Download Normal & abnormal puerperium

NORMAL & ABNORMAL
PUERPERIUM
Undergraduate Teaching Programme
Dr G Holding ST3
02/09/2015
Introduction
• Puerperium is defined as the period from delivery of
placenta through to six weeks after delivery
• The various changes that occurred during pregnancy
revert to the non-pregnant state
Postnatal care
• Uterus/genital tract
• Vaginal loss (lochia)
• Perineum
• Wound
• Bladder
• Bowels
• Breasts
• Pain
• Fatigue
• Emotions
Normal Puerperium
• Cardiovascular system – extra load on heart disappears
by second week
• Uterus - pregnant term uterus weighs about 1000g; at
6/52 weighs about 100g
• Vaginal loss (lochia) – volume and duration of vaginal
discharge is variable and changes, average 3-6 weeks
• Perineum – vagina & perineum initially increase in
oedema; most muscle tone regained by 6/52
Normal Puerperium
• Bladder - passing urine can initially be painful, stress
incontinence
• Bowels - constipation common, haemorrhoids
• Breasts - engorged and tender 2-3 days post delivery,
usually resolves, milk replaces colostrum
Normal Puerperium
• Pain – ‘after pains’ as uterus contracts, postoperative
pain, back ache
• Fatigue – disturbed sleep, recovering from birth
• Emotions – baby blues, anxiety
Abnormal Puerperium
• Bleeding
• Sepsis
• Thromboembolism
• Pre-eclampsia/hypertension
• Psychiatric disorders
Post Partum Haemorrhage (PPH)
• Primary PPH is blood loss of 500ml or more occurs within
the first 24 hours after delivery
• Secondary PPH is ‘excessive’ loss occuring between 24
hours and 6 weeks postpartum
PPH
• Causes
– Early PPH: uterine atony, retained placenta, lower
genital tract trauma, uterine rupture, inversion,
coagulopathy, haematoma
• Incidence
– Vaginal delivery: 4% incidence
– Caesarean delivery: 10% incidence
– Delayed ‘secondary’ PPH occurs in 1-2% of patients,
usually due to infection, retained products, or both
• Management
– History – how much bleeding? Risk factors
– Examination – Inspection lower genital tract, bimanual
examination
– Investigations – FBC/clotting/X-match
– Treatment – resuscitation/uterine massage/
pharmacological therapy/surgery
Sepsis
• Number 1 cause of maternal death in the UK
• Endometritis
• Group A streptococci
• E. coli
• Chlamydia
• Incidence:
• Vaginal delivery 1-3%
• Elective LSCS 5-15%
• Urinary tract infections - bacteruria 33%, symptomatic
infection 2%
• Wound infection - perineal infection 0.5 – 10%, LSCS
wound 3-15% reduced to 2% with abx
• Mastitis – staph aureus, abscess complicates 5-11%
cases
Thromboembolism
• VTE is number three ‘direct’ cause of maternal death in
the UK
• Statutory VTE assessment on everyone admitted to UK
hospitals
• High index of suspicion, not just in obvious presentations
such as chest or calf pain
Pre-eclampsia/hypertension
• Pre-eclampsia - usually settles in the first 24 hours after
delivery but can be unpredictable
• 50% cases of eclamptic fit, the first fit is post partum
• Treatment:
– BP control (nifedipine; labetolol infusion)
– Magnesium sulphate for prevention of further fits
• Common to have a residual hypertension lasting some
weeks
– Aim to keep BP at less than 140/90
Psychiatric disorders
• Four disorders
• Postpartum blues
– transient disorder
– lasts hours to weeks
– characterized by bouts of crying and sadness
• PND
– more prolonged affective disorder
– weeks to months, and even years
– Not well defined in terms of diagnostic criteria, but signs and
symptoms same as depression in other settings
• Postpartum psychosis
– first postpartum year, usually begins abruptly at 5-15 days
– refers to a group of severe and varied disorders that elicit psychotic
symptoms
• Incidence
– 50-70% develop symptoms of postpartum blues
– PND occurs in 10-15%
– PTSD affects 1% of mothers but most will not report it
• Often, may only materialise years later, for instance when the woman
experiences emotional or physical symptoms surrounding planning of a future
pregnancy
– Puerperal psychosis in 0.2%
• Morbidity and mortality
– Can have hugely deleterious effects on the mother, the relationship with
the partner, the family, and on social, cognitive, and emotional
development of the newborn
– Suicide is one of the top causes of maternal death within a year of
childbirth
Treatment
• Postpartum blues - little effect on a patient's ability to
function, often resolves by day 10
– No pharmacotherapy is indicated
– Providing support and education has been shown to have a
positive effect
• PND generally lasts for 3-6 months
– 25% of patients still affected at 1 year
– Affects ADLs
– Supportive care/reassurance is first-line but low threshold for drug
therapy
• Postpartum psychosis
– Supervised by a psychiatrist and may involve hospitalisation
– Generally lasts only 2-3 months
Other issues
• Breast feeding
• Sexual intercourse
• Contraception
• Resuming normal activities
Any Questions ?