Abnormal Puerperiu and Postnatal Care

Purperium

Definition:It is period about 6-8 weeks following delivery during which the changes produced by pregnancy.

Abnormal Puerperium

1. Puerperal infection ----> retention 2. UT complication ----> incontinence ----> stress I

true 3. Thrombo embolism4. 2nd P.P HE5. Subinvloution of the uterus6. Foot drop 7. Mental disorder

Genital Tract Infection:AE: 1. Predisposing Factors:

1. General2. Anternatal Factor

Intranatal factor

2. Organism 1. Exogenous 2. Endogenous Streptococci:

Streptococci:a. B haemolytic strep group A b. B haemolytic strep group B C. B haemolytic strep group 0 d. Non-haemolytic streptococci e. Anaerobic streptococci

Staph: Staph aureus Anaerobic staph

Bacilli: G negative aerobic bacilli E coli, Klebsiella

G negative anaerobic bacillus -----> bacteroids

Gm positive anaerobic bacilli

ROUTE OF INFECTION: Primary Sites: placental site, wound and laceration, clots and pluc.

tissue

Secondary Sites: pelvic cellulitis, thrombophlebitis, pelvic peritonitis, generalized peritonitis, septicaemia, and septic shock

COMPLICATIONS: Spread of infection Renal failure Death Secondary infertility Sheehan

CLINICAL PICTURE --- depends on site of infection

INVESTIGATIONS: History Examination Special investigations

TREATMENT: Prophylaxis: Antenatal, intranatal case, postnatal

Active Treatment: 1. General treatment ----> rest

----> diet ----> fluid

2. Medical treatment ----> antipyretic ----> analgesics ----> antibiotics

3. TTT of complication

Puerperal Pyrexia

Definition:

A rise of temperature above 3SoC

occurring in first 3 weeks of puerperium

persistent at least 2H hours on

recurring within this period.

AE:

Puerperal sepsis

Breast infection

Urinary infection

Episiotomy infection

Wound infection

Other types of infection as respiratory infection,

malaria, gluteal abscess, typhoid

INCIDENCE: Infection, haemorrhage, hypertension,

disorder remain the most causes of death.

Primary Puerperal SepsisDefinition:Genital tract infection after delivery. It is the

commonest cause for puerperal infection.

The causative organism1. Anaerobic streptococci 2. Group A haemolytic streptococci 3. Staphylococci causing suppurative and pus 4. E. coli and non-haemolytic streptococci 5. Specific organism as cl. welchii and tetani

Mode of infection

1. Exogenous infection ----> attendant

2. Endogenous: organism already present in genital tract

3. Autogenous: organism transmitted to genital tract from other parts of body

SITES OF INFECTION A) Primary Sites:

1. The placental site 2. Laceration of cervix, vagina or perineum 3. Dead tissue retained in the uterus as placental remnant or blood clot

B) Secondary Sites: -> ext. from primary site 1. Parametritis 2. Salpingo-oophoritis 3. Pelvic thrombophlebitis 4. Pelvic and generalized peritonitis

C) Generalized Spread: Septicaemia or pyrexia

PREDISPOSING FACTORS 1. Introduction of bacteria 2. Anaemia 3. Prolonged or instrumental delivery - PRM

PATHOLOGY

1. Uterus ----> Uterus puerperal endometritis localized type septic puerperal endometritis generalized type

2. Infected laceration ----> greenish yellowish 3. The parametrium ----. pelvic cellulitis from: direct

lymphatic: cervix, vaginal vault 4. The tubes and ovaries ----> acute salpingo-oophoritis 5. The peritoneum ----> through lymphatic by direct 6. Pelvic veins ----> pelvic thrombophlebitis

CLINICAL PICTURE I. Uterine Infection:

a. In the mild type ---> onset 4 days after delivery

b. In the severe type ---> onset 2-3 days or even one day after delivery, increased temperature and pulse, headache and malaria, UT tender, involuted and lochia scanty.

II. Infected Laceration: Mild pyrexia, local discomfort, tenderness, oedema

and congestion

III. Parametritis: At 10 days after delivery with increased temp and

pulse, vague abdominal pain, backache, U/E = tender mass extending from UT to 1st pelvic wall on one or both sides.

* SOFTENING ----> parametric abscess

IV. Salpingo-oophoritis: Fever, rigor, vomiting, lower abdominal pain,

tenderness at rigidity

V. Peritonitis: a. Pelvic peritonitis ---> as complication of

salpingitis b. Generalized peritonitis ---> rigor, fever, t pulse

VI. Septicaemia: ----> occurred about the third and fourth

day after delivery secondary to UT infection

VII. Thrombophlebitis: Secondary to UT infection 7 - 10 days after

delivery

InvestigationA. HistoryPre-existing infection before labour TB, UTI Anaemia, toxaemia and diabetes Difficult labour on spontaneous Instrumental used or any complication Catheterization Onset of pyrexia Sore throat, busy mict.

B. General Examination: 1. Pulse, temp, BP 2. Anaemia or jaundice 3. Tonsillitis 4. Breast, heart and chest 5. LL ---> thrombophlebitis

c. Abdominal Examination: 1. Tenderness in abdomen, int, loin 2. Rigidity 3. Height, fundus and any abdominal mass

D. Vaginal Examination: 1. Lochia 2. Laceration 3. Bi-manual examination size and mobility, uterus 4. Speculum examination to see cervix + vagina

E. Laboratory Investigations: 1. Swab from the upper vagina or cervix 2. Catheter specimen of urine for culture 3. Full blood picture Hb, RBCs and leucocytes 4. Widal test, x-ray chest, blood film for malaria

PROPHYLAXIS PUERPERAL SEPSIS A. Antenatal:

1. Diet, vitamin + mineral 2. Treat disease as anaemia, toxaemia or diabetes 3. Treat vaginal discharge

B. Intrapartum 1. Proper delivery 2. Strict asepsis -----> patient -----> instrument

-----> attendant 3. In prophylactic, antibiotic

c. Postnatal: 1. Aseptic precaution 2. Early isolation of suspected cases

TREATMENT OF SEPSIS

I. General Treatment: 1. Isolation of patient 2. Light diet 3. Correct anaemia 4. Relieved pain by analgesics 5. Give mild laxative

II. Antibiotic: 1. Vaginal swab and give correct antibiotic

III. Promotion of Drainage: 1. Sensitivity position 2. Ergometra 3. Removal of suture 4. Drainage of pelvic abscess 5. Gentle of any piece of placenta

IV. General Peritonitis: 1. Heavy dose, antibiotic IV _ Ryle tube + IV fluid

V. Septic Thrombophlebitis: 1. Antibiotics 2. Anticoagulant 3. Immobilization of limb

Postnatal Care

AIMS:1. Detection of any abnormality that from

pregnancy and labour. 2. Follow-up of complication in pregnancy. 3. Advice regarding breast feeding, diet, hygiene4. Advice regarding contraception.

 

The Gynaecological Conditions Which May Be Found Are:

1. Perineal Laceration:

Not repaired within 24 hours ----> need operation 3 - 6

months

2. Vesico-Vaginal Fistula:

* Fix catheter for 10 - 15 h + antibiotic after 3 - 6

months -----> fistula may heal if small or may need

operation

3. Prolapse + 8.1.: * Pelvic floor exercises if condition persist -----> operation, 3 - 6 months.

4. RVF of uterusNo symptoms ----> no treatment There is symptom ----> correct ut manually ----> insert Hodge

pessaries 4-6 weeks

5. Cervical Erosion: * No treatment before 3 months * Persists cauterized

6. Sub-InvolutionErgometrium + antibiotic

THE CAUSES OF SUB-INVOLUTION 1. Retained placental segment 2. Infection 3. RVF ---> congestion 4. Over distension of uterus as twins and hydramnios 5. Fibroid 6. Non suckling 7. Bad general condition and anaemia in case of antepartum and postpartum hemorrhage