Download Normal and Abnormal Puerperium

Normal and Abnormal
Puerperium
Azza Alyamani
Department
Obstetrics & Gynecology
Normal Puerperium
Definition
It is the period following delivery of the baby and
placenta to 6 weeks postpartum.
It is the period during it ,the reproductive
organs & maternal physiology returns towards the
pre pregnancy state .
Anatomic and physiologic changes :
1. Uterine Involution
2. Return of Menstruation.
3. Vagina.
4. Cardiovascular System.
(1) Uterine Involution
* it rapidly decreases in weight from 1000 g - 100 g
in the first 3 weeks postpartum.
* lochia
=lochia ruba:
bloody discharge in the first few
days after delivery.
=lochia serosa: the discharge becomes pale in
color after 3 – 4 days.
=lochia alba: uterine discharge assumes a
white or yellow-white color by
the 10th day postpartum.
NB:
foul-smelling lochia suggests endometritis.
(2) Return of menstruation
* non-nursing mothers:
menstruation returns by 6 – 8 weeks.
* nursing mothers:
may develop lactating amenorrhea.
NB:
In all women , although ovulation may not occur
for several months ,particularly in nursing mothers
contraceptive use should be advised during the
puerperium to avoid an undesired pregnancy.
(3) Vagina
* the supportive tissues of the pelvic floor
gradually returns its former tone.
* women who deliver vaginally should be
taught & encouraged to perform
Kegel excercises
(4) Cardiovascular system
* cardiac output & plasma volume gradually
returns to normal during the first 2 weeks.
* marked weight loss occurs in the first week
as a result of the decrease of plasma volume
and the deuresis of the extracellular fluid.
Breastfeeding
* Advantages:
= inexpensive , in good supply usually,
= accelerates uterine involution ,because suckling
stimulates the release of oxytocin ,thus causing
increased uterine contractions.
= immunologic advantages for the baby , as breast
milk contains several types of maternal antibodies,
which provides the newborn with passive immunity
against certain infectious diseases ,until its own
immune mechanisms become fully functional
by 3 – 4 months.
Correct
Wrong
* Complications
1. Fissured Nipples:
= nipples may become fissured and nursing
become painful and difficult.
= breast fissures are a portal of entry for
bacteria, so they should be managed aggressively
by lanolin breast cream.
= further breast feeding should be stopped , milk
can be expressed manually until the nipples
heal and breastfeeding can be resumed.
2. Mastitis :
= uncommon complication usually develops
after 2 – 4 weeks.
= symptoms & signs
low grade fever , chills , indurated ,red and painful
segment of the breast.
= caused by Staphylococcus aureus bacteria
from the infant’s oral pharynx.
Mastitis
= mother should start antibiotics immediately,
such as dicloxacillin for 7-10 days.
= breastfeeding may be discontinued so, breast
pump can be used to maintain lactation .
however , suppression of lactation is advisable.
= if a breast abscess develops , it should be
surgically drained.
3. Drug passage to the newborn:
= infant ingest up to 500 ml of breast milk /day.
thus , maternally administrated drugs that
pass to breast milk may have significant effect.
= amount of drug in breast milk depends on:
* maternal drug dose.
* rate of maternal clearance.
* physiochemical properties of the drug.
* composition of the breast milk with respect to
fat and protein.
* infant GA at birth.
Effects of selected drugs on breastfeeding infants:
(1) Sedatives
diazepam
(2) Salicylates
(3) Anticonvulsants
phenobarbital
phenytoin
(4) Narcotics
heroin
methadone
(5) Antibiotics
penicillin
ampicillin
erythromycin
nitrofurantoin
tetracycline
Sedation
May cause platelet dysfunction.
Sedation
Sedation & decreased suckling.
May cause addiction.
Infant death.
3 antibiotics modify bowel flora & allergy.
may hemolytic anaemia in infants with
glucose 6 phosphate dehydrogenase
.
discoloration of teeth&
bone growth.
Cont.
(6) Thyroid drugs
thyroxine
propyl thiouracil
May interfere with screening for hypoth.
Nodular goiter.
(7)Drugs have no
adverse effects :
* antipsychotics as
chlorpromazine
haloperidol
* antihypertensives
methyldopa
propranolol
* Digoxin
* analgesics
acetaminophen
no adverse effects .
Abnormal Puerperium
Puerperal Disorders:
1. Puerperal Pyrexia.
2. 2ry Postpartum Hemorrhage.
3. Thromboembolism.
4. Perineal Complications.
5. Bladder Dysfunction.
6. Bowel Dysfunction.
Puerperal Pyrexia
Definition:
a temperature of 38C or > lasts for 2 days
or > in the first 10 days postpartum,
exclusive of the first 24h.
Fever during puerperium must be regarded as
result in from genital tract infection
(puerperal sepsis)
until prove otherwise.
Causes:
1. genital tract infection ( puerperal sepsis ).
2. milk engorgement ,mastitis & breast abscess
3. DVT & PE.
4.
5.
6.
7.
UTI.
chest infection.
CS delivery, wound infection & fasciites.
meningitis.
Genital Tract Infection
( Puerperal Sepsis)
Incidence:
3%
7% of all direct maternal deaths , excluding deaths
after abortion.
Etiology:
Puerperal infection is usually poly microbial
involves contaminants from the bowel
that colonize the perineum and
lower genital tract.
The most frequently identified organisms are :
* Group B Streptococcus.
* Mycoplasma species.
* others:
=Gram +ve
-beta-hemolytic streptococcus gr.A,B,D
-staphylococcus aureus.
-staphylococcus faecalis.
=Gram –ve
-E coli
-Hemophilus influenzae.
-gardenella vaginalis.
=Anaerobes
as; Bactroides fragilis.
=Miscellaneous
as; Chlamydia trachomatis
Predisposing Factors:
1. manual removal of the placenta.
2. placental separation exposes a large raw area.
3. retained products of conception & blood clots.
4. CS wound ,episiotomy and genital tract
lacerations.
Risk Factors
1.
2.
3.
4.
5.
instrumental delivery.
internal fetal monitoring.
multiple vaginal examinations.
prolonged ROM and chorioamnonitis.
cervical cerclage.
6. Non obstetric :
.. Obesity.
.. DM.
.. HIV.
Factors that determine
the clinical course & severity of the infection:
1. general health and resistance of the woman.
2. virulence of the causative organisms.
3. presence of predisposing factors as bl. Clots,
hematoma or retained products of conception.
4. timing of antibiotic therapy.
Diagnosis
A. Clinical Picture
symptoms:
• fever ,rigors, malaise, headache.
• vomiting and diarrhoea.
• abdominal discomfort.
• offensive lochia.
• 2ry PP Hge.
signs:
• pyrexia and tachycardia.
• uterus is large and tender.
• infected wounds as CS or perineal lacerations
• peritonism and paralytic ileus (severe cases).
• indurated adnexae due to parametritis.
• fullness in pelvis due to abscess.
Investigations:
1. FBC
2. Coagulation Profile
3. RFT & Electrolytes
anaemia, leukocytosis ,
thrombocytopenia.
DIC.
fluid & electrolytes
imbalance.
acidosis & hypoxia.
4. Arterial blood gas
( septiceamic shock)
5. High vaginal swabs
infection.
and blood cultures.
6. Pelvic US :
=retained products = adnexal mass
=pelvic abscess.
Management
Prevention:
1. awareness of general hygiene principles.
2. good surgical technique with proper hemostasis.
3. prophylactic antibiotics
especially in emergency CS.
a single intra operative dose of cephalosporin+
metronidazole.
Treatment
A. Mild and Moderate infections :
broad spectrum antibiotic as:
cephalosporin + metronidazole.
in the first 48h ,antibiotic should be given IV.
B. Severe infections :
septic/endotoxic shock
appropriate antibiotics should be aggressively
given ,any delay could be fatal.
Complications
1. Pelvic abscess
salpingo- ophoritis and pelvic peritonitis . This
could progress to a generalized peritonitis and
the development of pelvic absess.
2. Pelvic Peritonitis
metritis and parametitis.
3. Septic Thrombophlebitis
spread to distant sites via lymphatics , bl.v to
the iliac vessels or directly via the ovarian
vessels.
Necrotizing Fasciitis
* fatal infection of skin ,fascia and muscle. It occurs
in the perineal tears, episiotomy sites & CS
wounds.
* caused by a variety of bacteria including
anaerobes.
* in addition to signs of infection ,there is extensive
necrosis which is managed by surgical removal of
the necrotic tissue under general anesthesia and
split-thickness skin grafts. This is essential to
avoid mortality.
(2) Secondary Postpartum Hemorrhage
* it is fresh bleeding from the genital tract after
the first 24 h. till 6 weeks after delivery.
(7 – 14 days).
* the most common cause is retained placental
reminants. Endometritis is another cause. Then
bleeding disorders ,hormonal contraception and
choriocarcinoma.
* associated features are cramps abdominal pain.
the uterus is larger than expected and signs of
infection as tenderness .
* Management
* Diagnosis :
US is mandatory.
* Treatment :
= IV blood transfusion.
= Syntocinon infusion.
= Antibiotics
should be given if placental tissues are found
even without evidence of overt infection.
= evacuation of the uterus under general
anesthesia .
(3) Perineal Complications
1.perineal discomfort
* it is the single major problem for mothers in
the first 3 days .
* discomfort is greatest in the presence of
episiotomy ,spontaneous tears following
instrumental delivery.
* treatment
• local cooling by crushed ice.
• topical anaesthetics as 5% lignocaine gel.
• analgesics ; paracetamol or NSAIDs as;
diclofenac suppositories at delivery
followed by another 12h latter.
2. perineal infection
* uncommon , but if signs of infection occur
these must be taken seriously.
* caused by bacterial contamination during
delivery ,thus swabs from infected wounds
for culture & antibiotic sensitivity.
* treatment
..antibiotics.
..drainage if pus collected by removal of
any skin sutures.
..if spontaneous opening of repaired tears
or episiotomy ,in presence of infection,
should be irrigated twice daily & healing
is allowed by secondary intention.
(4) Bladder Dysfunction
* Voiding difficulty and over-distention of the
bladder are not uncommon after delivery ,
especially ,if epidural or spinal anesthesia
has been used.
* Causes
• after epidural anesthesia the bladder may
take 8 – 12h to regain normal sensation.
During this time about 1 liter of urine is
produced and therefore ,urinary retention
occurs.
• caused also by pain or peri urethral edema
due to traumatic delivery as :
instrumental delivery , multiple extended
lacerations ,vulvo vaginal hematomas .
* Distended bladder is diagnosed by being
palpated as a suprapubic cystic mass or it may
displace the uterus upwards or laterally , so
increasing the height of the uterine fundus.
* treatment
if regional anesthesia has been used ,urinary
catheter should be left in situ for the first
12 – 24h especially if the residual urine in the
bladder is > 300 ml.
* Important
stress incontinence is a rare problem in the
puerperium ,thus any urine incontinence
should be investigated to exclude obstetric
fistulae.
(5) Bowel Dysfunction
* Constipation is a common problem in the
puerperium. It caused either by interruption
in the normal diet and dehydration during
labor or as a result of fear of evacuation due
to pain from a sutured perineum.
* Advice on adequate fluid & fiber intake is
necessary.
* In repaired 3rd and 4th degree perineal tears,
avoidance of constipation & straining is very
important as it would disrupt the repaired anal
sphincter and cause anal incontinence.
* It is important to give Lactulose and fibers as;
Regulan immediately after repair for 2 weeks.
* Long -term anal incontinence following repair
of 3rd and 4th degree perineal tears occurs in
5% and recto-vaginal fistula in 3% in the
postpatum period.
* Occult anal sphincter trauma occurs in 10-30%
of primiparous women , due to disruption of
the internal anal sphincter detected by
trans anal US.
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