura- tions are 94 % in air. What is the SINGLE most likely diagnosis?

4. A 40-year-old woman, who has had a previous caesarean delivery, experiences brisk vaginal bleeding immediately following vaginal delivery of a 36-week gestation baby (birth weight 3.8 kg). 10 min prior to the delivery, there was acute onset fetal bradycardia and cessation of uterine contractile activity. The urinary catheter shows haematuria. The placenta was delivered without complication. Bimanual compression of the uterus is extremely painful for the woman. Despite an estimated blood loss of 500 ml, she appears pale and clammy with BP 90/30 and pulse 120 bpm. Which one of the following is the most likely cause for the excessive genital tract bleeding?

5. A 40-year-old woman, who has had three previous vaginal deliveries, experiences brisk vaginal bleeding immediately following vaginal delivery of 36-week gestation twins (birth weights 2.0 and 1.9 kg). An episiotomy was not required. The placenta was delivered without complication. She received an epidural top-up 30 min before delivery. The estimated blood loss is 700 ml. Which one of the following is the most likely cause for the excessive genital tract bleeding?

6. A 32-year-old woman presents to delivery suite with a 3-day history of worsening pelvic pain and vaginal bleeding with clots. She is at 5 days postnatal having deliv- ered her baby by kiwi cup vacuum delivery at 41 weeks’ gestation. She has a BMI of 32. Her BP is 130/80 mmHg, pulse is 108 bpm, temperature is 37.9 and oxygen saturations are 95 % in air. She has pelvic tenderness on examination. What is the SINGLE most likely diagnosis?

7. Which one of the following statements is correct in relation to postpartum depression?

8. Which one of the following best defines secondary postpartum haemorrhage?

9. Which one of the following correctly states how much energy is provided by human milk through breastfeeding?

10. Which one of the following correctly states the calorific energy requirements for a new born infant born at term gestation?

11. Postpartum anaemia is defined as a haemoglobin less than

12. A 34-year-old woman attends the postpartum clinic with complaints of superficial dyspareunia. She delivered a 4.5 kg baby with the help of outlet forceps 2 months back. She is currently breastfeeding. On local examination the perineum is healthy, no signs of atrophic vaginitis. On palpation, there is definite tenderness in the episi- otomy scar. What will be your advice to her

13. You are attending a regional annual perinatal morbidity and mortality meeting. How is perinatal mortality in UK defined ?

14. A 25-year-old low-risk woman delivered a healthy baby at term by an emergency caesarean section for massive APH. Estimated blood loss was 1.5 L, uneventful recovery. What is the risk of abruption in her next pregnancy?

15. A 28-year-old para 1 who is keen to breast feed is being debriefed are  her caesarean section the previous day. She has had a variety of complex mental health issues and you discuss her management with the psychiatrist who has come to visit her on the ward. Which of the following drugs is the safest for the infant if the mother is breast feeding

16. A 36-year-old primigravida has an emergency caesarean section for failure to progress following a long period of augmentation and delivers a 4.8 kg baby. Despite various uterotonics, the uterus remains hypotonic and there is bleeding. The haemorrhage stops temporarily with compression. A decision to perform a B-Lynch suture is performed. A suture on a large needle is requested. Which would be the best suture material to use?

17. Ms. XY is brought to the A + E department, unwell. She is a para 1, post-SVD 3 days ago with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP 80 systolic, RR 24 breaths/min and temp 39° C and she feels cold and clammy. She reports heavy offensive lochia. She has been fluid resuscitated now and commenced on oxygen by mask. What is the next immediate step in her management?

18. Ms. XY is a para 1 who delivered 1 week ago. She was diagnosed to have GDM (diet controlled), and her plasma glucose levels have now returned to normal. What follow-up should she have postpartum?

19. Ms. XY is a para 1, day 1 postpartum and known to have essential hypertension and asthma. She was not medicated throughout her pregnancy. Her blood pressures postpartum have been 150–160 (S) and 95–100 (D). Her urine PCR is 20. She is breastfeeding. Which of the following treatment options are best suited to her ?

20. Ms. XY is brought to the A + E department, unwell. She is a para 1, post-SVD 3 days ago with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP 80 systolic, RR 24 breaths/min and temp 39° C and she feels cold and clammy. She reports heavy offensive lochia. She has been fluid resuscitated now and commenced on oxygen by mask. Which of the following blood results reflect severe sepsis?

21. Ms. XY is brought to the A + E department, unwell. She is a para 1, post-SVD 3 days ago with ragged membranes noted at delivery. Her observations include pulse 128 bpm, BP 80 systolic, RR 24 breaths/min and temp 39° C and she feels cold and clammy. She reports heavy offensive lochia. Which of the following antibiotics are best suited to her?

22. Ms. XY is now a para 1, with A negative blood group. She has just delivered in the midwifery-led unit and has had to theatre for a manual removal of a retained pla- centa. Her baby at 0+ve. Kleihauer test suggests a fetomaternal haemorrhage of 6 mLs. How much anti-D should she receive?

23. Drugs are prescribed in pregnancy upon the assumption that their positive effect on health outweighs the probability and severity of any harm to the mother and fetus. On this basis, which SINGLE drug is most likely to be contraindicated for maternal use when breastfeeding?

24. Ms. XY was diagnosed to have an acute DVT at 34 weeks of gestation. She received antenatal LMWH. She has delivered this morning (38 weeks). She would like to discuss warfarin for postpartum thromboprophylaxis as she would rather avoid nee- dles. She would like to breastfeed. Which of the following treatment options are best suited to her ?

25. Ms. XY is on day 1 postpartum following a vaginal delivery at home. She presents to the A + E department in septic shock. She gives history of a fever and sore throat leading up to the delivery. What is the most likely organism responsible for her condition?

26. Ms. XY is in theatre recovery after repair of a 3B perineal tear. You come to debrief her about the procedure. What percentage of women are asymptomatic after EAS repair at 12 months ?

27. A 38-year-old Asian mother has delivered her fourth baby normally. She is a known Type 2 diabetic and was taking Met- formin prior to pregnancy for glycemic control. From 32 weeks gestation, Isophane insulin was added twice daily in addition to Metformin to achieve glycemic control. The woman is planning to breast feed. What advise should be given with regard to a hypoglycemic agent in the postnatal period?

28. A 17-year-old Para 1 is attending for postnatal follow-up 6 weeks after an emergency caesarean section for severe pre-eclampsia and HELLP at 27+ 2 days gestation. The baby was severely growth-restricted and is still in the neonatal unit. What is her risk of pre-eclampsia in a future pregnancy?

29. A woman who is a recent immigrant to the United Kingdom is admitted in labour and delivers rapidly. At delivery, the midwife had noted that the liquor was offensive and appropriate swabs were taken. The mother is also noted to have a low-grade pyrexia and mild tachycardia. Within minutes of antibiotic administration, the mother collapses and anaphylactic shock is diagnosed. An A, B, C, D, E approach has been initiated. What is the definitive treatment for anaphylaxis?

30. A primigravida aged 30 attends the antenatal clinic for booking. She is known to have Bipolar Disorder and was taking lithium, which was stopped preconceptually due to concerns over fetal tox- icity. Her mother is known to have bipolar disorder. What is her risk of developing postpartum psychosis?

31. A 35-year-old grand multipara has had a major postpartum haemorrhage (PPH) following a normal delivery. Mechanical and pharmacological measures have failed to control the bleeding. Examination has confirmed that there are no retained placental tissue in the uterine cavity and absence of trauma to genital tract. What is the most appropriate first-line surgical management?

32. Active management of the third stage of labour reduces the risk of PPH. By what proportion is the risk of PPH reduced by prophylactic oxy- tocic agents?

33. A 33-year-old multiparous woman has been taking therapeutic low molecular weight heparin (LMWH) from 34 weeks gestation for confirmed pulmonary embolism. She has an uncomplicated spontaneous normal vaginal delivery at 38 weeks gestation. What is the most appropriate postnatal management?

34. A 37-year-old primigravida, 102 kg, and a BMI of 40 kg/m2 is seen in the antenatal clinic for booking. She has conceived following a long period of subfertility through assisted conception. Ultrasound scan had confirmed a di-chorionic, di-amniotic twin pregnancy of 11+ 5 days gestation. Prophylactic LMWH had been given throughout pregnancy. A category 3 caesarean section had been performed at 37 weeks. What is recommended as the best practice with regard to reducing maternal risk of VTE in the puerperium?

35. A 25-year-old woman goes into spontaneous labour at term. She has an undiagnosed Chlamydia infection. What is the chance that she will develop a puerperal infection if she delivers vaginally?

36. Chlamydia testing should be performed in women with lower gen- ital tract symptoms and intrapartum or postpartum fever, and in mothers of infants with ophthalmia neonatorum. When should the test of cure be done after initial treatment in pregnancy?

37. In a breastfeeding population, what is the risk of mother to child transmission of HIV due to breastfeeding?

38. What proportion of cases of neonatal Herpes simplex infection are due to HSV-2?

39. A woman with confirmed obstetric cholestatish as a normal vaginal delivery. How long after delivery should repeat liver function tests be per- formed?

40. A  woman in the second postpartum week presents with confusion, bewilderment, delusions and hallucinations. She feels hope- less and care of the baby has been affected. What is the most likely diagnosis?

41. Mental disorders during pregnancy and the postnatal period can have serious consequences on the health of the mother and her baby. It is vital that these women be managed by the appropriate health-care professionals. Which health-care professional(s) should care for pregnant women with a history of postpartum psychosis?

42. Postpartum psychosis is a psychiatric emergency usually needing admission. What is the incidence of postpartum psychosis in the general population?

43. A woman in the first postpartum week presents with mood swings ranging from elation to sadness, irritability, anxiety and decreased concentration. Care of the baby is not impaired and the woman does not feel suicidal. What is the most likely diagnosis?

44. At a woman’s first contact with primary care or her booking visit and during the early postnatal period efforts should be made to ask about the woman’s mental health and well-being using the 2 item GAD2 Scale: What is the GAD-2 scale used for?

45. A woman with a history of severe depression presents with mild depression in pregnancy or the postnatal period. What is the best plan of care?

46. All health-care professionals providing assessment and interventions for mental health problems in pregnancy and the postnatal period should understand the variations in their presentation and course. Along with this there should be knowledge of how these variations affect treatment, and the context in which they are assessed and treated (e.g., maternity services, health visiting and mental health services). When a woman with a known or suspected mental health problem is referred in postnatal period within what time frame should assessment for treatment be initiated?

47. A 27-year-old primigravida presents at 35+3 weeks’ gestation with a headache and 24 hours of no fetal movement. An IUFD and preeclampsia are diagnosed. Induction of labour is performed. Four days are delivery her BP is still very labile, and she continues to require second-line oral therapy. She is troubled by lactation and breast pain. What would be the best management for her?

48. A 23-year-old medical student has delivered a healthy male neonate weighing 2900 g at term 36 hours ago by SVD. T e mother is generally t and well and has been granted a year out of her studies, having found out she was pregnant shortly are her elective in Papua New Guinea. She has noticed that, this morning, the neonate has rapidly developed severe bilateral conjunctivitis with a profuse purulent discharge. Last night the neonate’s eyes looked normal. What is the most likely causative organism in this case of neonatal conjunctivitis?

49. A 32-year-old primigravida commences a planned delivery in a rural stand-alone midwifery unit. A er 8 hours of established labour, the second stage of labour is diagnosed. The woman develops an urge to push 1 hour later and she commences pushing. Are 30 minutes late decelerations are heard on intermittent auscultation. On examination the fetus is cephalic, 2/5 palpable per abdomen, fully dilated, direct OP and at station spines −1. There is 3+ caput and 3+ moulding. A decision is made for transfer to hospital, although this is delayed because of treacherous snow-covered and ice-covered roads. On arrival at hospital3hourslatertheC Gisseverely abnormal, with examination endings unchanged and a category 1 caesarean section is performed. en minutes are delivery resuscitation is stopped for a few seconds while the neonate is reassessed. The fetus is still extremely oppy, with no pulse, no response to stimulation and no spontaneous breathing. It is blue. What is the infant’s 10-minute Apgar score?

50. A 32-year-old obese primigravida has a forceps delivery at 39+2 weeks’ gestation for suspected fetal compromise. Because the baby is not spontaneously crying at delivery, the obstetrician clamps and cuts the cord immediately. Shortly are wards, however, the baby spontaneously cries are stimulation by the midwife. The following day the baby feeds poorly and is found to be anaemic. The issue of cord clamping in term neonates is discussed and debated between the obstetricians and neonatologists at the next perinatal morbidity meeting. What is the best management regarding cord clamping in term neonates?

51. A healthy 34-year-old low-risk primigravida is referred to the obstetric antenatal clinic by her midwife at the woman’s request to discuss the management of the third stage of labour. Her antenatal group has advised her to have physiological management of the third stage of labour to improve bonding with her baby. They suggest that, as long as she delivers in a quiet room, her own endogenous oxytocin will work well and, as she is ‘low risk’; her chance of postpartum haemorrhage will be no higher than if she were to have an active management of the third stage. The woman asks you for your advice and rationale for this regarding management of her third stage of labour. Which is the best advice?

52. A 32-year-old low-risk primigravida presents with contractions at 26+0 weeks’ gestation. On examination the cervix is 5 cm dilated. She is admitted, steroids are given and a magnesium sulphate infusion is commenced. She is anxious and is keen to know a very approximate prognosis for her fetus. Approximately what percentage of live births at 26 weeks’ gestation will go on to survive without disability?

53. A 33-year-old primigravida with asthma delivers a live infant at term. There was no meconium. The infant makes no spontaneous attempt at breathing and is oppy. It is dried, covered and assessed. Five in ation breaths are performed. There is good chest movement on in ation. The neonate is then reassessed: there is a heart rate of around 50 bpm although still no breathing. Senior assistance is summoned and en route. What is the next immediate step?

54. A 34-year-old primigravida has a water birth. There is significant perineal trauma. On examination the external anal sphincter is completely severed, as is the internal anal sphincter, although the rectal mucosa is intact. What classification of perineal tear is this?

55. A 35-year-old now para 1 attends for perineal review are an episiotomy wound infection 1 week post delivery. All has healed well. She has had difficulties with a variety of contraceptive methods she has tried over a number of years and is keen to rely on lactational amenorrhoea. She asks about its e cacy. If a mother is amenorrhoeic, is less than 6 months postnatal and is exclusively breast, how effective is lactational amenorrhea as a method of contraception?

56. A 25-year-old para 5 is due to get a LNG-IUS inserted 4 weeks post caesarean section. She defaults the appointment due to child care, but attends 3 weeks later (7 weeks postnatally). She is formula feeding her infant. She remains amenorrhoeic and had sexual intercourse with her husband 2 weeks previously, but has not since because it was too uncomfortable. A pregnancy test is negative. She is very keen for contraception, ideally with LNG-IUS, but does not want a progesterone implant. What would be the best management?

57. A 37-year-old para 1 had significant gestational hypertension in her last few weeks of antenatal care. Postnatally the BP has not been under control despite maximum dose labetalol. She su ered intolerable side effects from nifedipine and is therefore commenced on an ACE inhibitor. She is breast feeding and is keen for something safe for her infant. Which of these ACE inhibitors has the most infant safety data in breast feeding?