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ABNORMALITIES OF THE PUERPERIUM

PUERPERAL PYREXIA :

Def:- A rise of temperature reaching 100.40f or more measured orally on two separate occasions at 24 hours apart with in first 10 days following delivery is called puerperal pyrexia.

Causes :

1) Puer. Sepsis 2) UTI

3) Mastitis 4) Infection of C.S. Wound

5) Pulmonary Infection 6) Septic pelvic thrombo phlebitis

7) A recrudescence of Malaria 8) Unknown origin

or pulmonary TB

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PUERPERAL SEPSIS :

Def.:- An infection of the genital tract e occurs as a complication of delivery is termed puerperal sepsis.

There has been marked decline in puer-sepsis during the past few decades. The reasons are :-

1) Better obstetric care

2) Improved health status and there by increased general resistance to combat infection.

3) Availability of wider range of antibiotics sensitive to the responsible organisions.

4) Declined virulence of streptococcus beta haemolytic

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PREDISPOSING FACTORS OF PUERPERAL SEPSIS :

Antepartum factors :

Malnutrition and anemia

Preterm Labour

Prom

Chr. Debilitating illness

Prolonged rupture of membranes > 18 hours

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Intrapartum factors :

Repeated vaginal examination

Prolonged rupture of membranes

Dehydration during labour

Traumatic operative delivery

Hemorrhage – antepartum or post partum

Retained bits of Pl. tissue or membranes

Placenta preavia

Caesarian delivery

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Micro Organisms responsible for puerperal sepsis :

Aerobic - Streptococcus haemolyticus Group – A

- ” ” Group – B

- Staphylococcus pyogens, aureus, E.coli, klebsiella, pseudomonas.

Anaerobic- Streptococcus, Bacteroids, Clostridia.

CLINICAL FEATURES :

I. LOCAL INFECTION (Wound Infection)

1) se temp., headache

2) Wound becomes red & swollen

3) Pus may form e leads to – disruption of the wound.

Severe high increase of temp. with chills & rigors.

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II. UTERINE INFECTION :

1. MILD - se in temp & PR

- Lochial – Offensive & Copious

- Uterus sub-involutes & tender

2. SEVERE - High rise of temp. often with chills & rigors.

- PR is rapid

- Lochia – Scanty & odourless

- Uterus may be sub involuted, tender & soft.

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III EXTRA UTERINE SPREAD : Parametritis - about 7 – 10th day

- Constant pelvic pain

- Tenderness on either sides on the hypogastrium

- Vaginal exam. – unilat tender indurated mass pushing the ut. to the contralateral side.

IV. PELVIC PERITONITIS : - Pyrexia with PR

- Lower abdomen pain & tenderness

- Muscle guard may be absent

- Vaginal exam.– tenderness on the Fornices and with movement of cervix

- Collection of Pus in POD - temp., diarrhea, bulging fluctuant mass felt through Fornix.

- Thrombophlebitis

- Septicaemia

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SEPTICAEMIA

Aetiology - MC bacteria, E. Coli

Bacterial cell wall lyses from Bacterial cell wall

Endotoxins released (Main Cause)

other Mediators eg. Histamine de to other bacterial substarices

Activation of kinins & coagulation complement System

Peripheral Vascular effects Direct Myocardial effect

[A] Arteriolar & Venular Ejection fraction

vasodilatations MAL Inadequate blood flow to tissues with Hypoxiadistribution of Blood flow

[B] Leucocyte aggregation

[C] Micro embolisation Multiorgan dysfunction

AV shunting Systemic vasmlar Micro vascularResistance in Sufficiency

Renal failure Pulnonary / failure Hepatic

Refractory Hypotension Cerebral & Severe Myocardial Depression

DEATH

SEPTICAEMIA

Aetiology - MC bacteria, E. Coli

Bacterial cell wall lysis

Endotoxins released (Main Cause)

other Mediators eg. Histamine de to other bacterial substarices

Activation of kinins & coagulation complement System

Peripheral Vascular effects Direct Myocardial effect

[A] Arteriolar & Venular Ejection fraction

vasodilatations MAL Inadequate blood flow to tissues with Hypoxiadistribution of Blood flow

[B] Leukocyte aggregation , Micro embolisation

[C] Endothelial cell injury Multiorgan dysfunction

AV shunting Systemic vasmlar Micro vascularResistance in Sufficiency

Renal failure /

Refractory Hypotension Cerebral & Severe Myocardial Depression

DEATH

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Investigation of puerperal pyrexia:

1. High vaginal and endocervical swab for culture

2. Urine –mid stream –c/s

3. Blood – TC,DC, hb%

platelet count – low indicates septicemia

4. Blood culture –

5. Pelvic ultrasound.

6. CT, MRI

7. Blood urea & electrolytes

8. X-ray chest

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Rx: -Adequate fluid & calorie – IV infusion

- anemia – oral iron –blood transfusion.

-pain –analgesia

-catheter - urine retention –UOP

-Antibiotics - Ampicillin

- Gentamycin

- Cefotaxime

- Metronidazole

Surgical – perineal wound – sutures to be removed & pus drained

- Retained products – evacuation >3 cms

- abscess –pus drained

- management of septic shock.

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Sub involution:

Def: When involution is impaired or retarded it is called sub involution

Causes: Pre –disposing factors are:

1. Grand multiparty

2. Over distention of uterus as in twins & hydramnios

3. Maternal ill health

4. Caesarian section

5. Prolapse of the ut.

6. Uterine fibroid

Aggravating factors are

1. Retained products of conception

2. Uterine sepsis

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Symptoms:

1. Abnormal lochial discharge excessive

prolonged

2 Irregular or excessive uterine bleeding

3 Irregular cramp like pain in cases of retained products or rise of temp. in sepses

Signs: The uterine height is more than normal for the particular day of puerperium

Management:

1 Antibiotics in endometriosis

2 Exploration of the uterus in retained products

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Urinary complication:

UTI: is most common cause of puerperal pyrexia

Inc: 1-5% of all deliveries

The inf. May be the consequence of any of the following

1. Recurrence of previous cystitis or pyelitis

2. Asymptomatic becomes overt

3. Inf. Contracted for the first time during puerperium is due to –

a) effect of frequent. Catheterisation either during labour or in early puerperium to relieve retension of urine.

b) stasis of urine during early puerperium due to lack of bladder tone and less desire to pass urine

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Organisms responsible are:

- E.coli

- klebsiella

- proteins

- staph. Aureus

Retension of urine: This is a common complication in early puerperium

Causes are:

1. Bruising & oedema of the bladder neck

2. Reflex from perineal injury

3. Unaccustomed position

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Rx of retension of urine:

If simple measure fails to initiate micturation,

An indwelling catheter is to be kept in situ for about 48 hours. This not only empties the bladder but helps in regaining the normal bladder tone and sensation of fullness. Appropriate urinary antiseptics should be administered for about 5-7 days.

Incontinence of urine: This is not a common symptom following birth.

Incontinence may be -

1 Overflow incontinence

2 Stress incontinence –usually manifests in late puerperium

3 True incontinence – in the form of genito – urinary fistula usually appears soon following Delivery or within 1st week of puerperium

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sis of stress incontinence is established by noting the escape of urine thr’ the urethral opening during stress. The exact nature of urinary fistula is established by noting the fistula site by examining the pt. in sims position using sim’s speculum or by ‘three swab test’ if the fistula is tiny.

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BREAST COMPLICATIONS:

1 Breast engorgement

2 Cracked and retracted nipple leading to difficulty in breast feeding

3 Mastitis and breast abscess

4 Lactation failure.

Breast engorgement:

Cause: is due to exaggerated normal venous and lymphatic engorgement of the breasts e precedes lactation. This in turn prevents escape of milk from the lacteal system

Onset: it usually starts (3rd or 4th day of post partum after the milk secretion

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Symptoms:

1 Considerable pain &feeling of tenseness or heaviness in both the breasts

2 Generalized malaise or even transient rise of temp.

3 Painful breast feeding

Rx

1 To support the breast ē a breast binder

2 Manual expression of any remaining milk after each feed.

3 To administer analgesics for pain

4 The baby should be put to the breast regularly at frequent Intervals.

5 In a severe case – gentle use of a breast pump may be helpful.

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Cracked nipple:

The nipple may become painful due to -

- loss of surface epi. ē the formation of a raw area on the nipple.

- due to a fissure situated either at the tip or base of the nipple

It is caused by –

a) Unclear hygiene resulting in formation of a crust over the nipple

b) Retracted nipple

c) Trauma from baby’s mouth due to incorrect attachment to the breast.

The condition may be asymptomatic but becomes painful when the infant sucks.

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Prophylaxis includes – local cleanliness during preg. &puerperium before and after each breast feeding to prevent crust formation over the nipple .

Treatment : Purified Lanonin with mother’s milk is applied 3 or 4 times a day to hasten healing when it is severe – mother should use a breast pump and infant is fed ē the expressed milk.

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PUERPERAL VENOUS THROMBOSIS &PULMONARY EMBOLISM

Venous thrombo –embolic diseases include:

- Deep vein thrombosis (ileofemoral)

- Thrombo phlebitis (superficial & deep veins)

- Septic pelvic thrombo phlebitis

- Pulmonary embolus

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Acetiopathogenisis:

4. platelets & adhesiveness 1. Normal pregnancy

rise in coagulation factors

1,2,7,8,9,10&12

5. Other risk

factors AETIOPATHOGENESIS 2. Venous stasis

gravid ut. Presses on 3. Thrombophilias IVC & iliac veins

- port. Op del a) Inherited

(10 times more) def. Of protein c &s

- obesity def. Of thrombin III

- Anaemia hyper homocystenaemia

- Heart disease b) acquired – due to

- Trauma to lupus anti coagulant &

venous wall antiphospholipid antibodies.

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DEEP VEIN THRMOBOSIS

Symptoms: - pain in calf muscles

- oedema legs

- rise in temp

O/E: - asymmetric oedema leg (diff. In circumference between affected & normal leg more than 2 cm)

- A positive Homan’s Sign – pain in the calf on dorsiflexion of foot.

INV: 1. Doppler us – ‘whoosh sound’

2. Real time Us soft tissue mass ē in the venous lumen

non –compressibility of the vein.

3. Venography

4. Fibrinogen scanning

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Pelvic thrombophlebitis :

extra pelvic spread thr’ rt. Ovarian vein to inf. Vena cava

thr’ lt. Ovarian vein

to

left renal vein

to

left kidney

retrograde extension to ilio –femoral vein

to produce ‘phlegmesia albadolens’

or

white leg

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Rx :

- Bed rest, foot and elevation

- anticoagulants – Heparin 15,000 units IV

-low molecular weight heparin

-warfarin

-vena cava filters – used where anticoagulants are

contra indicated

- fibrinolytic agent like streptokinase

- venous thrombectomy

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POSTS PARTUM TRAUMATIC NEURITS:

commonest form –FOOT DROP –unilateral

-appears on 1st day pp.

due to stretching of Lumbo sacral trunk by the prolapsed intervertebral disc between L5 and s1

direct pressure either by foetal head or by forceps blade on the lumbosacral cord or sacral plexus as a causative factor.

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Psychiatric disorders during puerperium:

puerperal blues: depression, anxiety, tearfulness, insomnia

post partum depression: –loss of appetite,

insomnia, social withdrawal

irritability, suicidal attitude

post partum psychosis: ‘schizophrenia’

fear, restlessness, confusion

Hallucination , delusion disorientation

Puerperal emergencies.: PPH

shock

PE

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TOXIC SHOCK SYNDROME

High fatality rates 10-15%

Acute febrile illness

-diffuse macular erythem.

To us rash – SUBCUTANEOUS EDEMA

commonly due to staph

Aureus – commonly found in young menstamating women who USE tampoons

c/f are due to

Staphylococcal endotoxin cansing

Profound endothelial injury

principal therapy

-massive fluid replacement

MACHANICAL – ventilatory support

- renal dialysis

- anti staphylococcal antibiotics