ABNORMALITIES OF PUERPERIUM

*PUERPERAL PYPREXIA *PUERPERAL SEPSIS *SUBINVOLUTION *URINARY COMPLICATION *BREAST COMPLICATION

*PUERPERAL VENOUS THROMBOSIS *PULMONARY EMBOLISM *OBSTETRIC PALSIES *PUERPERAL EMERGENCIES *PSYCHIATRIC DISORDERS

 PUERPERAL

PYREXIA

DEFINITION:A rise of temperature reaching 100.4F or more on 2 operate occasion at 24 hrs apart within first 10 days following delivery is called puerperal pyrexia.

 CAUSES
Puerperal sepsis Urinary tract infection Mastitis Infection of CS wound Pulmonary infection Malaria Tuberculosis Unknown

 PUERPERAL SEPSIS
DEFINITION:An infection of genital tract which occur as a complication of delivery is termed as puerperal sepsis.

PREDISPOSING FACTORS
Organism from outside Organism resistant to antibiotic Low host resistance Multiplication of organism

oANTEPARTUM FACTORS
1. 2. 3. 4. 5. Malnutrition & anemia Preterm labour Premature rupture of membrane Chronic debilitating illness Prolonged rupture of membrane

oINTRAPARTUM FACTORS
1. 2. 3. 4. 5. 6. 7. 8. Repeated vaginal examination Prolonged rupture of membrane Dehydration & ketoacidosis Traumatic operative delivery Hemorrhage Retained bits of placenta Placenta previa CS

MICROORGANISM RESPONSIBLE FOR PUERPERAL SEPSIS

AEROBIC:1. Streptococcus haemolytic group A 2. Streptococcus haemolytic group B 3. Staphylococcus aureus 4. E . Coli 5. Klebsialla

ANAEROBIC
1. Anaerobic streptococcus 2. Becteriods 3. Clostridia

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 .

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 pus which resulting in necrosis and sloughing. VAGINA:- the vaginal laceration are infected directly or by extension from the perineal infection. The mucosa is swollen resulting in necrosis and slouhing.

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.

SPREAD OF INFECTION
PELVIC CELLULITIS:- spread of infection to the pelvic cellular tissue by direct or lymphatic or by haematogenous routes. The infection cause exudation and formation of a mass confined to one side. SALPHINGITIS:- may be interstitial( due to lymphatic) or perisalphingitis (following pelvic peritonitis) or endosalphingitis(tubal mucosa). Pelvic peritonitis may be due to spread of infection a) directly through the tubes

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.

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.

3) Uterus is subinvouted and tender. SEVERE:1) Rise in temp, with chills & rigor 2) 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 the general condition.

 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.

DIAGNOSTIC EVALUATION
HISTORY:- antenatal history anemia, antepartum hemorrhage. Intranatal history preterm labour, no. of internal examination, duration of labour, method of delivery. Postnatal history fever, associated symptoms related to site of lesion.

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)

 X-ray (for check lung pathology) Blood urea & electrolytes( for detect renal failure)

MANAGMENT
GENERAL MANAGEMENT:1. Isolation of the patient(heamolytic streptococcus) 2. Adequate fluid & calorie 3. Anemia oral iron & blood transfusion 4. Pain analgesics 5. Urinary retention- catheter 6. Chart pulse, resp, temp, I/O, lochial discharge

 ANTIBIOTICS- gentamycin( 2mg/kg iv 8hrly), ampicillin(1gm iv 6hrly), clindamycin (900mg iv 8hrly), cefotaxime(1gm 8hrly ), metron (0.5gm iv 8hrly) SURGICAL MANAGEMENT: Perineal wound- stiches removed to drain pus then re-stiched. Retained uterine products- evacuation Pelvic abscess- colpotomy Rupture or perforation, multiple abscesshystrectomy

SUBINVOLUTION
DEFINITION:- when involution is impaired or retarded is called subinvolution.

CAUSES
Grand multiparity Over distension of uterus( twins) Maternal illness CS Prolapsed uterus Retroversion Uterine fibriod

CLINICAL MANIFESTATION
SYMPTOMS- abnormal lochial discharge, irregular excessive uterine bleeding, irregular cramps . SIGNS- uterine height is greater than normal, it feels boggy & softer.

MANAGEMENT
Antibiotics in endometritis Exploration of uterus in retained products Pessary in prolapsed or retroversion.

URINARY COMPLICATION
URINARY TRACT INFECTION:- It is one of the common cause of puerperal pyrexia Infection may be consequence of the following1. Recurrence of previous cystitis or pyelitis 2. Asymptomatic bacteriuria RETENTION OF URINE (treatment is catheter is introduce) INCONTINENCE OF URINE

 SUPPRESSION OF URINE (it occurs if 24 hrs urine output is less then 400 ml)

BREAST COMPLICATION
BREAST ENGORGEMENT: CAUSE- it is due to venous and lymphatic engorgement 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.

 PREVENTION1. Avoid prelacteal feeds 2. Initiate breast feeding early 3. Exclusive breast feeding 4. Feeding in correct position

 MANAGEMENT: Support the breast with binder & brassiere Manual expression of any remaining milk after feeds Analgesics for pain Baby should be put to breast regularly Gentle use of breast pump

 CRACKED NIPPLE It is due to : Loss of surface epithelium with the formation of a raw area on the nipple Fissure situated either at the tip or the base of the nipple CAUSES Unclean hygiene resulting in formation of crust over the nipple Retracted nipple Trauma from babys mouth due to incorrect attactment.

SYMPTOMS Painful when infant sucks If infected, infection may spread to deeper tissue producing mastitis MANAGEMENT Correct attachment(provide relief from pain) Fresh human milk & saliva has got healing property Purified lanonin with mothers milk is applied 3-4 times a day to fasten healing

 Mother should use the breast pump & feed the infant with expressed milk Miconazole lotion is applied over the nipples as well as babys mouth.

RETRACTED AND FLAT NIPPLE It is commonly seen in primi, if baby is not attached properly and suck adequately In this cases manual expression of milk can be done.

ACUTE MASTITIS
DEFINITION:It is infection of the breast tissue due to organisms like staphylococcus aureus, s. epidermidis and streptococci. MODE OF INFECTION 1) Infection that involves the breast parenchymal tissue leading to cellulitis 2) Infection gain access through the lactiferous duct leading to primary mammary adenitis.

 ONSET:- acute during late 1st week of puerperium. Acute mastitis occur even several weeks after the delivery CLINICAL FEATURES SYMPTOMS:1. Malaise & headache 2. Fever(102f) with chills 3. Severe pain and tender swelling SIGNS:a) Presence of toxic features b) Presence of wedge shaped swelling c) Skin is red, hot and flushed and feels tense & tender

 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

BREAST ABSCESS

 FEATURES 1. Flushed breast not responding to antibiotics 2. Edema of the overlying skin 3. Marked tenderness 4. Swinging temp TREATMENT:- the abscess is drained under GA by a deep incision extending from areola margin to prevent injury to the lactiferous duct. Finger exploration is done to break up the walls of loculi. The abscess can also be drained by needle aspiration

 Micaconazole lotion or gel on both the nipples after each feed & into infant mouth thrice daily for 2 weeks.

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

MANAGEMENT
Maintenance of effective lactation: ANTENATAL1. 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

 PUERPERIUM1. 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

PUERPERAL VENOUS THROBOSIS

Thrombosis 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

DEEP VEIN THROMBOSIS

 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)

 DIAGNOSTIC VALUATION DOPPLER SOUND:- it is done to detect the velocity of blood flow in the femoral vein by noting alteration in the characteristic of WHOOSH sound. VENOGRAPHY:- Injecting non- ionic water soluble radio- opaque dye to note the filling defect in venous lumen FIBRINOGEN SCANNING

PELVIC THROMBOPHLEBITIS
Postpartum thrombophlebitis originates in the thrombosed veins at the placental site by organism when localised in pelvis, it is called pelvic thrombophlebitis

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

DIAGNOSTIC EVALUATION
ultrasound CT scan MRI

MANAGMENT
Pt is put to bed rest and foot is raised up to heart level Pain analgesics Infection antibiotics Anticoagulant heparin 15000U, warfarin High quality elastic stockings Fibrinolytic agents- streptokinase Venous thromboectomy

PULMONARY EMBOLISM
o o o o CAUSES:Hemorrhage Hypertension Sepsis Deep vein thrombosis

 SYMPTOMS:o Acute chest pain and air hunger o Tachypnoea o Dyspnoea o Tachycardia o Rise in temp

 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

MANAGEMENT
RESUSCITATION- includes cardiac massage, oxygen therapy and intra venous heparin infusion I V FLIUD SUPPORT THROMBOLYTIC THERAPY- streptokinase EMBOLECTOMY

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

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

PUERPERAL EMERGENCIES
IMMEDIATE1. PPH 2. Shock 3. Post partum eclampsia 4. Pulmonary embolism 5. inversion

 EARLY( within 1st wk) 1. Retention of urine 2. Urinary tract infection 3. Puerperal sepsis 4. Breast engorgement 5. Mastitis and breast abscess 6. Pulmonary infection 7. Anuria

 DELAYED 1. Secondary PPH 2. Pulmonary embolism 3. Thrombophlebitis 4. Psychosis 5. Post partum cardinomyopathy 6. Post partum haemolytic uraemic syndrome

PSYCHIATRIC DISORDERS

 RISK FACTORS PAST HISTORY psychiatric illness, puerperal psychiatric illness FAMILY HISTORY major psychiatric illness, marital conflict PRESENT PREGNANCY caesarean delivery, difficult labour, neonatal complication OTHERS- unmet experience

PUERPERAL BLUES
It is transient state of mental illness observed 3-4 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

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 (serotonin uptake inhibitors)

POST PARTUM PSYCHOSIS(schizophrenia)

It is commonly seen in women with past history of psychosis ONSET- within 4 days of delivery MANIFESTATION- fear, restlessness, confusion, hallucination, delusion, disorientation, suicidal and infanticidal impulses MANAGEMENT- chlorpromazine 150mg stat and 50150mg thrice a day, sublingual oestradiol 1mg thrice a day, ECT(electro convulsion therapy),lithium( breast feeding is contra indicated)

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