CFB OG02 Puerperium And Related Problems
The puerperium is the six-week postpartum period during which the maternal reproductive organs and physiology return to the pre-pregnant state, and related problems include postpartum hemorrhage, puerperal sepsis, thromboembolism, and lactation disorders.
Puerperium and Related Problems
The puerperium is the 6-week window after delivery during which the maternal body reverses the profound physiological changes of pregnancy. This lecture covers what is normal (so you can detect deviations), what can go wrong (bleeding, infection, urinary problems, mental health), and what to do about it. For exams, this is a favourite topic because it blends physiology, clinical reasoning, and psychosocial medicine into one neat package.
Learning objectives (derived from lecture outline) [1]:
- Understand normal puerperal physiology: uterine involution, lochia, hormonal changes, pelvic floor, cardiovascular.
- Recognise and manage abnormal lochia, secondary PPH, and subinvolution.
- Identify causes of puerperal pyrexia and initiate appropriate management.
- Manage perineal, bladder, and bowel problems in the puerperium.
- Distinguish puerperal blues from postpartum depression (PND) from puerperal psychosis.
- Know miscellaneous puerperal considerations: Anti-D, rubella vaccination, contraception, cervical screening.
How this fits into exams: The 2016 SAQ Q2 directly tested secondary PPH history/exam/investigations [3]. The 2024 MCQ Q14 tested the distinction between PND and puerperal blues [4]. The 2022 MCQ Q13 tested DVT in the puerperium [5]. The 2023 MCQ Q38 tested Sheehan syndrome [6]. The 2025 MCQ Q10 tested investigation for puerperal DVT [7]. Expect SAQ or minicase stems involving a woman presenting days-to-weeks postpartum with bleeding, fever, or mood disturbance.
"The period during which the maternal body returns to the non-pregnant state after delivery. Usually the 6-week period after delivery." [1]
"~70% of women describe at least one physical problem within the first 12 months postpartum." [1]
Why 6 weeks? This is roughly the time for uterine involution to complete and hormonal axes to reset. It's a clinical convention rather than a sharp biological cutoff—problems can (and do) extend beyond 6 weeks.
2. Normal Physiological Changes in the Puerperium
"Day 1: umbilical level — '1 finger breadth per day.' Day 10–14: not palpable abdominally. 6 weeks: non-pregnant size. Internal cervical os closed by week 2." [1]
"Involution usually faster in breastfeeding." [1]
Why faster with breastfeeding? Suckling stimulates oxytocin release from the posterior pituitary. Oxytocin causes myometrial contraction, compressing blood vessels at the placental site and accelerating the process of involution. This is the same mechanism exploited by synthetic oxytocin (Syntocinon) used to prevent PPH.
Clinical pearl: On puerperal ward rounds, you palpate the uterine fundus daily. If the fundus is higher than expected for the postpartum day, think subinvolution — and investigate for retained products of gestation (POG) or endometritis.
"Lochia = shedding of decidua. Also contains erythrocytes, white blood cells, epithelial cells, bacteria." [1]
| Day | Appearance | Why |
|---|---|---|
| Day 1–4 | Red lochia (lochia rubra) | Fresh blood from placental site + decidual debris |
| Day 4–8 | Brown lochia (lochia serosa) | Old blood + serous exudate |
| Day 9 onwards | Serous/yellowish-white (lochia alba) | Mainly WBCs, epithelial cells, mucus |
"Mean duration 24–36 days (range 2–90 days). Beyond 6 weeks is not unusual (up to 1/3)." [1]
What is abnormal? [1]:
- Subinvolution of the uterus
- Persistent red lochia
- Excessive lochia (= secondary PPH)
- Foul-smelling lochia
"These can be signs of retained products of gestation and/or endometritis." [1]
After delivery, the rapid fall in oestrogen and progesterone (from loss of the placenta) allows prolactin to act on breast tissue, initiating lactogenesis. Suckling maintains prolactin levels and triggers oxytocin for milk ejection ("let-down reflex"). See CFB OGPAE02-1 and OGPAE02-2 for detailed lactation physiology [8].
Covered in detail in Sections 6 and 7 below.
- Cardiac output remains elevated for ~24–48 hours postpartum (autotransfusion from contracted uterus), then gradually falls.
- The hypercoagulable state of pregnancy persists into the early puerperium → peak risk for VTE is the first 6 weeks postpartum [9].
- Physiological anaemia of pregnancy resolves as plasma volume contracts faster than red cell mass.
- WBC count may be physiologically elevated in early puerperium (up to ~25 × 10⁹/L in the first day) — do not automatically attribute leucocytosis to infection without clinical correlation.
3. Management of Subinvolution and Abnormal Lochia
The lecture presents a decision algorithm [1]:
Key principle: Always resuscitate before proceeding to surgery in an unstable patient. Antibiotics are given in virtually every scenario except simple observation, because infection and retained products often coexist.
The lecture presents a G1P0, NSD, with a fibroid, whose puerperal record shows normal lochia, well vital signs, and a Hb drop from 12 to 10.9. The answer is D: Observe, see in MCHC for PN check — because the lochia is normal, the patient is well, and the slight Hb drop is expected [1]. A fibroid can cause the uterine fundus to be higher than expected, mimicking subinvolution, but as long as lochia is normal and the patient is well, no intervention is needed.
4. Postpartum Haemorrhage (PPH)
"Primary PPH: Loss of blood estimated to be > 500 ml, from the genital tract, within 24 hours of delivery." [1]
"Secondary PPH: Any significant bleeding from the genital tract 24 hours after delivery till 6 weeks. (Poorly defined.)" [1]
Why is secondary PPH "poorly defined"? Unlike primary PPH with a clear volume threshold, secondary PPH has no universally agreed volume cutoff — it is any bleeding significant enough to warrant clinical attention.
4.2 Secondary PPH / Persistent Lochia — Clinical Approach
"A temporary increase in bleeding at this time may represent menses; in such cases, bleeding should stop within a few days." [1]
"Increased vaginal bleeding within 5 weeks of delivery is unlikely to be due to return of menstruation." [1]
This is a crucial clinical implication: if a woman bleeds heavily at postpartum week 2–3, do NOT dismiss it as menses. Investigate properly.
- Review delivery record for any risk factors for retained POG or postpartum endometritis
- Whether placenta has been sent for histology (to rule out gestational trophoblastic disease)
- On any medications that may predispose to uterine bleeding (e.g. Chinese herbs, anticoagulants)
- Any symptoms of uterine infection (abdominal pain, fever, foul-smelling vaginal discharge)
- Any sexual intercourse after delivery and contraception
- Latest cervical smear result
Why check for GTD? Occasionally, a partial molar pregnancy is not diagnosed antenatally. If the placenta was not sent for histology, you may miss persistent trophoblastic disease causing ongoing bleeding and rising β-hCG.
Why ask about sexual intercourse? Could the "postpartum bleeding" actually be a new pregnancy complication? Also relevant for contraception counselling.
- Pallor (anaemia from blood loss)
- Abdominal tenderness (endometritis)
- Cervical lesion / abnormal vaginal discharge on speculum examination (r/o cervical pathology)
- Cervical excitation tenderness (PID/endometritis)
- Uterine size (subinvolution → retained POG)
- Cervical os status (open or closed) (open os with products visible = incomplete miscarriage-like picture; open os in secondary PPH suggests products being expelled)
The lecture references the O&G departmental protocol C-4.2 for persistent lochia. Standard investigations include:
- FBC (assess degree of anaemia)
- Blood group and cross-match (if significant bleeding)
- Coagulation profile (if heavy bleeding; r/o DIC)
- β-hCG (r/o GTD or new pregnancy)
- High vaginal swab / endocervical swab (r/o infection)
- Pelvic ultrasound (r/o retained POG — look for echogenic material in uterine cavity)
- MSU (r/o concurrent UTI if febrile)
37 y/o G1P1, GBS+, MI for PROM, delivered by low forceps at 37+1 weeks, BL 300 ml, placenta checked complete, presented with increased lochia at postpartum 2 weeks. P/E: tender uterus, blood-stained vagina, cervical os closed. The answer is A: Endometritis [1].
Why endometritis? Risk factors include: prolonged rupture of membranes (PROM), GBS colonisation, instrumented delivery (forceps), and medical induction. The placenta was checked complete (less likely retained POG). Cervical os is closed (products not being expelled). Tender uterus = inflamed endometrium. At 2 weeks postpartum, return of menstruation is too early to be the cause.
5. Return of Ovulation and Menstruation
"After delivery, ovulation is suppressed by high levels of prolactin. When prolactin returns to non-pregnant level, ovulation will occur." [1]
"Ovulation seldom occurs before 3 weeks after delivery, unless prolactin release is suppressed with drugs." [1]
"Median time for ovulation to occur is 6 weeks after delivery in non-breast feeding women and even longer in breast-feeding women (but the range is wide)." [1]
"Suckling increases the sensitivity to oestrogen feedback → decreases pulsatile GnRH release → decreases FSH and LH → no ovulation." [1]
"But 10% of women do have ovulatory cycles while breastfeeding." [1]
This is why the lactational amenorrhoea method (LAM) is only ~98% effective, and only if exclusive breastfeeding, amenorrhoeic, and < 6 months postpartum. Beyond that, it is unreliable.
| Group | First Menstruation |
|---|---|
| Non-lactating | Usually 6–8 weeks; range ~45–94 days (6.5–13.5 weeks) |
| Lactating | 72.4% remain amenorrhoeic at 6 months; 42.1% at 13 months |
"Increased vaginal bleeding within 5 weeks of delivery is unlikely to be due to return of menstruation." — Therefore investigate for pathology.
"Amenorrhoea after delivery need not be investigated until 6 months after delivery or 6 months after weaning in the lactating mother." — Do not chase amenorrhoea in breastfeeders.
"Contraception: needed before return of menstruation." — Because ovulation precedes menstruation by ~2 weeks, a woman can conceive before her first period returns.
6. Puerperal Pyrexia
"Presence of fever in a mother ≥ 38°C in puerperium." [1]
| Category | Examples | Clinical Clues |
|---|---|---|
| Pelvic organ infection | Endometritis, retained POG | Tender uterus, foul lochia, subinvolution |
| Breast | Engorgement, mastitis, abscess | Red/swollen breast, painful breastfeeding |
| Wound infection | Episiotomy, caesarean wound, drip site | Erythema, discharge, dehiscence at wound |
| Thromboembolism | DVT, PE | Calf swelling/tenderness, dyspnoea, tachycardia |
| UTI | Cystitis, pyelonephritis | Dysuria, frequency, loin pain |
| Respiratory | URTI, pneumonia (especially post-anaesthesia) | Cough, sputum, crackles |
| GI | Gastroenteritis | Diarrhoea, vomiting |
Exam Trap: DVT Presenting as Fever
Students often focus on infectious causes of puerperal pyrexia and forget that thromboembolism can cause fever. The 2022 MCQ Q13 and 2025 MCQ Q10 both tested DVT in the postpartum period. If a post-caesarean patient has fever + calf tenderness + shortness of breath, think DVT/PE first, not just wound infection. Risk factors: caesarean section, obesity (BMI > 35), pre-eclampsia, immobility, older maternal age [5][7][9].
The lecture references O&G departmental protocol C-4.3 [1].
Risk factors: Caesarean section (single biggest risk factor, especially emergency CS), prolonged rupture of membranes, multiple vaginal examinations, retained POG, GBS colonisation, instrumented delivery.
Organisms: Polymicrobial — Group A & B streptococci, enterococci, anaerobes (Bacteroides), E. coli, staphylococci.
Treatment: Broad-spectrum IV antibiotics (typically a combination such as IV amoxicillin + metronidazole + gentamicin, or as per local protocol). If retained POG suspected, evacuate uterus after starting antibiotics.
From surgical notes [10]:
- Most common in first 3 months of breastfeeding
- Organism: Staphylococcus aureus (most common)
- Progresses to abscess in ~25% if untreated
- Management: continue breastfeeding (complete emptying), antibiotics (1st-gen cephalosporin or flucloxacillin), NSAIDs; if abscess → needle aspiration or I&D
- Does NOT require cessation of breastfeeding
7. Other Physical Complaints in the Puerperium
"The perineum may be torn during delivery or deliberately cut (episiotomy) to facilitate delivery. Even when the perineum appeared intact, some muscle fibres may be damaged." [1]
"Long-term complications: urinary incontinence, faecal incontinence." [1]
Why hidden damage matters: Occult 3rd/4th degree tears (involving the anal sphincter) can be missed at delivery and present later with faecal incontinence. Endoanal ultrasound may be needed for assessment.
7.2 Pelvic Floor and Bladder Function
"Bladder may be over-distended during labour and becomes atonic → incomplete emptying. Pelvic floor muscles stretched and innervation partially damaged in vaginal delivery. Descent of the uterus and bladder neck. Stress incontinence." [1]
| Feature | Details |
|---|---|
| Symptoms | Unable to void (complete); void small volumes frequently (incomplete retention or UTI); incontinence (overflow) |
| Signs | Uterine fundus too high or deviated; bladder palpable; note any vulval/vaginal haematoma |
| Confirmation | Residual urine after voiding — by catheterisation or ultrasound estimation |
Why does the fundus deviate? A full bladder pushes the uterus to one side (usually the right) and elevates the fundal height. This can mimic subinvolution. Always catheterise before concluding the uterus is subinvoluted.
- Encourage voiding: toilet/commode (not bedpan), running warm water over perineum, adequate perineal pain relief, suprapubic pressure
- Catheterisation: indwelling catheter when retained volume > 500 ml; keep for 48 hours
- Exclude UTI: save CSU for C/ST when inserting catheter
- Pelvic floor physiotherapy (first-line, always)
- Surgical repair (strengthening pelvic floor and elevating bladder neck) if physiotherapy not effective
- Surgical treatment should only be used > 6 months after delivery and when the woman does not want more children
- Refer to urogynaecology clinic
Why wait > 6 months? Many women recover pelvic floor function spontaneously in the months after delivery. Operating too early risks unnecessary surgery and also risks damaging repairs with a subsequent delivery.
- Constipation due to perineal pain (reluctance to strain)
- Haemorrhoids common (due to increased intra-abdominal pressure in pregnancy, aggravated by delivery)
- Pelvic floor weakening + anal sphincter damage → faecal incontinence
G1P1, low forceps, epidural anaesthesia (EA). Puerperal record: uterine fundus deviated to right, pain+, Foley catheter drained small volume of urine, bowels not opened. The answer is C: Urinary retention [1].
Why? Epidural anaesthesia reduces bladder sensation → over-distension during labour → atonic bladder postpartum. The bladder is full, deviating the uterus to the right and elevating the fundal height. Forceps delivery may have also contributed to perineal swelling and urethral oedema. The Foley drained only a small volume because it may have been inserted after partial voiding, or there may be kinking — the clinical picture points to retention.
8. Mental Health Problems in the Puerperium
"Change in family structure, additional responsibilities, change in role of the mother (wife → mother, working woman → housewife, loss of freedom), change in role of the father." [1]
"The need for support: newborn is entirely dependent, rapid physiological changes cause discomfort, fatigue from labour aggravated by child care, anxiety from inexperience, coming to terms with new role." [1]
"Common mood change — 50% of mothers. Day 4 or 5. Transient: half day to 2–3 days. Tearful, labile mood, irritable." [1]
"If symptoms persist for 1 week, need to exclude depression." [1]
Why day 4–5? This coincides with the sharp fall in oestrogen and progesterone postpartum, plus the onset of reality (sleep deprivation, engorgement, overwhelming new responsibility). It is a physiological adjustment, NOT a psychiatric disorder.
8.3 Postpartum Depression (PND)
"Affects 10% of mothers. Within 6 months of delivery. Symptoms similar to depression during other periods." [1]
| Feature | Puerperal Blues | Postpartum Depression |
|---|---|---|
| Duration | Transient, at most a few days | Persists over a week |
| Suicidal thoughts | No | Present in severe cases |
| Guilt feeling | Little | Significant guilt, fear of harm |
| Self-esteem | No loss | Loss of self-esteem |
| Psychomotor retardation | No | Yes, in severe cases |
2024 MCQ Q14: Blues vs PND vs Psychosis
A G1P1, 4 weeks postpartum after failed induction → LSCS, has low mood, guilt about not looking after baby well, and fleeting suicidal thoughts about jumping. The answer is B: Postpartum depression. Why not blues? Blues occurs day 4–5 and is transient; this is 4 weeks out with persistent symptoms, guilt, and suicidal ideation. Why not psychosis? There are no psychotic features (hallucinations, delusions, loss of insight). Why not normal reaction? Suicidal thoughts cross the line from normal adjustment [4].
"Common. Suffering of the mother. Affects the family. Affects the development of the child. Severe cases: suicide, infanticide." [1]
- Medical profession: low index of suspicion, attribute symptoms to fatigue
- Patient/family: attribute symptoms to fatigue, afraid of stigmatisation, don't seek help
- Help not readily available
| Reduce Risk | Increase Risk |
|---|---|
| Planned pregnancy | Unplanned pregnancy |
| Supportive partner and family | Poor family/marital relationship |
| Well adjusted at work and home | Poorly adjusted |
| Experienced helper for postpartum care | Socially isolated |
| Previous history of depression | |
| Other life events during pregnancy |
"Self-administered, at 6–8 weeks after delivery. 10 questions (each score 0–3) on mood and behaviour. Cut-off score in original study: 13 (detects 90% of PND with good specificity, but NOT diagnostic). Local study showed need to use lower cutoff (11)." [1]
Key point: EPDS is a SCREENING tool, not diagnostic. A score ≥ 13 (or ≥ 11 locally) triggers clinical interview for formal diagnosis.
"DSM-5: within 4 weeks of delivery (ICD-10: within 6 weeks). At least 5 depressive symptoms present for at least 2 weeks." [1]
"Distinguishing cognitive symptoms related to the baby and motherhood: doubting her ability to care for and nurture her baby; guilt about inability to feel love for her baby." [1]
"Symptoms may go unnoticed in the initial period. Patients may only present even one year after delivery." [1]
- Psychosocial and psychological intervention: peer support, non-directive counselling, CBT, interpersonal psychotherapy
- Pharmacological: SSRI
Practical note for breastfeeding mothers: Sertraline and paroxetine are generally considered safer SSRIs during breastfeeding (lower infant exposure via breast milk). This is a common viva/OSCE question.
"Rare: incidence ~0.1–0.2%. Psychotic, loss of insight. Visual hallucination common." [1]
"50% develop postpartum psychosis with no risk factor. 50% recurrence in Hx of PN psychosis. 20% recurrence in women with bipolar disorder. Higher risk if FHx of PN psychosis." [1]
"Onset within 2 weeks of delivery. > 50% of symptoms onset on day 1–3. Sudden onset and rapid deterioration." [1]
"Prophylaxis after delivery: lithium, typical or atypical antipsychotics. Usually responds well to treatment. Good short-term prognosis. 26% reported ongoing symptoms one year after delivery." [1]
Puerperal Psychosis is a Psychiatric Emergency
This is one of the few psychiatric emergencies in obstetrics. The combination of loss of insight + potential for infanticide or suicide means that these patients need immediate psychiatric assessment, often inpatient admission (ideally to a mother-and-baby unit), and pharmacological treatment. The key differentiator from PND: presence of psychotic features (hallucinations, delusions, disorganised behaviour, loss of insight).
| Feature | Puerperal Blues | PND | Puerperal Psychosis |
|---|---|---|---|
| Prevalence | ~50% | ~10% | 0.1–0.2% |
| Onset | Day 4–5 | Within 6 months | Within 2 weeks (usually day 1–3) |
| Duration | Hours to 2–3 days | Weeks to months | Variable; may recur |
| Key features | Tearful, labile mood | Depressed mood, guilt, suicidal ideation | Hallucinations, delusions, loss of insight |
| Insight | Preserved | Preserved | Lost |
| Treatment | Reassurance, support | Psychotherapy ± SSRI | Admission, antipsychotics ± lithium |
| Prognosis | Self-limiting | Good with treatment | Good short-term; 50% recurrence risk |
9. Other Rarer Puerperal Abnormalities
"Perineal/vaginal haematoma, deep vein thrombosis, faecal incontinence, urinary fistulae, Sheehan syndrome." [1]
The postpartum period carries the highest risk of VTE in the entire pregnancy journey [9]. Risk factors: caesarean section (especially emergency), obesity, pre-eclampsia, immobility, older maternal age, thrombophilia.
Investigation: Ultrasound Doppler of lower limb venous system (confirmed in 2025 MCQ Q10 as the correct answer for DVT) [7]. D-dimer is unreliable in pregnancy/puerperium (physiologically elevated).
Treatment: LMWH is the anticoagulant of choice in pregnancy and early puerperium. Warfarin can be used postpartum (safe in breastfeeding) once the acute phase is managed [9].
Sheehan syndrome = postpartum hypopituitarism due to pituitary infarction/necrosis following severe postpartum haemorrhage and hypovolaemic shock.
Why does the pituitary infarct? During pregnancy, the pituitary gland enlarges (lactotroph hyperplasia driven by oestrogen), increasing its metabolic demand. This enlarged gland is supplied by a portal venous system with limited arterial input, making it vulnerable to ischaemia. Severe PPH → hypotension → ischaemic necrosis of the anterior pituitary.
Clinical features (from 2023 MCQ Q38) [6]:
- Failure of lactation (loss of prolactin) — often the earliest sign
- Failure of menstruation to return (loss of FSH/LH)
- Other features of hypopituitarism: fatigue, cold intolerance (TSH loss), hypotension (ACTH/cortisol loss), eventually growth hormone deficiency
The 2023 MCQ Q38 answer: The associated endocrine problem is A: Arginine vasopressin deficiency (diabetes insipidus) — because the posterior pituitary can also be affected (though less commonly), leading to central DI [6][11].
Rare in developed settings but can occur after prolonged obstructed labour (especially in low-resource settings) or as a complication of caesarean section. Presents with continuous urinary leakage. Types: vesicovaginal fistula (most common), ureterovaginal fistula.
"Rhesus negative mother: Anti-D immunoglobulin to non-sensitised women within 72 hours following delivery of a Rhesus-positive baby." [1]
Why 72 hours? This is the window to destroy fetal Rh+ red cells that have entered the maternal circulation during delivery before the mother's immune system mounts a primary antibody response. Preventing sensitisation protects future pregnancies from haemolytic disease of the newborn.
"Rubella antibody negative mother: Advise vaccination and contraception for 1 month." [1]
Why contraception for 1 month? The MMR vaccine is a live vaccine. Although the theoretical risk to a fetus is extremely low, the recommendation is to avoid pregnancy for 28 days after vaccination as a precaution.
"Cervical screening: following local guideline." [1]
"Contraception." [1]
Contraception counselling in the puerperium:
- Ovulation can return as early as 3 weeks postpartum → contraception should be discussed before discharge.
- Progestogen-only methods (POP, implant, depot injection, LNG-IUS) can be started immediately postpartum and are safe during breastfeeding.
- Combined hormonal contraception (COC, patch, ring) should be avoided in the first 6 weeks postpartum in breastfeeding women (may reduce milk supply; also increased VTE risk in the early puerperium).
- IUCD can be inserted immediately post-placental or at the 6-week postnatal check.
- LAM: only reliable if exclusively breastfeeding, amenorrhoeic, and < 6 months postpartum.
The lecture references NICE 2021 Postnatal Care guidelines [1]. Key points:
- First postnatal contact within 36 hours of birth
- Assess maternal physical recovery, mental health, infant feeding, and baby wellbeing
- Routine puerperal check at 6–8 weeks: assess wound healing, lochia, mood (EPDS), contraception, breastfeeding, blood pressure (if hypertensive disorder of pregnancy)
- Screen for mental health at every contact
"Management of normal puerperium. Early detection of deviation from normal. Help mother adjust to changes. Postpartum problem is common (PPH and infection). Need to watch out for postpartum mood problem. Exclude life-threatening events. Other aspects: postnatal exercises, contraceptive advice, psychosocial." [1]
13. Exam Intelligence
| Year | Question | Topic | Key Points |
|---|---|---|---|
| 2016 SAQ Q2 [3] | 31 y/o, heavy PV bleeding 10 days post LSCS | Secondary PPH Hx/PE/Ix | Ask about delivery details, placental histology, medications, infection symptoms, sexual intercourse, cervical smear; examine for pallor, tenderness, cervical os, uterine size; Ix: FBC, USS, swabs, β-hCG |
| 2022 MCQ Q13 [5] | 38 y/o G1P1, 4 days post LSCS, leg pain + SOB | DVT/PE post-caesarean | Risk factors: CS, BMI 35, pre-eclampsia, failed induction. Answer: DVT |
| 2023 MCQ Q38 [6] | 32 y/o, failure to lactate, no menses after severe PPH | Sheehan syndrome | Associated endocrine problem: AVP deficiency (DI) |
| 2024 MCQ Q14 [4] | 36 y/o G1P1, 4 weeks post LSCS, low mood, guilt, suicidal thoughts | PND vs blues vs psychosis | Answer: PND (persistent > 1 week, guilt, suicidal ideation, no psychotic features) |
| 2025 MCQ Q10 [7] | 40 y/o G1P1, 2 days post emergency LSCS, fever + calf tenderness | Investigation for puerperal DVT | Answer: US Doppler of lower limb venous system |
| Trap | Correct Approach |
|---|---|
| Calling day-4 tearfulness "PND" | Puerperal blues if < 1 week and no suicidal ideation |
| Dismissing postpartum PV bleeding at 2 weeks as menses | Menses unlikely < 5 weeks postpartum; investigate for secondary PPH |
| Attributing elevated fundal height to subinvolution when bladder is full | Always catheterise/check residual urine before diagnosing subinvolution |
| Using D-dimer to investigate DVT in postpartum | D-dimer is unreliable (physiologically elevated); use USS Doppler |
| Forgetting DVT as a cause of puerperal pyrexia | Always include DVT/PE in differential for postpartum fever |
| Stopping breastfeeding for mastitis | Continue breastfeeding; only stop if abscess drainage site near areola |
Q1 (SAQ-style): A 30-year-old G1P1 presents with heavy vaginal bleeding 12 days after normal vaginal delivery. Describe your approach to history, examination, and investigations. (10 marks)
Markscheme: History — review delivery record (mode, complications, placental completeness, histology sent?), medications (anticoagulants, Chinese herbs), symptoms of infection (fever, abdominal pain, foul-smelling lochia), sexual intercourse/contraception, latest cervical smear. Examination — pallor, abdominal tenderness, speculum (cervical lesion, vaginal discharge), bimanual (uterine size, cervical os status, cervical excitation tenderness). Investigations — FBC, G&S/crossmatch, coagulation, β-hCG, HVS/ECS, pelvic USS, MSU.
Q2 (MCQ-style): Which of the following is the MOST LIKELY diagnosis for a woman at postpartum day 5 who is tearful, irritable, and has labile mood but no suicidal thoughts and is coping with baby care?
Markscheme: Puerperal blues. Key: day 5 onset, transient, no suicidal thoughts, no guilt/loss of self-esteem.
Q3 (SAQ-style): List 5 causes of puerperal pyrexia. (5 marks)
Markscheme: Endometritis/retained POG, mastitis/breast abscess, wound infection (episiotomy/CS/drip site), DVT/PE, UTI. (Also accept: URTI/pneumonia, gastroenteritis)
Q4 (MCQ-style): A 32-year-old woman who had severe PPH now presents with failure to lactate and amenorrhoea at 6 months postpartum. What is the diagnosis?
Markscheme: Sheehan syndrome (postpartum pituitary necrosis). Failure of lactation = prolactin loss. Amenorrhoea = gonadotrophin loss.
Active Recall - Puerperium and Related Problems
High Yield Summary
Puerperium = 6-week period for return to non-pregnant state. Involution: fundus at umbilicus on day 1, not palpable by day 10–14, non-pregnant by 6 weeks. Lochia: red → brown → serous; mean 24–36 days; abnormal if persistent red, excessive (secondary PPH), or foul (endometritis). Puerperal pyrexia (≥ 38°C): think endometritis, mastitis, wound infection, DVT/PE, UTI. Urinary retention: common after epidural/instrumented delivery; full bladder deviates uterus; catheterise if residual > 500 ml. Blues (50%, day 4–5, self-limiting) vs PND (10%, persistent > 1 week, guilt, suicidal ideation; screen with EPDS ≥ 11–13; treat with psychotherapy ± SSRI) vs Puerperal psychosis (0.1–0.2%, onset day 1–3, hallucinations, loss of insight; psychiatric emergency; lithium/antipsychotics). Sheehan syndrome: pituitary necrosis after severe PPH → failure of lactation + amenorrhoea + hypopituitarism. Miscellaneous: Anti-D within 72 hrs for Rh-negative mother; rubella vaccination + 1 month contraception; contraception before first menses (ovulation precedes menstruation); bleeding < 5 weeks postpartum is NOT menses — investigate.
[1] Lecture slides: CFB (OG02) Puerperium and Related Problems.pdf [2] Lecture slides: CFB (OGPAE02-1) Physiology of Lactation, Breast Feeding and Infant Feeding (Part I).pdf [3] Past papers: 2016 Fourth Summative SAQ.pdf, Question 2 [4] Past papers: 2024 Fourth Summative MCQ.pdf, Question 14 [5] Past papers: 2022 Fourth Summative MCQ.pdf, Question 13 [6] Past papers: 2023 Fourth Summative MCQ.pdf, Question 38 [7] Past papers: 2025 Fourth Summative MCQ.pdf, Question 10 [8] Lecture slides: CFB (OGPAE02-2) Physiology of Lactation, Breast Feeding and Infant Feeding (Part II).pdf [9] Senior notes: Block A - Leg swelling and chest pain_ deep vein thrombosis; pulmonary embolism; Thrombophilia.pdf [10] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf, p281 [11] Senior notes: Block A - I keep on bumping into people on my side_ pituitary tumours; hypopituitarism.pdf
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