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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
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