PUERPERIUM& Post Partum Hemorrhage

Dr. Tamar ShalemShaare Zedek Medical Center

Puerperium

Post Partum Hemorrhage (PPH)

Abnormalities of the Puerperium

PUERPERIUM

Puerperium defines as a period of 6 weeks following delivery, in which

a number of changes in anatomy and physiology occur.

DEFINITION

ANATOMIC CHANGES REPRODUCTIVE SYSTEM

Weight

Pregravid uterus: 50 - 100 g Uterus at term: 1000 - 2000 g

Length Non-pregnant : 6 - 8 cm

At term: 40 cm

UTERUS

UTERUS

Size

after 24 h Reduced to 20 w gestation

after 48 h Reduced to 14 w gestation

descends to pelvic cavity within 2 w

returns to non-pregnant size within 4 w

UTERUS

Within 2-3 days patients begin to passvaginal discharge Called lochia.

Definition: the superficial necrotic layer of

pregnant endometrium (decidua).

Contains: RBC / WBC Decidua Epithelial cells Bacteria

UTERUS

Stages: lochia rubra (days 1-4) lochia serosa (days 5-7) lochia alba (days 7-14)

vaginal discharge is normal up to 6 w.

CERVIX

Following parturition the cervix is very

distensible, thin and flabby even with a well

contracted uterus, and may show tears

along its margins.

Dilated state: 2-3 cm after few days 1 cm at 1 w non-pregnancy state in 6-

12w

VAGINA

Following parturition the vagina ishyperemic - swollen - smooth.

The normal rugae reappear within 3 w.

The edema usually resolve by 6 w.

SYSTEMIC CHANGES

•CARDIOVASCULAR CHANGES•URINARY TRACT CHANGES •HEMOTHOLOGICAL CHANGES

CARDIOVASCULAR CHANGES

The significantly altered cardiovascular

system returns to a non-pregnant state

2-3 w after delivery.

Blood volume decreases by 33% in 72 h

due to blood loss and diuresis.

Increased heart rate and cardiac output

return to baseline within 2 w.

URINARY TRACT CHANGES

In the first days after labor: Over distention of bladder Incomplete emptying Traumatic bacteruria

URINARY TRACT CHANGES

Risk Factors for complicationsEpidural analgesiaVolume overloadPitocin (ADH effect)Episiotomy & lacerations

URINARY TRACT CHANGES

Puerperal diuresis usually occurs after2-5 days after labor.

Structural changes : Dilatation of bladder, Ureters and renal pelvis may persist for 3

m or more.

HEMATHOLOGICAL CHANGES

Blood count:

Leukocytosis (up to 30,000)LymphopeniaThrombocytosis

Blood volume: returns to normal in 1 w – increased

Hct.

CLINICAL & PHYSIOLOGICAL ASPECTS

Gustav Climt

WEIGHT LOSS

5-6 Kg - immediately fetus

amniotic fluid placenta

blood loss

2-3 Kg - within few days diuresis

PAINS

After pains (multipara >> nullipara)

Breast enlargement

Post spinal headache

Episiotomy/and lacerations

POST-PARTUM BLUES

Mild depression after labor is very common, lasts 2-3 days, and is self-limited.

Factors:•emotional letdown•pains of early puerperium• fatigue & loss of sleep•anxiety over taking care of the baby•defected self imaging

Mild depression after labor is very common, lasts 2-3 days, and is self-limited.

Factors:• emotional letdown• pains of early puerperium• fatigue & loss of sleep• anxiety over taking care of the baby• defected self imaging

POST-PARTUM BLUES

Treatment:anticipation, recognition & reassurance.

Attention :If the symptoms lasts more than 10 days or getting worse:Consider post-partum psychosis.

טיפול ביולדת לאחר לידה השגחה בחדר לידה לשעה-שעתיים )ניטור סימנים

וכמות דימום(

וידוא מתן שתן - למניעת .overflow incontinence

מוביליזציה מהירה

מתן זריקת anti D לאמהות שהןRh שליליות שעות מהלידה(.72 חיובי )תוך Rh להן תינוקות

.חיסון אדמת/ וריצלה

הטיפול ביולדת לאחר לידה ש' לאחר לידה נרתיקית ללא סיבוכים.48שחרור - ימים לאחר ניתוח קיסרי ללא סיבוכים.5

הנחיות בשחרור לגבי מצבים בהם יש לפנות לרופא:חום, דימום משמעותי, כאב ונפיחות ברגליים וקוצ"נ.

שבועות מהלידה.6 ביקורת גניקולוג - • יחסי מין -רצוי להימנע מיחסי מין עד לביקורת גניקולוג• שב'.6-8 מחזור - בלא מניקות יחלו מחזורי ביוץ תוך •

חד'.6 בהנקה מלאה יחלו מחזורי ביוץ לאחר אמצעי מניעה - במניקות גלולות על בסיס פרוגסטרון או •

IUD.

POSTPARTUM HEMORRHAGE

POSTPARTUM HEMORRHAGE

Early PPH occurs during the first 24 h after delivery.Late PPHoccurs after 24 h but before 6 weeks afterdelivery .Definition:1. more than 500cc blood loss at delivery.2. 10% change in Hct in Post Partum

period. 3. a need for blood transfusion.

POSTPARTUM HEMORRHAGE

incidence:The overall incidence for all deliveries: Early PPH 3-6% Late PPH 0.5-1.3%

Mortality: PPH contributes 30% of 500,000

pregnancy relateddeaths that occur each year worldwide.

Incidence

Vaginal delivery- 5–8%. PPH is the most common cause of

excessive blood loss in pregnancy. PPH is the main cause for transfusions in

pregnant women. 3rd leading cause of mortality in the USA.

1/6 of maternal deaths. In less-developed countries, hemorrhage is a

leading causes of death.

POSTPARTUM HEMORRHAGE

Early PPH - etiologies:

Uterine atony- 50%Lower genital tract laceration –

20%Retained placental fragment – 5-

10%Uterine ruptureUterine inversionPlacenta accretaHereditary coagulopathy

POSTPARTUM HEMORRHAGE

Risk Factors

Coagulopathy Hemorrhage/blood transfusion during previous pregnancy Anemia Grand multiparity Multiple gestation/ large infant/ polyhydramnios Dysfunctional labor Oxytocin induction or augmentation of labor Rapid or tumultuous labor PET / eclampsia Vaginal delivery after previous cesarean birth General anesthesia for delivery Forceps delivery

Uterine atony

.

Uterine atony Predisposing causes:

excessive manipulation of the uterus general anesthesia uterine overdistention )twins or polyhydramnios( prolonged labor grand multiparity uterine leiomyomas operative delivery and intrauterine manipulation, oxytocin induction or augmentation of labor previous hemorrhage in the third stage uterine infection extravasation of blood into the myometrium )Couvelaire

uterus( intrinsic myometrial dysfunction.

POSTPARTUM HEMORRHAGE

Late PPH - etiologies:

• Infections• Retained placental fragments

•Hereditary coagulopathy

POSTPARTUM HEMORRHAGE - complications

Postpartum hypotension may lead to partial or total necrosis of the anterior pituitary gland and cause postpartum panhypopituitarism, or Sheehan's syndrome. failure to lactate amenorrhea decreased breast size loss of pubic and axillary hair hypothyroidism adrenal insufficiency

The condition is rare )< 1:10,000 deliveries )

Treatment

Predelivery Blood type & cross-matched test Large bore IV Blood reserve in blood bank

Third stage of labor Uterotonic agents Manual removal of placenta Repair of lacerations/ Episiotomy Evaluation of persistent bleeding

Treatment

Measures to control bleeding Manual exploration of the uterus )&birth

canal( Bi manual pressure & massage Uterine packing Uterotonic agents Blood replacement Radiographic embolization of pelvic

vessels Operative management

Treatment

Operative management Uterine artery ligation B-Lynch suture Internal artery ligation Hysterectomy

Uterine artery ligation

B-Lynch suture

Internal Iliac artery ligation

Abnormalities of the Puerperium

Puerperal fever Endometritis

Cesarean section wound infection Episiotomy infection Analgesia complications

Puerperal Fever

Puerperal morbidity due to infection has occurred if the patient's temperature is higher than 38 °C on 2 separate occasions at least 24 hours apart following the first 24 hours after delivery.

Morbidity and Mortality

Major cause of morbidity associated with childbirth.

8% of maternal death.

Puerperal Fever

Main cause: endometritis. UTI is the next most common infection. Neglected or virulent endomyometritis

may progress to more serious infection Generalized sepsis septic pelvic thrombophlebitis pelvic abscess

Extragenital infections are much less common than endometritis and urinary tract infections.

Endometritis

Etiology 

Lactobacillus Diphteroides Corynebacterium Staphylococcus Streptococcus* Escherichia*

Gardnerella Klebsiella*Proteus* EubacteriumGaffyka Prevotella

Peptostreptococcus Veillonella Bacteroides Fusobacterium*

Mycoplasma Ureaplasma

Etiology

Almost all postpartum infections are caused by bacteria normally present in the genitalia of pregnant women.

The lochia is an excellent culture medium for organisms ascending from the vagina.

70% of puerperal soft-tissue infections are mixed infections.

Cesarean Section is the most common identifiable risk factor for development of puerperal infection.

Etiology

Risk Factors: prolonged rupture of the membranes )> 24

hours(, chorioamnionitis excessive number of digital vaginal examinations prolonged labor )> 12 hours( toxemia intrauterine pressure catheters )> 8 hours( fetal scalp electrode monitoring preexisting vaginitis or cervicitis operative vaginal deliveries cesarean section intrapartum and postpartum anemia poor nutrition obesity low socioeconomic status coitus near term

Symptoms and Signs

Fever tender uterus lochia may or may not have a foul odor. Leukocytosis )> 10,000/ L( In more severe disease:

high fever, malaise, abdominal tenderness, ileus, hypotension, and generalized sepsis may be seen.

Usually develops on the 2nd or 3rd postpartum day.

Early fever )within hours of delivery( and hypotension are almost pathognomonic for infection with hemolytic streptococci.

Treatment

The choice of antibiotics depends on the suspected causative organisms and the severity of the disease.

Treatment usually starts IV after caltures are taken.

Options:

Clindamycin + Aminoglycoside Single-agent therapy with second or third generation

cephalosporins

Treatment

The response to therapy should be carefully monitored for 24–48 hours.

Deterioration or failure to respond determined both clinically and by laboratory test results requires a complete re-evaluation.

Ampicillin is added when the patient has a less than adequate response to the usual regimen, particularly if Enterococcus spp. are suspected.

Intravenous antibiotics are continued until the patient has been afebrile for 24–48 hours.

Cesarean Section Wound Infection

Wound infection occurs in 4–12% of patients following cesarean section.

Risk factors: obesity diabetes prolonged hospitalization before cesarean section prolonged rupture of the membranes chorioamnionitis endomyometritis prolonged labor emergency CS anemia

Symptoms and Signs

Fever with no apparent cause that persists to the fourth or fifth POD.

Wound erythema and tenderness may not be evident until several days after surgery.

Occasionally, wound infections are manifested by spontaneous drainage.

Cesarean Section Wound Infection

The organisms responsible for most wound infections originate on the patient's skin.

S aureus is the organism most commonly isolated.

Streptococcus species, E coli, and other gram-negative organisms that may originally have colonized the amniotic cavity are also seen.

Rarely- necrotizing fasciitis and the closely related synergistic bacterial gangrene.

Radical debridement of necrotic and infected tissue is the cornerstone of treatment.

Episiotomy Infection

0.5–3% Surprising low incidence. Excellent local blood supply could be the

explanation. Correlates severity of the

laceration/episiotomy Other genital infection increase the risk.

Symptoms and Signs

Pain is the most common symptom. Spontaneous drainage is frequent, so a mass

rarely forms. Incontinence of flatus and stool may be the

presenting symptom of an episiotomy that breaks down and heals spontaneously.

Disruption of the wound and gaping of the incision.

A necrotic membrane may cover the wound and should be debrided if possible.

A careful rectovaginal examination should be performed to determine whether a rectovaginal fistula has formed.

Treatment

Initial treatment is opening and cleaning the wound in order to promote formation of granulation tissue.

Warm baths. Closure of an infected episiotomy is likely to fail

and may make ultimate closure more difficult. Surgical should be undertaken only after

granulation tissue has covered the wound. Increasing trend towards early repair of

episiotomy wound dehiscence.

Urinary Tract Infection

2–4% of women postpartum. Following delivery, the bladder and lower

urinary tract remain somewhat hypotonic, and residual urine and reflux result.

Risk factores: asymptomatic bacteria, chronic UTIs, and anatomic disorders of the bladder, urethra, and kidney.