Abnormalities of Puerperium

8/4/2019 Abnormalities of Puerperium

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ABNORMALITIES OF PUERPERIUM


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*PUERPERAL PYPREXIA

*PUERPERAL SEPSIS*SUBINVOLUTION

*URINARY COMPLICATION*BREAST COMPLICATION


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*PUERPERAL VENOUS

THROMBOSIS*PULMONARY EMBOLISM

*OBSTETRIC PALSIES*PUERPERAL EMERGENCIES

*PSYCHIATRIC DISORDERS


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PUERPERAL PYREXIA

DEFINITION:-

A rise of temperature reaching 100.4F or

more on 2 operate occasion at 24 hrsapart within first 10 days following

delivery is called puerperal pyrexia.


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CAUSES

Puerperal sepsis

Urinary tract infection

Mastitis

Infection of CS wound

Pulmonary infection

Malaria

Tuberculosis

Unknown


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PUERPERAL SEPSIS

DEFINITION:-

An infection of genital tract which occur as a

complication of delivery is termed as

puerperal sepsis.


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PREDISPOSING FACTORS

Organism from outside

Organism resistant to antibiotic

Low host resistanceMultiplication of organism


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oANTEPARTUM FACTORS

1. Malnutrition & anemia

2. Preterm labour

3. Premature rupture of membrane

4. Chronic debilitating illness

5. Prolonged rupture of membrane


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MICROORGANISM RESPONSIBLE FOR

PUERPERAL SEPSIS

AEROBIC:-

1. Streptococcus haemolytic group A

2. Streptococcus haemolytic group B3. Staphylococcus aureus

4. E . Coli

5. Klebsialla


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ANAEROBIC

1. Anaerobic streptococcus

2. Becteriods

3. Clostridia


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SOURCE OF INFECTION

ENDOGENOUS:- organism are present in the

genital tract before delivery.

AUTOGENOUS:- organism is present elsewhere in

the body (skin, throat) & migrate to the genital organ

by blood stream .


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SITES OF INFECTION

PERINEUM:- laceration on the perineum, whether

repaired or not ,are likely to be infected by

organism like staphylococcus aureus, there may

be collection of sangopuruvlent discharge or puswhich resulting in necrosis and sloughing.

VAGINA:- the vaginal laceration are infected

directly or by extension from the perinealinfection. The mucosa is swollen resulting in

necrosis and slouhing.


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CERVIX:- cervical infections are common as is it a

common site for pathogenic organism.

UTERUS:- endometritis, the decidua specially over

the placental site is primarily affected.


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SPREAD OF INFECTION

PELVIC CELLULITIS:- spread of infection to the pelviccellular tissue by direct or lymphatic or byhaematogenous routes. The infection causeexudation and formation of a mass confined to one

side.

SALPHINGITIS:- may be interstitial( due to lymphatic)or perisalphingitis (following pelvic peritonitis) orendosalphingitis(tubal mucosa). Pelvic peritonitismay be due to spread of infection

a) directly through the tubes


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b) Lymphatic spread.

c) Bursting of parametrial abscess.

SEPTIC PELVIC THROMBOPHLEBITIS:- may involve

the ovarian veins, uterine veins, pelvic veins and

rarely inferior vena cava. The infected thrombus

may undergo complete resolution or suppuration.

SEPTICEMIA AND SEPTIC SHOCK:- may be due to

haemolytic streptococci or anaerobic streptococci.Septicemia may cause lung abscess, meningitis,

pericarditis, endocarditis or multi organ failure.


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CLINICAL MANIFESTATION

LOCAL INFECTION:-

1) rise in temp, malaria or headache

2) Local wound becomes red & swollen

3) Pus may lead to disruption of wound

UTERINE INFECTION:-

MILD:-

1) Rise in temp & pulse rate

2) Lochial discharge becomes offensive & copious.


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3) Uterus is subinvouted and tender.

SEVERE:-

1) Rise in temp, with chills & rigor2) Pulse rate is rapid

3) Lochia is plenty and odourless

4) Uterus may be subinvouted SPREADING INFECTION:-

Parametritis :- rise in temp with chills & rigor,

intense pain, gradual deterioration of thegeneral condition.


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Pelvic peritonitis:- pyrexia with increase pulse

rate, lower abdominal pan, collection of pus in

pouch of Douglas

General peritonitis:- high fever with rise in pulse,

vomiting, abdominal pain, pt looks very ill &

dehydrated

Septicemia :- high rise in temp, blood culture is

positive, s/s of metastatic infection in the lung

may appear.

Bacteraemia, endotoxic or septic shock:-hypotension, oliguria, RDS.


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DIAGNOSTIC EVALUATION

HISTORY:- antenatal history anemia,

antepartum hemorrhage.

Intranatal history preterm labour, no. of internal

examination, duration of labour, method ofdelivery.

Postnatal history fever, associated symptoms

related to site of lesion.


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CLINICAL EVALUATION

Pulse & temp

Abdominal examination( involution& tenderness)

Internal examination( Lochia, wound)

Limbs (Thrombophlebitis)

INVESTIGATION:- Culture swab

Urine analysis

Blood Hb, WBC, culture

Pelvic ultrasound(retain bits of conception)


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X-ray (for check lung pathology)

Blood urea & electrolytes( for detect renal failure)


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MANAGMENT

GENERAL MANAGEMENT:-

1. Isolation of the patient(heamolytic

streptococcus)

2. Adequate fluid & calorie

3. Anemiaoral iron & blood transfusion

4. Pain analgesics

5. Urinary retention- catheter

6. Chart pulse, resp, temp, I/O, lochial discharge


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ANTIBIOTICS- gentamycin( 2mg/kg iv 8hrly),

ampicillin(1gm iv 6hrly), clindamycin (900mg iv

8hrly), cefotaxime(1gm 8hrly ), metron (0.5gm iv8hrly)

SURGICAL MANAGEMENT:-

Perineal wound- stiches removed to drain pusthen re-stiched.

Retained uterine products- evacuation

Pelvic abscess- colpotomy

Rupture or perforation, multiple abscess-

hystrectomy


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SUBINVOLUTION

DEFINITION:- when involution is impaired or

retarded is called subinvolution.


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CAUSES

Grand multiparity

Over distension of uterus( twins)

Maternal illness

CS

Prolapsed uterus

Retroversion

Uterine fibriod


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CLINICAL MANIFESTATION

SYMPTOMS- abnormal lochial discharge, irregular

excessive uterine bleeding, irregular cramps .

SIGNS- uterine height is greater than normal, it

feels boggy & softer.


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MANAGEMENT

Antibiotics in endometritis

Exploration of uterus in retained products

Pessary in prolapsed or retroversion.


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URINARY COMPLICATION

URINARY TRACT INFECTION:- It is one of the

common cause of puerperal pyrexia

Infection may be consequence of the following-

1. Recurrence of previous cystitis or pyelitis

2. Asymptomatic bacteriuria

RETENTION OF URINE (treatment is catheter is

introduce)

INCONTINENCE OF URINE


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SUPPRESSION OF URINE (it occurs if 24 hrs urine

output is less then 400 ml)


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BREAST COMPLICATION

BREAST ENGORGEMENT:-

CAUSE- it is due to venous and lymphaticengorgement of breast, it is mainly occur in

primiparous & pt with inelastic breast. ONSET- usually after milk secretion starts

SYMPTOMS

1. Pain & feeling of tenderness or heaviness

2. Rise in temp with malaise

3. Painful breast feeding.


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PREVENTION-

1. Avoid prelacteal feeds

2. Initiate breast feeding early3. Exclusive breast feeding

4. Feeding in correct position


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MANAGEMENT:-

Support the breast with binder & brassiere

Manual expression of any remaining milk afterfeeds

Analgesics for pain

Baby should be put to breast regularly

Gentle use of breast pump


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SYMPTOMS-

Painful when infant sucks

If infected, infection may spread to deeper tissueproducing mastitis

MANAGEMENT-

Correct attachment(provide relief from pain)

Fresh human milk & saliva has got healing

property

Purified lanonin with mothers milk is applied 3-4times a day to fasten healing


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Mother should use the breast pump & feed

the infant with expressed milk

Miconazole lotion is applied over the nipplesas well as babys mouth.


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RETRACTED AND FLAT NIPPLE

It is commonly seen in primi, if baby is not attached

properly and suck adequatelyIn this cases manual expression of milk can be

done.


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ACUTE MASTITIS

DEFINITION:-

It is infection of the breast tissue due toorganisms like staphylococcus aureus, s.

epidermidis and streptococci. MODE OF INFECTION

1) Infection that involves the breast

parenchymal tissue leading to cellulitis2) Infection gain access through the lactiferous

duct leading to primary mammary adenitis.


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ONSET:- acute during late 1st week of puerperium.Acute mastitis occur even several weeks after thedelivery

CLINICAL FEATURESSYMPTOMS:-

1. Malaise & headache

2. Fever(102f) with chills

3. Severe pain and tender swellingSIGNS:-

a) Presence of toxic features

b) Presence of wedge shaped swelling

c) Skin is red, hot and flushed and feels tense & tender


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MANAGEMENT

a) Breast support

b) Plenty of oral fluids

c) Breast feeding with good attachment

d) Fluioxacillin 500mg, erythromycin

e) Analgesics

f) Milk flow is maintained by breast feeding


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BREAST ABSCESS


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FEATURES

1. Flushed breast not responding to antibiotics

2. Edema of the overlying skin3. Marked tenderness

4. Swinging temp

TREATMENT:- the abscess is drained under GAby a deep incision extending from areolamargin to prevent injury to the lactiferousduct. Finger exploration is done to break up

the walls of loculi. The abscess can also bedrained by needle aspiration


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Micaconazole lotion or gel on both the nipples

after each feed & into infant mouth thrice daily

for 2 weeks.


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LACTATION FAILURE

CAUSES:-

1. Infrequent sucking

2. Depression or anxiety

3. Reluctance to nursing

4. Ill development of nipples

5. Painful breast lesion

6. Suppression of prolactin

7. Prolactin inhibition


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MANAGEMENT

Maintenance of effective lactation:-

ANTENATAL-

1. Counsel the mother regarding advantages of

nursing the baby with breast milk

2. To take care of any breast abnormalities

3. To maintained adequate breast hygiene


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PUERPERIUM-

1. Adequate fluid intake

2. To nurse the baby regularly

3. Painful local lesion is to be treated

4. Metoclopromide and sulpiride found to

increase milk production


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PUERPERAL VENOUS THROBOSISThrombosis of leg veins and pelvic veins is one of

the common complication in puerperium

Venous thrombo- embolic disease are

Deep vein thrombosis

Thrombophlebitis( superficial & deep veins)

Septic pelvic thrombophlebitis

Pulmonary embolism


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DEEP VEIN THROMBOSIS


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SYMPTOMS:-

a) Pain in calf muscles

b) Edema in legs

c) Rise in temp

d) A positive Homans sign( pain in the calf on

dorsiflexion of the foot may be present)


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DIAGNOSTIC VALUATION

DOPPLER SOUND:- it is done to detect the

velocity of blood flow in the femoral vein bynoting alteration in the characteristic of

WHOOSH sound.

VENOGRAPHY:- Injecting non- ionic watersoluble radio- opaque dye to note the filling

defect in venous lumen

FIBRINOGEN SCANNING


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PELVIC THROMBOPHLEBITISPostpartum thrombophlebitis originates in the

thrombosed veins at the placental site by

organism when localised in pelvis, it is called

pelvic thrombophlebitis


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CLINICAL FEATURES

it develops in 2nd wk of puerperium

Mild pyrexia with chills and rigor

Headache, malaise and rising pulse

Affected leg is swollen, painful, white and cold

Blood count shows polymorphonuclear

leucocytosis


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DIAGNOSTIC EVALUATION

ultrasound

CT scan

MRI


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MANAGMENT

Pt is put to bed rest and foot is raised up toheart level

Pain analgesics

Infection antibioticsAnticoagulant heparin 15000U, warfarin

High quality elastic stockings

Fibrinolytic agents- streptokinaseVenous thromboectomy


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PULMONARY EMBOLISM

CAUSES:-

o Hemorrhage

o Hypertension

o Sepsis

o Deep vein thrombosis


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SYMPTOMS:-

o Acute chest pain and air hunger

o Tachypnoea

o Dyspnoea

o Tachycardia

o Rise in temp

DIAGNOSIS:


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DIAGNOSIS:-

o Chest X-ray( to rule out pneumonia and

atelectasis)o ECG( for tachycardia)

o ABG

o Doppler ultrasound( for DVT)o Lung scan

o Pulmonary angiography


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MANAGEMENT

RESUSCITATION- includes cardiac massage,

oxygen therapy and intra venous heparin

infusion

I V FLIUD SUPPORT

THROMBOLYTIC THERAPY- streptokinase

EMBOLECTOMY

OBSTETRIC PALSIES( postpartum


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OBSTETRIC PALSIES( postpartum

traumatic neuritis)

The commonest form of obstetric palsy in

puerperium is foot drop.

It is due to stretching of lumbosacral trunk by the

prolapsed intravertebral disc between L5 and S1 Neurological examination can reveals the case


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MANAGEMENT

Rest in bed about 6 wks

Use splint to prevent damage of overstretched

paralysed muscles

Massage and electrical stimulation of the

muscles

Active exercise is encouraged


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PUERPERAL EMERGENCIES

IMMEDIATE-

1. PPH

2. Shock

3. Post partum eclampsia

4. Pulmonary embolism

5. inversion

EARLY( within 1st wk)


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EARLY( within 1st wk)

1. Retention of urine

2. Urinary tract infection3. Puerperal sepsis

4. Breast engorgement

5. Mastitis and breast abscess

6. Pulmonary infection

7. Anuria

DELAYED


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DELAYED

1. Secondary PPH

2. Pulmonary embolism

3. Thrombophlebitis

4. Psychosis

5. Post partum cardinomyopathy

6. Post partum haemolytic uraemic syndrome


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PSYCHIATRIC DISORDERS


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RISK FACTORS

PAST HISTORYpsychiatric illness, puerperal

psychiatric illness

FAMILY HISTORYmajor psychiatric illness,

marital conflict

PRESENT PREGNANCYcaesarean delivery,

difficult labour, neonatal complication

OTHERS- unmet experience


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PUERPERAL BLUES

It is transient state of mental illness observed3-4 days after delivery and lasts for few days

It occur 50% of post natal mothers CLINICAL MANIFESTATION- depression,

anxiety, tearfulness, insomnia, negative

feelings toward infant TREATMENT- reassurance and psychological

support


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POST PARTUM DEPRESSION

It observed in 10-20% mothers

ONSET- 4-6 months following delivery or abortion

MANIFESTATION- loss of energy & appetite,

insomnia, social withdrawal, irritability, suicidal

attitude

TREATMENT- fluoxetine or paroxetine (serotoninuptake inhibitors)

POST PARTUM


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POST PARTUM

PSYCHOSIS(schizophrenia)

It is commonly seen in women with past history ofpsychosis

ONSET- within 4 days of delivery

MANIFESTATION- fear, restlessness, confusion,hallucination, delusion, disorientation, suicidal andinfanticidal impulses

MANAGEMENT- chlorpromazine 150mg stat and 50-150mg thrice a day, sublingual oestradiol 1mg thricea day, ECT(electro convulsion therapy),lithium( breastfeeding is contra indicated)


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THANK YOU

Abnormalities of Puerperium

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