175 Postpartum Care for the PANCE: No Estrogen Before Day 21

Hello and welcome to episode 175 of the Physician Assistant Exam Review Podcast. Today we’re going to be covering postpartum care, so contraception and the postpartum visits. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review and I’ve been behind the microphone here for 15, over 15 years now helping PA students. Our goal here is to make you better students to move through the content in a way that’s going to help you to produce on exams, to retain information longer and to then show that on your high stakes exams. That’s exactly what we’re doing. We’re going to jump in today with the priming questions and get things started right off the bat.

Okay, so number one, a breastfeeding mother needs a blood pressure medicine after delivery. What’s the best place to start? So if we’re talking about after pregnancy, after delivery, if we need to give mom has high blood pressure, where are we going to start her for her blood pressure medication? Name the three requirements of lactational amenorrhea method. So here we’re talking about contraception. Name the three requirements of the lactational amenorrhea method. Number three, in a woman who is not breastfeeding, what’s the earliest postpartum day to start a combined estrogen pill?

That seems like a really good test question to me. In a woman who is not breastfeeding, what’s the earliest postpartum day to start a combined estrogen pill? What postpartum test screens for diabetes after gestational diabetes? What postpartum test do we use to screen for diabetes after gestational diabetes? And number five, our last one, a severe headache and blood pressure of 164 over 112 on postpartum day six, call for what seizure prophylaxis? So if we have a patient coming in with a massive headache, she’s postpartum day six, 164 over 112 is her blood pressure, what are we going to do for seizure prophylaxis for her?

All right, perfect. We’re going to jump in and cover those two sections today. Like I said, postpartum contraception and postpartum follow-up visits, that’s going to be what we’re going to try to chunk down to today. Oh, if you haven’t noticed, I’ve also introduced a, last week I introduced a second podcast into the feed, which is Rapid Rounds. We just go through questions like this, I did last week, I did about 15, we’ll see how it goes moving forward. I want to keep them kind of tight and kind of short, but that’s what’s going to come out in the second podcast, right in the same feed. So that’ll be there for you.

You can check that out.

All right, so let’s, in episode 174, we covered normal puerperium and breastfeeding. Today we’re going to finish normal postpartum care, right? So postpartum contraception, let’s start there. This is contraceptive plan initiated before hospital discharge. So if they don’t want more kids, what are we going to do? We’re going to, this is going to depend a little bit on breastfeeding and time since delivery. Those are our two factors.

So the lactational amenorrhea method or LAM, lactational amenorrhea method, about 98% effective, which I was a little bit surprised that it’s that high. But it’s only while all three criteria are met. That’s really the key. So if any of these don’t hit, then it’s going to be far less useful as a, as a method of contraception. You must be breastfeeding exclusively day and night. That’s a major, major key here. Also, you must have amenorrhea since delivery and it must be with the infant under six months, so six months from delivery.

Within that window, from what I can find, the lactational amenorrhea method is about 98% effective, but all of those things have to be in place.

Let’s talk a little bit about medications. So you’re going to start with progestin only methods. This is safe any time postpartum, breastfeeding or not. That’s the key here. And what you’re going to get a test question on in my, in, from what I can see, progestin only is going to be okay right out of the door. So you can do the, you can do the implant right before discharge. That would be fine.

The progestin implant. You can do the Depo-Provera injection every three months. That’s okay to do right after delivery. Or you can do a progestin only pill taken at the same time, every single day. From there, you can move to a combined estrogen pill or patch or ring or whichever method that you want to use. Here’s the deal though. The contraindication in the first 21 days for all women against estrogen.

Here’s why the risk of clotting is elevated, especially in that first week to three weeks, that’s kind of that zone. So estrogen is going to increase clotting. So we don’t want to use it in the first three weeks. It will also interfere with milk production. So if we have someone who’s breastfeeding or wants to attempt to breastfeed, we don’t want to give estrogen during this period either. To me, that’s where I’d circle up and make a nice big circle of something I want to remember that I want to hold on to. So combined estrogen pills are going to be until day 21.

And at that point, the, that’s only if they don’t have additional risk factors.

Now, what are our additional risk factors for a estrogen pill, right? Age 35 or older, cesarean delivery, smoking, BMI 30 or higher, preeclampsia, transfusion at delivery, all these things we’re not going to still going to want to hold off for day 21 to 42 because it still has to do with that clotting issue.

Now, if they’re breastfeeding, you don’t want to give it to at least 30 days out. That sort of seems to be the line. That’s what I would go with. The question stem would likely describe a breastfeeding woman at her two week visit who’s looking for a birth control pill. And the key here is not to do the combined pill. You’re going to do progestin only again, because of that clotting risk and because of a milk production question. You can do an IUD.

You could place this, what I found was within 10 minutes of placental delivery, this seemed kind of odd to me, but you certainly can go right ahead and do that. The expulsion rate is a little higher at four weeks or at, or later after delivery, the expulsion rate goes down. This is completely compatible with breastfeeding, no issues there. Obviously this is contraindicated with a postpartum uterine infection. We’re not going to want to place it at that point. Postpartum sterilization. This would be a tubal.

We’ve actually moved a lot more toward bilateral salpingectomy over just tying the tubes because there’s a link to ovarian cancer, with the tubes. So we go ahead and actually just take them completely out. If we’re doing a cesarean, this is pretty straight forward. You’re already in the abdomen, or if you do a vaginal delivery, you can do a post vaginal, laparoscopic tubal. And, and that works just fine within 24, 48 hours of vaginal delivery. It’s not uncommon to do it at that point, but this is a permanent, decision, right? This is you’ve made the call.

Once we, once we remove the tubes, that’s a, that’s a big decision.

All right. So your exam keys for this section for lactational amenorrhea, we’re talking about exclusive breastfeeding, no period since delivery and the infant under six months, that’s the only way this is going to work pretty effective. If you have all of those, the other big one we talked about here was progestin only up to day 21, no estrogen before day 21. And if you’re breastfeeding, not before day 30. IUDs, you can place right away.

Perfect. Okay.

Let’s cover postpartum visits and follow-up, which is where we talk about all the things that happen that need to happen after delivery and then transitioning the patient to long-term care.

Now, if the patient had specific complications during pregnancy, then the follow-up test, we’re going to talk about those a little bit here as well.

Okay. Before the patient is discharged, an Rh-negative mother with an Rh-positive infant is going to get RhoGAM, right? An Rh-negative mom with an Rh-positive infant is going to get RhoGAM. Cause we don’t want her to create the antibodies. The timeline for that is 72 hours from delivery. Now remember the issue here is the, excuse me, is the Rh-positive infant blood mixing with Rh-negative mom’s blood. And then mom’s blood creates antibodies to Rh-positive, which will cause an issue down the road for the next pregnancy, not for this one, but possibly for the next one.

So the RhoGAM within 72 hours helps to prevent that. We’re going to give mom an MMR vaccine before she leaves. We’re going to give her a varicella vaccine before she leaves with the second dose coming at four to eight weeks later. Both vaccinations are compatible with breastfeeding. You do want to avoid pregnancy for four weeks after vaccination, but I don’t think you’re going to have a problem getting pregnant with pregnancy as you leave the hospital from your delivery. A Tdap can also be given before a patient is discharged.

All right. So let’s talk about the visit schedule. Things change a little bit for a patient who has a hypertensive disorder during pregnancy, because you’re going to want to do blood pressure checks. You can’t just let them go out on their own. So you need to check them within 72 hours if their numbers were pretty bad. Otherwise you can wait like a week to 10 days, but not so long as the initial follow-up, which comes at three weeks after delivery, you’re going to want to check in on them before that. A comprehensive visit comes at 12 weeks after delivery during that.

So we’re going to do blood pressure checks and everybody there. But if we have somebody with an issue throughout, we’re going to, you know, obviously check that a little tighter. Depression screening is going to be on the list here. Any positive response of self-harm, obviously we need to be paying attention to all these things.

Let’s talk a little bit about some complications, gestational diabetes. So we’re going to do a 75 gram, two hour oral glucose tolerance test at four to 12 weeks postpartum, because we’re going to be following up on that gestational diabetes. A fasting 126 or higher or two hour 200 or higher is very indicative for diabetes. A fasting of a hundred to 125 or two hour 140 to 199 is pre-diabetes. You can head over to the website to review all that physicianassistantexamreview.com. What is this episode, 175? If you do /175, it’ll take you right to the website and I’ve got all the notes there for you.

So you can, yes, it’d be good if you can remember all this, but it’s hard when you’re just listening out on a walk and driving your car or whatever you’re doing, you can head over to the website and find all that stuff. Here’s the major key though, that I wanted to point out and I’d highlight in the notes, hemoglobin A1C is not used at this point. And the reason is blood loss after delivery. It screws up the hemoglobin A1C. So we’re going to use a 75 gram, two hour glucose tolerance test to check on it four to 12 weeks after, and we’re going to go from there. That’s going to be the mainstay. You’re going to re-screen these patients every one to three years.

Unfortunately, they are at a higher risk for developing diabetes if they had gestational diabetes. If you have preeclampsia and gestational hypertension, this can develop or reoccur postpartum up to six weeks, but it’s most often the first week. So we need to, that’s why we want to bring those people in in that three to 10 day range to monitor blood pressure, all those things. New hypertension with a headache or visual changes or blood pressure, 160 systolic or 110 diastolic or higher. We’re managing that as preeclampsia. So the priming question, if you remember, we talked about this a little bit, right? We said, what, what do we want to do for seizure prophylaxis and somebody with a severe headache and super high blood pressure?

We’re going to start with magnesium sulfate for seizure prophylaxis. Then we’re going to give antihypertensives, IV labetalol, IV hydralazine, oral nifedipine, those kinds of things will be helpful here. Now the question is, what about breastfeeding? What can you use for blood pressure with someone who’s breast feeding? Well, you can use nifedipine and you can use labetalol. Those are two really good places to start. You can also use enalapril.

ACE inhibitors are contraindicated in pregnancy, but compatible with breastfeeding. So here, your question stem would likely describe something like a woman who had gestational diabetes, she’s six weeks out after delivery. And the question says, what do we do next? So I ask you, what do we do next? And the distractor here, the thing you don’t want to pick is a hemoglobin A1C. You want to pick two hour glucose tolerance test. Oh, the last thing, and I probably should have put this up with contraception.

We’ll put it down here at the bottom, planning the next pregnancy. This is, you want to wait about 18 months from delivery to next conception. And the reason is with a shorter interval, you have an increased risk of preterm birth and low birth weight. That’s the concern there.

All right. So what are our exam keys for this section? If we have a rubella nonimmune mother, we’re going to give an MMR postpartum. It’s compatible with breastfeeding. Gestational diabetes, we covered that already: 75 grams, a two hour oral glucose tolerance test at four to 12 weeks postpartum. Don’t do A1C. Preeclampsia can present postpartum.

So if you have someone who walks in postpartum with a massive headache and hypertension, think magnesium sulfate. ACE inhibitors are contraindicated in pregnancy, but compatible with breastfeeding. That’s probably something I would mark because I could see that being, you might call it a trick question, but I could see that being an answer choice and, being something that people miss.

All right. So putting this all together. The postpartum timeline, I think this is going to be really valuable again. This will be over on the website. Go to check it out there. 72 hours at 72 hours or within 72 hours, we’re going to give RhoGAM for an Rh-negative mom. Seven to 10 days, we’re going to do a blood pressure check.

21 days, we’re going to do earliest estrogen available. Four weeks is an IUD placement with the lowest expulsion rate. Four to 12 weeks is our oral glucose tolerance test after gestational diabetes, six weeks is our concern for postpartum preeclampsia, it goes away. At six months, our lactational amenorrhea method goes away. And at 18 months, this is the minimum interpregnancy interval. I think we went through that enough that I’m not, I didn’t want to take too long on it, we’ll go and you can go check it out in the notes. No problem.

Okay. So perfect. Now we wrapped up a lot pretty quick there. I know we repeated it a couple of times, but I want to really make sure that you get it and you have it locked in. That’s the purpose of the repetition is that you hold onto it and you can see how they’re coming in test questions. I try to present everything as though it’s coming in a test question. So our study tip for today is going to be exactly that.

Our study tip for the day is watch out for the traps. Look for the traps as you’re studying. This is a key that I always did. I didn’t realize I was doing it during PA school and it really helped me. I always think about how I would write a test question and how I would compare different things and how I would compare different treatments and what would be the distractor I would put in, what would be the trap that I would put in if I were writing this question. So as you’re studying, pay attention to those things because they’re coming, they’re a hundred percent coming.

So let’s look at a couple, just from today. If you have a patient with gestational diabetes and they’re six weeks out, and the question is, what are you going to do? What tests are you going to run? Well, what’s the trap? I mentioned it a couple of times. It’s hemoglobin A1C. We talked about the trap earlier, but not specifically.

I want to touch on it here. What’s the trap for a birth control pill after delivery. Well, the trap is giving estrogen within that 21 day period. We don’t want to do that. So you want to mark those things down in your notes. What, what’s the trap? What do I not want to do?

Another one we touch on at the end is your ACE inhibitor during breastfeeding. I put together a couple others just to illustrate the point. So this one’s pretty obvious, but I’d like to use obvious ones to illustrate points. You can come up with a deeper ones and we can work on those, but I’d like to use really simple explanations. It’s really simple, medicine. So you understand the tactic.

So let’s shift gears for a minute and look at musculoskeletal. If you look at tenderness over the anatomical snuff box after a fall and a normal X-ray, what’s the trap? The trap is sending the person home and thinking the X-ray is normal. So you’re fine, right? The answer is a thumb spica splint and repeat our X-ray, maybe get an MRI because this can be an occult fracture. The trap is sending her home with nothing. If you take one from cardiology, chest pain after cocaine use with a heart rate of 130, what do we give them?

The trap here is something like metoprolol. If I can say it, it’s a beta blocker, right? But then the alpha stimulation runs unopposed. So the arteries clamp down harder. The answer here is benzodiazepines. So you need to watch what you’re doing, but as you’re studying these things, I want you to keep an eye out for what the problem is going to be. How is it going to come in a test question?

What’s it going to look like? I hesitate to say they’re trying to fool you. I don’t like that terminology. I don’t think they’re trying to fool you at all, but I think they’re trying to make sure that you don’t do the, the thing that everybody wants to do wrong. They’re trying to avoid you doing that. So when you’re studying, have a little note, you know, what’s the trap for this? What would this look like?

How would they try to draw me out of this particular diagnosis or this particular treatment? Look into that. Real quick, before we do the answers to the priming questions. If you are working hard, staying up late and still struggling to get the scores that you want, that’s the gap that we look to close with 33 Days to Pass the PANCE, the October cohort is currently running and going fantastic. The December cohort is right around the corner. So if you’d like to get some more information or get on the wait list there, physicianassistantexamreview.com/33. That’ll make sure you get notified right away when that registration opens and we do have a set number of seats there.

So if you’re interested in the December cohort, you want to make sure that you’re on that wait list because you’ll get a little bit of early access to the registration before the public.

All right. So let’s answer our priming questions. A breastfeeding mother needs a blood pressure medicine after delivery. What’s the best place to start? We said nifedipine or labetalol, but the ACE is fine too. Name the three requirements of the lactational amenorrhea method. Name the three requirements of the lactational amenorrhea method, exclusive breastfeeding, no period since delivery, and the baby under six months.

In a woman who is not breastfeeding, what’s the earliest postpartum day to start a combined estrogen pill? Day 21. What postpartum test screens for diabetes after a diagnosis of gestational diabetes, 75 gram, two hour glucose tolerance test. I feel like maybe I should do some of these as what would be the trap for these. And obviously here it’s A1C. A severe headache and a blood pressure of 164 over 112 on postpartum day six call for what seizure prophylaxis? We’re worried about postpartum preeclampsia, and this would be magnesium.

Perfect. All right. Thank you guys so much for tuning in. I absolutely enjoy doing these every single week. Think different, work different, score different. See you next week.