PostPartum Woman and her baby Sarah Gopman MD Associate Professor Dept of Family and Community Medicine University of New Mexico July 1 2015 LearningPractice Objectives Screen for and treat postpartum depression ID: 420073
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Slide1
Outpatient Care of the PostPartum Woman and her baby
Sarah Gopman, MD
Associate Professor
Dept. of Family and Community Medicine
University of New Mexico
July 1, 2015Slide2
Learning/Practice ObjectivesScreen for and treat postpartum depression
Evaluate and treat postpartum thromboembolic disease
Recognize and treat
endomyometritis
,
c-section
wound infections, and
perineal
wound complications
Manage breastfeeding difficulties
Evaluate and manage newborn
hyperbilirubinemiaSlide3
Screening for and Treatment of Postpartum DepressionSlide4
A postpartum patient at risk for depression…
Josie is a 25 y/o woman cared for by you since she was 19
H/o major depressive d/o, including hospitalization for suicide attempt age 17
Intermittently on SSRI, stopped two months prior planned pregnancy, did well with cognitive behavioral therapy during pregnancy
H
ad a term NSVD of a healthy baby and is breastfeedingSlide5
What type of mood disorders occur in the postpartum period?
Postpartum/baby “blues”
~40-80% of women affected
Feeling overwhelmed
Irritability
Tearfulness
Exhaustion
Trouble falling or staying asleep
Usually resolves by two weeks postpartum
Increased risk of developing full postpartum depressionSlide6
What type of mood disorders occur in the postpartum period?
Postpartum depression
10-20% of women affected
Greatest risk is first 12 weeks after delivery, but risk persists for one year
Symptoms last more than 14 daysSlide7
What are postpartum depression symptoms?
Tearfulness, sad or flat affect, irritability, mood instability
Feeling inadequate, guilty, overwhelmed
Sleep and appetite disturbance
Intense worries or obsessive thoughts re. harm to the baby
Difficulty concentrating or making decisions
Lack of interest in the baby, family or activities
Poor bonding
Thoughts of death or suicide
Somatic symptoms: HA, CP, palpitations, numbness, hyperventilationSlide8
How is postpartum psychosis characterized?
1-2 in 1000 women affected
Agitation and anger
Anxiety/Paranoia
Insomnia/Delirium/Confusion
Mania (hyperactivity, elated mood)
Suicidal or homicidal thoughts
Auditory hallucinations (about the baby, of a religious nature)
Visual hallucinations (seeing or feeling “a presence” or “darkness”)
Delusions and commands to harm the infant (not just an obsessive thought)
EMERGENCY:
PSYCHIATRIC HOSPITALIZATION NECESSARYSlide9
What is the risk of suicide in the postpartum period?
“Suicides account for up to 20% of all postpartum deaths and represent one of the leading causes of
peripartum
mortality.”
(
2005 in Archives of Women’s Mental Health)Slide10
What is different about postpartum depression versus depression at other times of life?
Sleep deprivation is the norm postpartum
Strong societal expectations about maternal happiness postpartum
50% of postpartum depression goes undiagnosed
Postpartum depression affects mothers, children, partners, and familiesSlide11
How does maternal depression relate to pregnancy outcomes?
Maternal effects
Low weight gain
Increased use of cigarettes, alcohol, other substances
Ambivalence regarding the pregnancy
Neonatal/infant effects
Increased preterm
birth
Low birth
weight
Higher cortisol levels (sustained through adolescence)Slide12
How does postpartum depression affect maternal behavior?
Mothers who are depressed show
Less affectionate behavior and impaired bonding
Less response to infant cues
More hostile/intrusive interactions with their infants
Decreased rates of infant safety practicesSlide13
What are the risks to children when postpartum depression goes untreated?
Children of mothers with untreated depression
exhibit
More fussiness and colic
Impaired
emotional
development: fewer positive facial expressions
Poorer language
development: less vocalization
Difficulties with attention
Decreased cognitive skills
Increased risk for long-term behavioral
problems
Remission of maternal depression improves children’s mental and behavioral disorders
Consider depression during pregnancy and postpartum as an
exposure
with associated risks for the infant!Slide14
When should you screen your patient for postpartum depression?
Any routine infant or maternal postpartum visit
Special visits scheduled for following up on
hx
of depression
Example
First newborn check at 2 or 3 days after d/c
2 weeks postpartum
4-6 weeks postpartumSlide15
What method will you use to screen her?Postpartum Depression Screening Scale
35-item
Likert
response scale (“Strongly Disagree” to “Strongly Agree”)
Third grade reading level
Completed by patient in ~10 minutes
Addresses seven areas
Sleeping/Eating Disturbances
Anxiety/Insecurity
Emotional
Lability
Cognitive Impairment
Loss of Self
Guilt/Shame
Contemplating Harming OneselfSlide16
What method will you use to screen her?
Edinburgh Postnatal Depression Scale
10-item self-report scale (“Yes, most of the time” to “No, not at all”)
Each item scores 0-3 points, max score 30,
>
10 is cutoff for depression
Available in several languages
Intended for use at 6-8 weeks postpartum, but validated for use at other times
Completed by patient in ~5 minutes
A
ddresses symptoms of
Inability to laugh
Inability to look forward to things with enjoyment
Blaming oneself unnecessarily
Feeling anxious or worried
Feeling scared or panicky
Feeling that “things have been getting on top of me”
Difficulty sleeping because of unhappiness
Feeling sad or miserable
Crying
Thoughts of harming oneselfSlide17
How do the two screening methods compare?
Postpartum Depression Screening Scale
For combined major and minor postpartum depression
sensitivity 91%
specificity 72%
Edinburgh Postnatal Depression Scale
For combined major and minor postpartum depression
Sensitivity 68-80%
Specificity 77%Slide18
Which antidepressants can be used while breastfeeding?
Sertraline (Zoloft) currently favored SSRI during breastfeeding
Short half-life
Low or undetectable infant plasma levels
More follow-up data on infant development
Paroxetine (Paxil) and fluvoxamine (
Luvox
) also show low infant plasma levels
Use following with caution in patients w/ prior good effect
Fluoxetine (Prozac)--long half-life
Citalopram (
Celexa
)--high breast milk concentrationSlide19
What else do we know about antidepressant use while breastfeeding?
Omega-3 fatty acids showed significant response rate in one open-label study
Medication exposure to fetus via placental transfer is almost always greater than to the newborn via breastfeeding
Most national guidelines recommend six months of treatment once depression is in remissionSlide20
What are non-pharmacological options for treatment of postpartum depression?
Cochrane Review: any psychosocial or psychological intervention, compared to usual postpartum care, is associated with reduction in risk of continued postpartum depression
Breastfeeding may be somewhat protective against postpartum depression (oxytocin release?)Slide21
What are non-pharmacological options for treatment of postpartum depression?
Cognitive Behavioral Therapy
Good results w/ group approach
10-40% fail to complete full treatment (similar to pharmacotherapy)
May have enduring effects not seen w/ pharmacotherapy (up to two years)
Six sessions of non-directive counseling w/ child health nurses was more effective than routine primary care in Sweden
Telephone-based peer support out-performed care as usual (five 30-minute conversations
)Slide22
Back to your patient…You see Josie frequently in clinic in the early postpartum period (newborn checkups and her own visit)
At two weeks postpartum
S
he describes low energy, worrying that she is not a good mom, difficulty sleeping, prolonged episodes of crying
Denies SI/HI, hallucinations, etc.
Is able to care for her baby but not enjoying it much
You review options for treatment of postpartum depression, including risks of no treatment
She elects to start medication
Used sertraline with good effect previously, so you
rx
50mg daily
You see her in f/u in 2 weeks
F
eeling better, no mania, bonding with baby, but some
sx’s
persist
You increase sertraline to 100mg daily and schedule her back in 2 weeksSlide23
How can her partner and family members help?
Mothers without social support twice as likely to develop postpartum depression
Among Latina women, those satisfied with marital/partner relationships showed lower risk of depressive
sx’s
postpartum
Among high risk women, better social support
quicker improvement in depressive
sx’s
Educate partner about signs of mania/hypomania: can be uncovered w/ use of SSRI. Also educate about the importance of treatment!Slide24
Evaluation and Treatment of Postpartum Thromboembolic DiseaseSlide25
How do patients with thromboembolic disease present in the postpartum period?
Silvia is a 37 y/o G5P5 at
9
days s/p repeat c/s performed at 37
wks
for pre-
eclampsia
She has a BMI of 43
She presents w/ increasing left leg pain and swelling for 2 days
On exam, you note the left calf is 4cm larger in circumference than the right and is tender to palpation and slightly erythematous
She has no dyspnea, tachypnea, or hypoxia Slide26
What are the risk factors for thromboembolic disease in the postpartum period? Age > 35
BMI > 30
Grand
multiparity
Fam
hx
of VTE/thrombophilia
Bed rest
Immobility for
>
4 days
Pre-
eclampsia
Severe varicose veins
Cesarean delivery (OR 13.3, 95% CI 3.4-51.4)
Virtualmedicalcentre.comSlide27
What is the incidence of VTE in postpartum women?
0.5-3.0 per 1000 pregnancies
Equal incidence in each trimester and postpartum
90% of DVTs in pregnancy are in the left leg
PE is more frequent in the postpartum period than during pregnancy (RR 15.0, 95% CI 5.1-43.9)Slide28
How is VTE diagnosed in the postpartum period?
Venous compression ultrasonography is the preferred test for dx of DVT
89-96% sensitive and 94-99% specific for symptomatic proximal LE DVT in non-pregnant
patients
Current spiral CT technology is comparable to pulmonary angiography in positive and negative predictive values for PE
CT delivers more radiation to the breast than V/Q scan, which may be preferred in those w/ family
hx
of breast cancer Slide29
How is VTE treated in the postpartum period?
Warfarin can be started at the same time as low molecular weight heparin or unfractionated heparin
LMWH (1 mg/kg SC bid) or UFH (80 units/kg loading dose i
v
, then continuous i
v
infusion of 18 units/hour, or 17,500 units SC q12h)
aPTT
goal is 1.5-2.0 X upper limits of normal
Continue LMWH or UFH until INR is 2.0-3.0 for 2 consecutive days
Treat until 3-6 months post-diagnosis and for at least 6 weeks postpartum Slide30
Back to your patient…Her risk factors are: age, c/s, pre-e, obesity
Her LE
doppler
confirms left DVT
She is appropriate for outpatient treatment
Given LMWH 100mg SC in OBT
R
x for bid LMWH is phoned to her pharmacy and emergency prior authorization is approved
She also starts warfarin and is given a f/u
appt
in the
C
oumadin Clinic
Is that okay for breastfeeding moms?
Yes
Should she be given prophylaxis in a subsequent pregnancy?
Yes: She falls under the criteria of “no known thrombophilia with previous single episode of VTE associated with transient risk factor that
was
pregnancy- or estrogen-related.”Slide31
Endomyometritis, C-section Wound Infections, and
Perineal
Wound ComplicationsSlide32
A postpartum woman with fever…Delia is a 32 y/o G1P1, 7 days s/p c/s for failure to progress following induction for GDMA2
Complains of onset of fever and chills yesterday evening, resolved w/ ibuprofen overnight, recurrent this morning with temp 102 at home
Reports her VB has increased slightly in the last 24h, notes a foul vaginal odor and some vague abdominal painSlide33
How does postpartum endomyometritis present and what are the pathogens involved?
Temp
>
38.0 (100.4), chills
Uterine tenderness
Foul lochia
Lower abdominal pain
Fundus soft instead of firm, sub-
involuted
(above umbilicus, excessive VB)
Microbiology
U
sually mixture of 2-3 aerobes and anaerobes, including gram
pos
and
neg
; rarely GC/CT
Rare but potentially lethal bacteria: clostridium
sordellii
, clostridium
perfringens
, strep or staph toxic shock Slide34
What are risk factors for postpartum endomyometritis?
C
/s = most important
Prolonged labor or ROM
Lots of cervical exams
Internal monitors in labor
Manual placenta extraction
Maternal DM or severe anemia
BV or GBS colonizationSlide35
How is postpartum endomyometritis evaluated and diagnosed?
Physical exam
Fever, tachycardia
Uterine tenderness on abdominal or bimanual exam
L
ook for findings associated with other causes of fever, such as surgical site infection, pelvic abscess, mastitis, UTI/
pyelo
, DVT/PE
R
ising neutrophil count w/ increased bands (WBCs commonly elevated in labor, but should not continue to rise postpartum)
Blood cx
GC/CT if not done prior, positive earlier in pregnancy, or patient at increased risk
Imaging usually not indicated unless fever is persistent after 48-72h of
abx
or VB is heavy (fluid/debris/gas in uterus can be normal)Slide36
How is postpartum endomyometritis treated?
Clindamycin 900mg i
v
q8h plus gentamicin
5mg/kg
q24h (or 1.5mg/kg i
v
q8h), w/ 90-97% cure rate
Treat until clinically improved and afebrile X 24-48h; further oral
tx
not required unless bacteremia present based on positive blood cx
If fever persistent, add ampicillin, vs. change to ampicillin/
sulbactam
(
Unasyn
)1.5g
iv q6h, which can also be used first-line
U
terine suction
currettage
occasionally required to remove POCs shown on U/S (if not improving or bleeding heavy)
In late postpartum
endomyometritis
(1-6 weeks postpartum and usually milder
sx’s
, 15% of all disease), amoxicillin-
clavulanate
875mg
po
bid X 7 days
i
s acceptableSlide37
What if your patient presented with no fever, but increased pain at her c/s incision site? Risk factors for c/s wound infection similar to
endomyometritis
Wound appears erythematous and induration can be palpated
Evaluate for
seroma
, hematoma, or abscess, including probing down to the fascia w/ a sterile cotton-tipped applicator if the wound opens
Wound aspirate (rather than swab) for
cx
After drainage of an
abcess
/opening the wound, irrigate and pack w/ sterile gauze, w/ healing by secondary intention
Antibiotics
Cephalexin 500mg
po
qid
X 7 days
Clindamycin if MRSA suspected
B
oth are fine for breastfeeding
Close follow up is important
a
mamasblog.comSlide38
How do postpartum patients with perineal laceration complications present?
Tanya is a 20 y/o G1P1 s/p vacuum-assisted vaginal delivery for failure to descend and fetal intolerance of labor
She had a second degree
perineal
laceration repaired
She presents 3 days postpartum with
perineal
pain
She reports a subjective fever at home, but is afebrile in your office, with no recent antipyretic use
On
perineal
exam, no erythema, sutures appear intact, no foul-smelling discharge, external anal sphincter and
rectovaginal
septum intact, but a hematoma is noted of the left labiaSlide39
What is the differential diagnosis and treatment for perineal pain postpartum?
Labial/vaginal hematoma: incise, evacuate, and ligate the bleeding vessel(s) if continues to expand or appears infected; if stable and not large, may resorb spontaneously
Williams Obstetrics, 23 Ed.Slide40
What is the differential diagnosis and treatment for perineal pain postpartum
?
Perineal
infection
O
pen
any organized
abscess (imaging may be required to assess for tracking of the abscess into deep tissues)
C
onsider
removing suture
material
Verify
that a third or fourth degree laceration has not been
overlooked
Antibiotics (may
require
admission)
Look for hemorrhoids and anal
fissures, treat
accordingly
Discuss in private
whether pressured/forced
to have sex before completely
healedSlide41
Back to your patient…Delia has endomyometritis
by
hx
and exam
A
dmitted for iv gent and
clinda
B
ecomes afebrile after 18 hours of
abx
Tx’d
until afebrile for 24h and no fundal tenderness, then
abx
d/
c’d
and observed for 24h off
abx
, remained afebrile
Tanya has a 3 X 3 cm labial hematoma
She states “that lump has been there since a few hours after the delivery” and “it’s the same size as yesterday”
Vitals are normal
There is no surrounding erythema or induration
You elect conservative management, give precautions, and bring her back in 48h for re-examinationSlide42
Management of Breastfeeding DifficultiesSlide43
What types of breastfeeding difficulties do women encounter postpartum?
Cassandra is a 28 y/o G1P1, 10 days s/p term NSVD
Exclusively breastfeeding, 3 days of breast pain
Nipple pain starts at latch and lasts entire feeding, plus shooting pains that radiate from nipple back into breast occurring w/ letdown and feeding
No fevers, chills, or body aches
Nipples and areolae are bright pink; cracks and fissures on both nipples; no other erythema, warmth, induration or
fluctuance
Baby appears to have oral thrushSlide44
How is breast candidiasis evaluated?
Pain from
intraductal
yeast infections is often described as shooting and radiates from nipple to chest wall, and is out of proportion to the clinical exam
Nipple/areola may appear shiny or flaky
Skin scraping for microscopy
Positive breast milk culture
Often associated w/ other yeast infections in the infant, such as thrush or diaper area dermatitis
There is not universal agreement among clinicians and researchers regarding the existence of this clinical entitySlide45
How is breast candidiasis treated?
Infant and
mother treated
Topical
nystatin
or gentian violet for
infant
Topical
nystatin
,
miconazole
, or ketoconazole for
mother if infection seems to be cutaneous only (not
intraductal
)
Another option is oral
fluconazole (
Diflucan
) for
mom, +/- baby
(not FDA approved, but used
frequently for moms)
Mother: 400mg
po
on day one, then 200mg
po
daily X at least 10 days
Infant: 6-12mg/kg
po
on day one, then 3-6mg/kg
po
daily X at least 10 days
Blisstree.comSlide46
What are the risk factors for mastitis?
Most common in 2
nd
and 3
rd
weeks postpartum (75-95% occurring before infant is 3
mos
of age)
Poor breastfeeding technique
Infant cleft lip/palate or short frenulum
Cracked nipples
Missed feeding(s)
Nipple piercing
Poor maternal nutrition
Plastic-backed breast pads, tight bra
Yeast infection
Manual pump use
Breastfeedingbasics.comSlide47
What interventions can decrease the risk of mastitis?
Improve breastfeeding technique and latch
Apply expressed breast milk or lanolin to nipples and areolae
Treat yeast infections
Consider
frenotomySlide48
How is mastitis diagnosed and treated?Localized, unilateral breast tenderness and erythema
Fever, malaise, fatigue, body aches, headache
Breast milk cultures rarely indicated, unless infection fails to respond to
tx
Most common organism is S.
aureus
Treat with antibiotics and improving breastfeeding technique
Complete emptying of the breast is key, and breastfeeding should continue; this decreases risk of abscessSlide49
How is mastitis diagnosed and treated?Antibiotic choicesAmox
/
clav
875 mg
po
bid
Cephalexin 500 mg
po
qid
Clindamycin 300 mg
po
qid
Dicloxacillin
500 mg
po
qid
TMP/SMX 160/800 mg
po
bid (avoid in mothers of infants
<
2mos or sick infants of any age)
Duration of
tx
usually 10-14 days
Abscess should undergo
I&
D or
needle aspiration
, w/ fluid sent for culture,
and breastfeeding
can usually continueSlide50
Another patient with breastfeeding difficulties…Noemi is a 24 y/o G2P2 s/p NSVD at 36 weeks following spontaneous preterm labor
Mother and infant discharged home at 2 days postpartum, w/ LATCH score of 7-8
Followed closely in clinic for infant weight gain
Infant is now 6 weeks old, and mom returned to work 2 weeks ago
Having a hard time pumping at work, and thinks milk supply is decreasing
Baby’s grandma has been giving an ounce or two of formula, along w/ EMB, while mom at workSlide51
Why should we promote exclusive breastfeeding?
Human milk provides
Nutrients
and energy for rapid growth and
development
Protective
factors against
infection
Otitis media, diarrheal illness, upper respiratory infection
Decreases pain and suffering
Reduces lost work time for
parents
Chronic disease prevention
Diabetes mellitus
Celiac disease
Childhood cancers
Atopic disease
Multiple sclerosis
Inflammatory bowel diseaseSlide52Slide53
What are the costs of suboptimal breastfeeding in the U.S.?
2010 study by
Bartlick
and Reinhold, published in the journal
Pediatrics
Looked only at costs of pediatric diseases
Used “2007 dollars”
If
90%
of US families breastfed exclusively for 6 months, the U.S. would
save $13 billion
and
prevent 911 deaths
At
80%
compliance, savings would be
$10.5 billion
and
741 deaths Slide54
What are current breastfeeding recommendations?
American Academy of Pediatrics
and
American Academy of Family Physicians
4-6 months exclusively
Continue for at least 1 year
World Health Organization
4-6 months exclusively
Continue for at least two yearsSlide55Slide56
How can we help women maintain/increase breast milk production?
A
void introduction of formula
Pump q 3h when away from baby
Pump immediately after each feed
Adequate rest, nutrition, and hydration for mother
Have a “nurse-in”
Natural products: mother’s milk tea, oatmeal, etc.
Metoclopromide
course for mom: 10 mg
po
tid
X 10 days (or other regimens/drugs)
Advocate for breastfeeding-friendly policies in your own workplace and
community!Slide57Slide58
Evaluation and Management of Newborn JaundiceSlide59
A newborn at risk for hyperbilirubinemia…
Baby Girl T was delivered to a 40 y/o G1P0 at 35 6/7
wks
GA via emergent c/s for fetal
bradycardia
occurring following combined spinal-epidural for planned external cephalic version in setting of PPROM and breech
DOB 5-13-15 at 05:50,
Apgars
3 & 9,
L&D BW
2260g
PPV at delivery, MBU for couplet care,
MBU BW
2240g
Initial
bili
7.2 at 28 hours of life
Coombs negative
Exclusively breastfed
D/
c’d
home day 3, f/u day 5 with
bili
of 20.3,
wt
2120gSlide60
How is newborn jaundice evaluated in the outpatient setting? Is breast milk intake adequate?Insufficient
intake
decreased
stool
productionincreased
reabsorption of
bili
from
gutelevated
unconjugated (indirect)
bili
Weight loss or insufficient gain?
Poor urine or stool output? Persistent meconium stools?
Elevated
bililethargy
and poor
feedinghigher
bili
Inadequate
intakedehydration
, malnutrition, risk of kernicterus
Often called “breastfeeding jaundice” but should be called
“not-enough-breastfeeding jaundice”Slide61
How is newborn jaundice evaluated in the outpatient setting? Are there risk factors for hemolysis?
Polycythemia
Cephalohematoma
or bruising at birth
ABO incompatibility or Rh
isoimmunization
Red cell glucose metabolism enzyme deficiencies: pyruvate kinase
Hereditary spherocytosis or other RBC membrane
abnormalitiesSlide62
Could it be breast milk jaundice? What is that?Presents in the
first
or second
week of life
C
an
persist for
up to 12 weeks
Resolves spontaneously
Incidence 36% in exclusively breastfed infants
Hypothesized to involve a breast milk component that increases
enterohepatic
circulation of bilirubin
W
eight
gain
, stool/urine output, and physical exam should all be normal
Total
serum
bili
in
breast milk jaundice
alone
should be
<
12
mg/
dl
Conjugated (direct)
bili
should be less than 1mg/dlSlide63
How can you be sure it’s just breast milk jaundice? If direct bili
<1 but
total
bili
is
>
12, additional evaluation is needed
First r/o hemolysis:
hct
or
hgb
, reticulocyte count, coombs, peripheral smear
Test for G6PD deficiency
People of African
, Asian, Latino,
Mediterranean and
Middle Eastern
descent at higher risk
4.9% of world’s population
affected: 12
% of African American
men, 4.3
% of Asian American men
X-linked, but can also affect
females
Risk of false negative test from larger amount of G6PD in young RBCs, more released w/ hemolysis—consider retesting when jaundice is resolved
Review newborn metabolic screen results
Consider parental
bili
levels for Gilbert’s
Testing for all UGT
1A1
mutations is not readily available, but some are obtained w/ newborn metabolic screeningSlide64
What does UGT 1A1 do and what are the associated mutations? UGT 1A1 (uridine
diphosphate
glucuronosyltransferase
1A1) = hepatic enzyme that conjugates bilirubin
After conjugation,
bili
travels to small intestine in bile
Intestinal flora converts it to
stercobilin
Stercobilin
is excreted in stool
Beta-
glucuronidase
can
deconjugate
bili
Deconjugated
bili
is absorbed by intestinal mucosa and returned to liver via portal circulation (
enterohepatic
circulation)
UGT 1A1 mutations
Crigler-Najjar
type I: 1 in 1 million babies, no enzyme production, critically high
bili
, kernicterus and death if
untx’d
in newborn period, most die later in life of kernicterus; liver transplant is
currative
Crigler-Najjar
type II: indolent course, elevated
bili
but below LL, responds to
phenobarb
which induces UGT 1A1 production
Gilbert’s syndrome: ~8% prevalence,
eznyme
levels 1/3
rd
to 1/10
th
of normal, mild effect on
bili
but could be additive w/ another cause Slide65
What are some other non-hemolytic etiologies?
Biliary atresia
Neonatal hepatitis
Galactosemia
Hypothyroidism
Pyloric stenosis
Annular pancreas
Duodenal or
jejunal
atresia
Sepsis
Medication exposures: ceftriaxone,
dicloxicillin
,
sulphonamidesSlide66
Date
Time
Bili
Tx
Level
Weight
Action
5/14
09:45
7.2
10.5
Observe
5/15
07:00
10.0
13.2
Observe
5/16
06:00
13.8
15.5
2100
D/c home
5/18
08:45
20.3
18
2120
Admit for photo
tx
5/18
21:00
15.0
18
Continue photo
tx
5/19
08:30
10.7
18
2150
D/c
photo
tx
and d/c home
5/22
10:45
14.1
F/u
in 6d
5/28
09:15
18.0 (
dir
=0.4)
2330
MCH
consulted, f
eed
freq’ly
, f/u for
wt
6/1
15:45
17.8 (
dir
=0.4)
2410
F/u
4-7d
6/8
09:30
19.7 (
dir
=0.6)
2330
Wt
loss noted, MCH
consulted w/ plan
to admit,
PCP rec = no admit, supplement w/ formula, G6PD,
retic
, repeat coombs.
6/9
15:15
16.2 (
dir
=0.5)
2380
On-call resident
leaves
vm
for mom to go to
Peds
ED. Email communication b/w mom and PCP that
Peds
ED not needed.
6/10
2450
Got
30cc formula after each breast feed.
6/11
11:45
12.7 (
dir
=0.4)
Mom
notified by PCP, continuing care at
Pres
per prior plan.
Our patient’s clinical course…Slide67
Phototherapy GuidelinesSlide68
Newborn Jaundice Clinical Decision Making Pathway
Preer
GL, Philipp BL.
Understanding and managing breast milk jaundice. Arch
Dis Child Fetal Neonatal Ed (2010). doi:10.1136/adc.2010.184416Slide69
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