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Postpartum Office Visit

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1421. Hydrops Fetalis

. To evaluate the risk of fetal anaemia, Doppler measurement of the middle cerebral artery peak systolic velocity should be performed in all hydropic fetuses after 16 weeks of gestation. For suspected fetal anaemia, fetal blood sampling and intrauterine transfusion should be offered rapidly. All cases of unexplained fetal hydrops should be referred to a medical genetics service where available. Detailed postnatal evaluation by a medical geneticist should be performed on all cases of newborns (...) likely after birth. Recommended treatment depends on the underlying cause and gestational age. Preterm delivery is recommended only for obstetric indications. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic aetiology, an aetiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilise and treat critically ill

2008 Mentor

1422. Hospital Anxiety and Depression (HAD) Scale

pregnancy and in the postnatal period - see the separate and articles. (Men, however, have a higher risk of suicide.) Past history of depression. Significant physical illnesses, particularly those causing disability or chronic pain. Other mental health problems, such as schizophrenia or dementia. Psychosocial problems - eg, divorce, unemployment, poverty. Risk factors for depression in children and adolescents include family discord, bullying, physical, sexual or emotional abuse, comorbid disorders (...) and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Exploring thoughts of suicide. BMJ. 2017 Mar 30356:j1128. doi: 10.1136/bmj.j1128. ; NICE Interventional Procedure

2008 Mentor

1423. Hypothyroidism

may find the article more useful, or one of our other . In this article In This Article Hypothyroidism In this article For congenital hypothyroidism see the separate article. Hypothyroidism often has an insidious onset but has a significant morbidity. The clinical features are often subtle and nonspecific and may be wrongly attributed to other illnesses, especially in postpartum women and in the elderly [ ] . The earliest biochemical abnormality is an increase in serum thyroid‐stimulating hormone (...) or dyshormonogenesis. Infiltration of the thyroid - eg, amyloidosis, sarcoidosis and haemochromatosis. Secondary hypothyroidism Isolated TSH deficiency. Hypopituitarism - neoplasm, infiltrative, infection and radiotherapy. Hypothalamic disorders - neoplasms and trauma. Transient hypothyroidism Withdrawal of thyroid suppressive therapy. Postpartum thyroiditis. Subacute/chronic thyroiditis with transient hypothyroidism. Presentation Often insidious onset with nonspecific symptoms [ ] . Symptoms Tiredness, lethargy

2008 Mentor

1424. Hypopituitarism

: : for example, adenomas. Non-pituitary tumours: , , , chordomas, ependymomas, metastases. Infiltrative processes: , histiocytosis X, . Infections: cerebral abscess, , , , . Ischaemia and infarction: , , Sheehan's syndrome (postpartum haemorrhage with anterior pituitary infarction), (caused by an acute infarction of a pituitary adenoma). Empty sella syndrome: radiological diagnosis of absence of normal pituitary within the sella turcica. Usually benign and asymptomatic but may develop headaches (...) . Prevention Good obstetric care has reduced the incidence of postpartum hypopituitarism. Radiation therapy that minimises exposure to the pituitary gland reduces incidence and time of onset of hypopituitarism. Improved neurosurgical techniques reduce the likelihood of subsequent hypopituitarism. Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity

2008 Mentor

1425. Hypoparathyroidism

surge postnatally, thus resulting in hypocalcaemia. Infants of mothers with diabetes: hypomagnesaemia due to maternal magnesuria impairs PTH release and action. Delay in PTH surge postnatally: this can occur in otherwise healthy neonates. Maternal hyperparathyroidism: this results in hypercalcaemia which can cause prolonged PTH suppression in the neonate. Congenital or genetically inherited hypoparathyroidism Defects in parathyroid gland development: DiGeorge's syndrome: there is abnormal (...) ' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Hypoparathyroidism. Best Pract Res Clin Endocrinol Metab. 2012 Aug26(4):517-22. doi: 10.1016/j.beem.2012.01.004. Epub 2012 May 31. ; Hypocalcemia in the newborn. Indian J Pediatr. 2010 Oct77(10):1123-8. doi: 10.1007/s12098-010-0176-0. Epub 2010 Aug 25

2008 Mentor

1426. Hyperthyroidism in Pregnancy

considered the preferred anti-thyroid drug. The safest option is often to use propylthiouracil in early pregnancy, changing to carbimazole in the latter months. Close follow-up during pregnancy, with TSH receptor antibody (TRAb) status checked around 24-28 weeks to assess the risk of fetal and/or neonatal hyperthyroidism. There is a risk of disease worsening during the first trimester or in the early postpartum period; however, note that women may actually have better control of hyperthyroidism during (...) pregnancy. Anti-thyroid medication is safe when breast-feeding. Changes in thyroid physiology during pregnancy Thyroid gland enlargement. Increased gland vascularity. These changes reverse postnatally. Epidemiology It occurs in around 2 per 1,000 pregnancies in the UK. [ ] The most common cause is Graves' hyperthyroidism - overactivity resulting from the presence of TRAb. [ ] New-onset Graves' hyperthyroidism is estimated to occur in about 0.15% of pregnancies. [ ] Transient gestational hyperthyroidism

2008 Mentor

1427. Hypertension in Pregnancy

attention to this recent paper looking at the risk of developing hypertension after having had a hypertensive disorder of pregnancy [ ] . They found that in a first pregnancy in their 20s, 14% of the women developed hypertension in the first decade post partum, compared with 4% of women with normotensive first pregnancies in their 20s. The corresponding percentages for women with a first pregnancy in their 40s were 32% and 11%, respectively. In the year after delivery, women with a hypertensive disorder (...) of pregnancy had 12-fold to 25-fold higher rates of hypertension than did women with a normotensive pregnancy . Rates in women with a hypertensive disorder of pregnancy were threefold to 10-fold higher 1-10 years post partum and remained twice as high even 20 or more years later. Prevention Low-dose aspirin: see recommendation in high-risk groups as detailed under 'Management', above. Calcium supplementation: appears to reduce the risk of high BP in pregnancy, particularly for women at high risk

2008 Mentor

1428. HELLP Syndrome

racial origin. Antiphospholipid syndrome (APS) - 10.5% of patients with HELLP syndrome have APS. [ ] Presentation [ ] HELLP syndrome is a serious complication of pregnancy and may present at any time in the last half of pregnancy. 70% of cases present before delivery, peaking between 27 and 37 weeks of gestation but it can occur earlier or later. 30% of women with HELLP syndrome present postpartum, usually within 48 hours of delivery. Symptoms of HELLP syndrome are usually nonspecific. Onset (...) and coagulation tests. Postpartum HELLP syndrome may be treated with plasma exchange. Blood pressure control is essential. Women with severe liver damage may need liver transplantation. Prognosis If HELLP syndrome is not treated early, up to 25% of women may develop serious complications. Without treatment there is a significant mortality. The mortality rate among babies born to mothers with HELLP syndrome varies and depends mainly on gestation and birth weight. Complications [ ] Maternal: - 4-9%. - 9-20

2008 Mentor

1429. Gestational Diabetes

regimen to test their fasting pre-meal, one hour post-meal and bedtime blood glucose levels daily during pregnancy. Advise pregnant women with GDM to test their fasting and one hour post-meal blood glucose levels daily during pregnancy if they are on diet and exercise therapy, or taking oral therapy (with or without diet and exercise therapy) or single-dose intermediate-acting or long-acting insulin. Target blood glucose levels Agree individualised targets for self-monitoring of blood glucose, taking (...) if indicated) to women who have not given birth by this time. Consider elective birth before 40+6 weeks for women with GDM if there are maternal or fetal complications. Diabetes should not in itself be considered a contra-indication to attempting vaginal birth after a previous caesarean section. Explain to pregnant women with diabetes who have an ultrasound-diagnosed macrosomic fetus about the risks and benefits of vaginal birth, induction of labour and caesarean section. Postpartum care [ ] Women who have

2008 Mentor

1430. Haemolytic Disease of the Newborn

of the population who are RhD negative. This varies within ethnic minorities but, in the UK, it is highest in the Caucasian population (approximately 16%). Before immunoprophylaxis was available, HDN affected 1% of all newborns and was responsible for the death of one baby in every 2,200 births. [ ] Anti-D prophylaxis (mostly administered postnatally) and advances in neonatal care have reduced the frequency of HDN by almost a factor of 10 to 1 in 21,000 births. [ ] Deaths attributed to RhD alloimmunisation fell (...) of the condition is the presence of anti-D antibodies in the mother as detected by the indirect . All rhesus-negative women have this test performed in the UK at the first antenatal visit. Routine ultrasound screening may detect hydrops fetalis (see below) or polyhydramnios. Infants born to alloimmunised mothers may appear clinically normal in mild cases. Diagnostic findings include jaundice (yellow amniotic fluid, yellow vermix, yellow skin), pallor and hepatosplenomegaly. Kernicterus (bilirubin

2008 Mentor

1431. Gynaecology History and Examination

. Dyspareunia - superficial or deep. Urinary symptoms Leakage. Cloudiness. Haematuria. Hesitancy. Dysuria. Frequency. Strangury. Stress or urge incontinence. Obstetric history Number of children, details of pregnancy, labour and delivery, birth weights, complications. Miscarriages/terminations. Any postnatal problems - eg, depression. Conception difficulties/subfertility. Contraception Contraceptive history. Any recent unprotected intercourse. Reliability of method and user. Potential contra-indications (...) to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Urinary incontinence in women. BMJ. 2014 Sep 15349

2008 Mentor

1432. Growth and Failure to Thrive

abnormalities. IUGR often produces a small but hungry and eager baby. However, a combination of preterm and is more likely to cause difficulties. Toxins in utero may include tobacco, drugs of abuse (especially amfetamines and cocaine) and alcohol. may occur or the incomplete fetal alcohol effects. Infection in utero may include , and Postnatal causes include lack of adequate intake of nutrition: Lack of appetite may occur with , cental nervous system (CNS) pathology and chronic infection. Inability to suck (...) ? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references

2008 Mentor

1433. Gravidity and Parity Definitions (and their Implications in Risk Assessment)

for the possibility of postpartum haemorrhage. Good physiotherapy and postnatal follow-up for urogynaecological problems. Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report (...) a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; The interpretation and clinical application of the word 'parity': a survey. BJOG. 2007 Oct114(10):1295-7. ; Office for National Statistics ; Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies. BMJ. 2016 Apr 19353:i1753. doi: 10.1136/bmj.i1753. ; Incidence and outcomes

2008 Mentor

1434. Immunoglobulins - Normal and Specific

within 14 days of exposure to the primary case. Rubella contact in non-immune pregnant women where termination is unacceptable - it does not prevent infection but reduces symptoms and the risks to the fetus. Give as soon as possible after exposure only when termination is not acceptable. Measles, mumps and rubella (MMR) and anti-D may be given in the postpartum period (separate syringes and into different limbs). Measure rubella antibodies after eight weeks and vaccinate if necessary. However (...) , rubella vaccine is not effective for post-exposure prophylaxis. Measles contact, within 72 hours of exposure (some effect if given within six days) in: The immunocompromised. Non-immune pregnant women (but there is no evidence it prevents fetal loss). An infant aged under 9 months - if the mother is not immune An infant aged 6-8 months - if the mother is immune (because under 6 months the child is protected by maternal antibodies and after 9 months MMR can be given for prophylaxis following exposure

2008 Mentor

1435. Exomphalos and Gastroschisis

and postnatal period. [ ] Gastroschisis Scheduled preterm delivery may improve postoperative outcome. [ ] Some patients can be managed by plastic closure (vigorous stretching of the abdominal wall with gradual decompression of the abdominal contents from a temporary silo into the abdomen). In the majority of patients, however, primary closure of the defect is the main objective. This may need to be delayed if the intestines are too inflamed and hence too enlarged to be replaced in the abdominal cavity. Too (...) to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; The embryologic origin of ventral body wall defects. Semin Pediatr Surg. 2010 Aug19(3):209-14. ; Gastroschisis Embryology, Pathogenesis, Epidemiology. NeoReviews, Nov 2005 6

2008 Mentor

1436. Episiotomy and Tears

to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; Royal College of Obstetricians and Gynaecologists (2015) ; Health and Social Care Information Centre, 2010-2011 ; Royal College of Obstetricians and Gynaecologists ; Royal College of Obstetricians and Gynaecologists (March 2007) ; Do unsutured second-degree perineal lacerations affect postpartum functional outcomes? J Am Board Fam Med. 2007 (...) % of women who have a vaginal delivery will have some degree of perineal trauma and that 60-70% will require suturing. Many years ago perineal tears or cuts were not routinely repaired but left to heal spontaneously. In practice it is sometimes necessary to repair the wound to achieve haemostasis. One study found that women with sutured lacerations required increased analgesia at the time of hospital discharge compared with women with intact perineums or unsutured lacerations. [ ] At 12 weeks postpartum

2008 Mentor

1437. Endometritis

Endometritis Postpartum Endometritis. About Postpartum Endometritis | Patient TOPICS Try our Symptom Checker TREATMENT RESOURCES Try our Symptom Checker PROFESSIONAL Upgrade to Patient Pro / / Search Postpartum Endometritis Authored by , Reviewed by | Last edited 24 Feb 2017 | Certified by This article is for Medical Professionals Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European (...) Guidelines. You may find the article more useful, or one of our other . In this article In This Article Postpartum Endometritis In this article Definition Endometritis refers to infection or inflammation of the endometrium, the inner lining of the uterus. It can be divided into pregnancy-related (obstetric) or non-obstetric. Pathologically, it can be described as acute and chronic: Acute endometritis is characterised by the presence of more than five neutrophils in a 400 power field in the endometrial

2008 Mentor

1438. Genital Herpes in Pregnancy

postnatally from somebody other than the mother. Staff or relatives with an active oral HSV lesion or herpetic whitlow, who come into contact with the neonate, should be advised about the risk of postnatal transmission and avoid direct contact between the lesion and the neonate. Did you find this information useful? Thanks for your feedback! Why not subscribe to the newsletter? Email address * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date (...) with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; British Association of Sexual Health and HIV and Royal College of Obstetricians and Gynaecologists (Oct 2014) ; NICE Evidence Services (UK access only) ; Use of acyclovir, valacyclovir

2008 Mentor

1439. General Learning Disability Full Text available with Trip Pro

, trauma, asphyxia. Neonatal: eg, intraventricular haemorrhage, hypoglycaemia, meningitis, severe neonatal jaundice. Postnatal: Accidental or non-accidental injury. Infection: eg, encephalitis, meningitis. Anoxia: asphyxia, status epilepticus, near drowning. Metabolic, endocrine: hypoglycaemia, hypernatraemia, hypothyroidism. Poisoning: lead, carbon monoxide. Malnutrition. Presentation [ ] This will depend on the cause. It would typically include: Poor performance on tasks such as learning, short-term (...) difficulties: This has probably been exacerbated by a decrease in surveillance by post-education health and social care services, and the increased 'tightening' of eligibility criteria to ration access to specialist support . Poor self-care, which may affect hygiene, diet, exercise, physical health and mental health. Lack of a supportive social network. Lack of regular employment. Lack of regular income. Boredom. Harmless behaviour interpreted as aggression by others [ ] . Temper tantrums. Criminal

2008 Mentor

1440. Gastrointestinal Infections in Pregnancy

be a late-onset illness (2-3 weeks postnatally). The case fatality rate for fetal or neonatal listeriosis is 10-50%. Salmonella spp. - the maternal prognosis is excellent; however, rarely, the fetus may be affected. There are case reports of intrauterine death, premature delivery and neonatal infection. Campylobacter spp. - rarely, this has been linked to fetal death, premature labour or neonatal sepsis (from case reports). [ ] Haemolytic uraemic syndrome may complicate E. coli O157 or Shigella spp (...) * We'd love to send you our articles and latest news by email, giving you the best opportunity to stay up to date with expert written health and lifestyle content. By clicking 'Subscribe' you agree to our and . Subscribe Thanks for your feedback. if you would like to report a specific issue with this page, please visit our . Thank you, we just sent a survey email to confirm your preferences. Further reading and references ; NICE CKS, March 2013 (UK access only) ; The role of infection in miscarriage

2008 Mentor

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