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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 ?