Download Lecture 19 – Abnormalities of puerperium

Lecture 19
ABNORMALITIES OF THE
PUERPERIUM
Prof. Vlad TICA, MD, PhD
ABNORMALITIES OF THE
PUERPERIUM
OBJECTIVES
 Importance of puerperal infections to maternal
morbidity and mortality
 Definition of puerperal fever and puerperal sepsis
 Various puerperal abnormalities
 Causes of puerperal fever
 Aseptic and antiseptic measures to be adopted for the
prevention of puerperal sepsis
 Management of the various abnormalities
ABNORMALITIES OF THE
PUERPERIUM
SEPSIS
 is the commonest complication during puerperium, but largely
preventable
ABNORMALITIES OF THE
PUERPERIUM
PUERPERAL INFECTION
 Any bacterial infection of the genital tract after delivery
 Incidence: 6 %
 The most important cause of maternal death
 Temperature 38° C or higher recorded 2x in the first 10 days
postpartum, exclusive of the first 24 hours, and to be taken by
mouth by a standard technique at least 4x daily
PUERPERAL INFECTION
RISK FACTORS
 PROM
 Anemia
 Hemorrhage
 EP and CS
 Placenta retain
PUERPERAL INFECTION
MANIFESTATIONS
 Acute vulvitis vaginitis and cervicitis
 Uterine infection
 Adnexal infections
 Breast infection
 Urinary infection
 Septic pelvic thrombophlebitis
 Other incidental infections
PUERPERAL INFECTION
COMMON PATHOGENS
 Aerobes
 Group A, B, and D streptococci
 Gram-negative bacteria: Escherichia coli, Klebsiella
 Staphylococcus aureus
PUERPERAL INFECTION
COMMON PATHOGENS
 Anaerobes
 Petococcus species
 Petostreptococcus species
 Bacteroides fragilis group
 Clostridium species
PUERPERAL INFECTION
COMMON PATHOGENS
 Other
 Chlamydia trachomatis
 Mycoplasma species
PUERPERAL INFECTION
DIAGNOSIS
 History
 Physical examination and PV
 Lab finding
 Differential diagnosis
PUERPERAL INFECTION
TREATMENT
 Nutrition
 anemia prevention
 Antimicrobial treatment
 broad-spectrum, high dose, long time
 Drainage
 Treatment of thrombophlebitis
ABNORMALITIES OF THE
PUERPERIUM
PUERPERAL SEPSIS
 Definition
 Risk Factors for Puerperal Sepsis
 Diagnosis
 Management
 Complication
PUERPERAL SEPSIS
DEFINITION
 Infection of genital tract between delivery & 42 days after
delivery
 2 or > features to be present:
 Pelvic pain
 Fever: 38.5° C
 Vaginal D/S
 Smell of D/S
 Subinvolution
PUERPERAL SEPSIS
RISK FACTORS
 Anaemia
 Malnutrition
 DM
 Prolonged labor
 Obstructed labor
 Prolonged PPROM
 Frequent vaginal examinations
PUERPERAL SEPSIS
RISK FACTORS
 Operative delivery
 Un-repaired tears
 PPH
 Poor hygiene
 Poor aseptic technique for delivery
 Manipulations high in the birth canal
 Retained bits of placenta or membranes
 Pre-existing STDs
PUERPERAL SEPSIS
DIAGNOSIS
 Endometritis
 Subinvolution
 Pelvic cellulites
 Salpingitis & peritonitis
 Pelvic thrombophlebitis
 Septicaemia
PUERPERAL SEPSIS
MANAGEMENT
 Preventive
 Good antenatal care
 Proper intra-natal care
 Post natal care
 Curative
 General care
 Antibiotics for infection
 Local care of various wounds
PUERPERAL SEPSIS
COMPLICATIONS
 Septicaemia
 Septic shock
 DIC
 Pulmonary embolization
 Distant spread of infection
 Kidney failure
 Death
PUERPERAL SEPSIS
LATE COMPLICATIONS
 Menstrual problems
 Chronic pelvic pain
 Chronic PID
 Secondary infertility
INFECTIONS ASSOCIATED WITH
CHILDBIRTH PROCESS
(OTHER THAN PUERPERAL SEPSIS)
 Breast Problems
 Urinary Problems
 Venous Thrombosis
BREAST PROBLEMS
 Retracted / cracked nipples →
 Breast engorgement
 Mastitis
 Breast abscess →
 Failure of lactation
BREAST PROBLEMS
ENGORGEMENT
 2-4 days postpartum, if not breastfeeding
 Anytime whilst breastfeeding
 Conservative management:
 Tight bra, ice packs, analgesia
 Bromocriptine
MASTITIS
BREAST PROBLEMS
 Regional staph aureus infection
 Fever, focal erythema, oedema &
tenderness
 3rd - 4th week
 Uncommon
 >50% of cases are in primiparas
 Management:
 Feed or pump (overcome obstruction)
 Oral antibiotics
 Analgesia
 Aspiration/I&D for abscess (10%)
URINARY PROBLEMS
 Retention
 Incontinence
 Infection
VENOUS THROMBOSIS
 Due to hypercoagulable state of pregnancy
 Predisposing factors:
 Increasing maternal age
 Obesity
 Anaemia
 Dehydration
 Trauma
 Infection
 Smoking
 Reduced mobility
PUERPERAL MORBIDITY
(OTHER THAN INFECTION)
 Secondary Hemorrhage
 Puerperal Psychic Problems
 Obstetric Palsy
SECONDARY HEMORRHAGE
DEFINITION
 Uterine bleeding by 24 hours after delivery
CAUSES
 Infection
 Retained bits of placenta & membranes
 Subinvolution
 Problems of incision (vulval haematoma, caesarean scar
dehiscence)
 Trophoblastic disease
PUERPERAL PSYCHIC PROBLEMS
 Postnatal blues
 Postnatal depression
 Puerperal psychosis
POSTNATAL BLUES
 50%
MANIFESTATIONS
 Tearful
 Sad
 Sleep disturbed
 Restless
 Headaches
 Poor concentration
MANAGEMENT
 Reassure, support
POSTNATAL DEPRESSION
 10-25% in 1st year
 Peak 3-4 weeks
 2/3 self limiting; 1/3 sustained/severe
 MANIFESTATIONS: Irritable, tired, decreased libido, guilt,
unable to cope, undue anxieties
 MANAGEMENT: psychotherapy, counselling, antidepressants
PUERPERAL PSYCHOSIS
 1/500-800
 5% commit suicide, 4% kill baby
 20% - again next pregnancy, 50% psychotic again later in life
MANIFESTATIONS
 Suspicious – denies pregnancy
and baby
 Delusions
 Hallucinations
 Confusion
 Cognitive impairment
RISK FACTORS
 Previous psychosis, unmarried, C/S, infection, perinatal death
OBSTETRIC PALSY
 Severe neuralgia due to pressure on lumbo-sacral nerve plexus
 Foot drop
 Rarely femoral, obturator or sciatic nerves may be involved
 Spontaneous recovery usually
 Physiotherapy is helpful
CONCLUSIONS
 Importance of history
 Systematic evaluation
 Proper advise & motivation regarding contraception
 Importance of immunization for new born
 Stress upon postnatal exercises
THANKS !