Normal and abnormal puerperium by Dr Yin Moe


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Normal and abnormal puerperium by Dr Yin Moe

  2. 2. Definition• Puerperium – a period from the expulsion of the placenta until 6 – 8 weeks after birth, during which time the uterus and other organs and systems return to their pre pregnant state and lactation is initiated.• Many changes take place within the first 10 - 14 days.• Role changes7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 2
  3. 3. Endocrine changes• Removal of the placenta alters the physiological state – rapid clearance of hormones from plasma and extra cellular fluid• HPL disappears by 1-2 days• hCG detected for 2 weeks• Alpha feta protein – several weeks• Oestrogens/progesterone – rapid loss• Ovarian function – low for first 2 weeks7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 3
  4. 4. • FSH/LH suppressed during pregnancy remain low for 2 weeks following birth, both in lactating and non lactating women, gradual increase over 6 weeks.• Tends to be a period of infertility7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 4
  5. 5. Placental Site• Dramatic decrease in size brings uterine walls into close apposition and transforms uterus into hard globular mass.• This has the effect of applying pressure on the placental site - prevents haemorrhage• 18cm diameter- 9cm• Promoted by continual action of oxytocin. 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 5
  6. 6. Uterine InvolutionWeight of uterus after birth 1 kg 6/52 no longer palpable 6/52 50-60g? Caused by withdrawal of placental hormonesBy day 5 - wt 500gms7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 6
  7. 7. Involution – ‘turning inwards’ 3 processes• Ischemia occurs as a result of collapse of blood vessels• Autolysis is physiological process by which involution of uterus is achieved. Breakdown of intracellular protein by proteolytic & hydrolytic enzymes.• Phagocytocis – disposes of elastic/fibrous tissue 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 7
  10. 10. Endometrium• Regeneration begin 1-2 days after birth• Differentiation into 2 layers superficial – barrier to infection basal – source of new endometrium• Regeneration takes approx 2-3 weeks.• Placental site regenerates slowly over 6 -7 weeks7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 10
  11. 11. LochiaReflects the process of involution and restorationof the endometrium – characteristic postnataldischargeMean duration – 21-33 daysShorter in multips and with smaller babies• Lochia rubra: fresh blood from placenta• Lochia serosa: brownish pink after 4 days• Lochia alba: white7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 11
  12. 12. Cervix and Vagina• Cervix bruised, swollen, oedematous and little tone.• By end of 1st week cervix decreased in size, closed by end 2nd week• Vagina smooth, oedamatous, pouting and blue-ish.• After 3-4 wks ruggae appear. 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 12
  14. 14. • Episitomy • Lacerations • Sexual intercourse7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 14
  15. 15. Cardiovascular Changes• Following birth dramatic changes in haemodilution – cardiovascular instability.• Cardiac output elevated for 1-2 hours after birth begins to stabilise after about 10 mins. Decreases until 10th day. Normal by 2 weeks.• Cardiovascular system reverts to normal in 2 - 4 weeks.• Days 2 -5 diuresis dissipates the extra cellular fluid, up to 3 Kgs weight loss7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 15
  16. 16. Coagulation• Profound physiological changes in the blood and dramatic changes in coagulation and haemostatic mechanisms.• Changes protect women from haemorrhage.• Levels remain high for 10 days• DVT/PE – increased risk if trauma, sepsis, immobility 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 16
  17. 17. Blood Volume Changes• Decreases rapidly over 24 hours. Increase in haemconcentration, Hb rises.• By 6-9 weeks returned to normal.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 17
  18. 18. Urinary Tract• 24-48 hours rapid diuresis – decreases plasma volume of blood to non-pregnant levels.• High oestrogen augments effects of ADH - increases blood volume• Larger quantities of nitrogen – autolysis• Trauma to bladder base, oedema7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 18
  19. 19. c• To provide sound family planning information and advice• To care for and monitor the progress of the mother in the postnatal period and to give all necessary advice to the mother on infant care to enable her to ensure the optimum progress of the newborn infant• To examine and care for the newborn infant; to take all initiatives which are necessary in case of need and to carry out immediate resuscitation 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 19
  20. 20. PUERPERAL PYREXIA• A temperature of 38.0°C (100.4°F) or higher, which occurs on any 2 of the first 10 days postpartum, exclusive of the first 24 hours, and which is taken orally by a standard technique at least four times daily. (Joint Committee on Maternal Welfare)• Some common sites of infection causing puerpural pyrexia – Chest – Throat – Breasts – Urinary tract – Pelvic organs – Wounds – caesarean, perineal7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 20
  21. 21. PUERPERAL PYREXIA CAUSE DESCRIPTION Genital tract infection -Tender bulky uterus. -Prolonged bleeding/pink or discoloured lochia. -Painful inflamed perineum. -Most common infective organisms; Escherichia coli, Group A streptococcus spp., Staphylococcus spp. Urinary tract infection -Frequency in micturation, painful micturation, haematuria. -Rigors seen in cases of pyelonephritis -Most common infective organisms; Escherichia coli, Proteus spp. and Klebsiella spp. Mastitis -Painful, hard, red breast abscess -Nipple trauma and cellulitis -Most common infective organism; Staphylococcus spp Postoperative infection -high risk of postpartum septicaemia, wound problems and fever (following Caesarean section) -Usual presentation; Painful, red suture line, tenderness on deep palpation, lochia pink/coloured. Deep venous thrombosis -Caused by venous stasis. -Painful, swollen calf. Others -Viral infection or chest infection.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 21
  22. 22. PUERPERAL PYREXIA • Causative organisms – Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria. – Anaerobic organisms include Bacteroides, Peptostreptococcus, Peptococcus, and Clostridium perfringens.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 22
  23. 23. PUERPERAL PYREXIA • Full examination of chest, breasts, legs, lochia and bimanual vaginal examination should be done. • Majority of infections originate from the urinary or genital tract. • Caused by poor sterile technique, delivery with significant manipulation, caesarean birth, or overgrowth of local flora.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 23
  24. 24. 1) Post partum haemorrhage (PPH)• Primary PPH is defined as bleeding from the genital tract of 600 ml or more in the first 24 hours following delivery. Such bleeding usually occurs very unexpectedly due to retained placental tissue or birth canal trauma.• Secondary PPH - bleeding occurs after the first 24 hours of delivery until the end of the puerperium.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 24
  25. 25. 2) Puerperal sepsis:• It is a fibrile changes occurring during puerperium due to invasion of genital tract by pathogenic bacteria.Sites of infection:• Wound: mainly the placental site and wounds of the perineum, vulva, vagina or cervix. Dead tissue: usually blood clots, and retained placental fragment.Predisposing factors:• General: as anaemia, ante partum hemorrhage, post partum hemorrhage, malnutrition and toxaemia.• Local: as lacerations, sloughing and premature rupture of the membrane.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 25
  26. 26. Signs and Symptoms:• Headache,• Raised temperature,• Vomiting,• Dry tongue and lips.• Abdominal examination revealed a supra pubic tenderness and rigidity. The perineum, vulva, vagina or cervix are become infected and lochia is foul odour.Treatment:• The primary goal of treatment is concerning the causes and its predisposing factors for the infection.• At this time lactation and physiotherapy program should be stopped until fever disappear.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 26
  27. 27. URINARY PROBLEMS• Urinary retention or voiding difficulties may occur postnatally secondary to painful tears involving the bladder or use of epidurals in labour.• Retention occurs usually immediately after delivery and is partially due to the sudden decrease in intra abdominal pressure –there is a decreased stretch reflex response following bladder filling.• Methods that can encourage micturation –early ambulation –pelvic floor exercises –hot baths7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 27
  28. 28. URINARY PROBLEMS  True incontinence occurs rarely but is usually associated with a vesico-vaginal fistula  After surgical repair, the patient is to undergo physiotherapy to strengthen the pelvic floor muscles.7/31/2012 © Reed Group NORMAL AND ABNORMAL PUERPERIUM 28
  29. 29. THROMBOEMBOLISM• Risk of thromboembolism rises 5 fold during pregnancy & puerperium• Majority of deaths occur in the puerperium• The symptoms and signs of venous thromboembolism:– leg pain and swelling (usually unilateral)– lower abdominal pain– low-grade pyrexia– dyspnoea– chest pain– haemoptysis– Calf muscles are tender and painful on firm palpation.• If DVT & pulmonary embolism is suspected – bilateral venogram and/or lung scan should be carried out within 24-48 hrs. – full anti-coagulant therapy (heparin) should be started immediately.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 29
  30. 30. PSYCHIATRIC PROBLEMS• Divided into three conditions based on their severity –”Baby blues” –Postpartum depression –Postpartum psychosis (most severe, may result in suicide/infanticide)• A syndrome seen among fathers is linked to the mood changes of their wives. –May be due to the added responsibility of having a child and decreased attention from the wife.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 30
  31. 31. PSYCHIATRIC PROBLEMS• Management–Postpartum blues: no specific treatment other than support and reassurance from family members and friends.–Postpartum depression: exclude medical causes (eg. thyroid dysfunction), individual/group psychotherapy for mild cases, medication (antidepressants)/ hospitalization/ electroconvulsive therapy for moderate to severe cases.–Postpartum psychosis: Inpatient treatment with medication (mood stabilizers-eg. lithium/valproic acid) and/or electroconvulsive therapy.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 31
  32. 32. CHARACTERISTIC “Baby Blues” Postpartum Depression Postpartum PsychosisIncidence 30%-75% 10%-15% 1%-2%Time of Onset 3-5 days after delivery Within 3 to 6 months after Within 8 weeks after delivery deliveryDuration Days to weeks Months to years (if untreated) Months to years (if untreated)Associated to stressors No Yes, especially lack of support Linked to hormonal changes after deliveryHistory of mood disorder No association Strong association Strong associationFamily history of mood No association Strong association Strong associationdisorderTearfulness Yes Yes YesMood Lability Yes Often present, but sometimes Yes mood is uniformly depressedAnhedonia No Often YesSleep disturbances Sometimes Nearly always AlwaysSuicidal thoughts No Often Almost always in psychosis stageThoughts of harming baby Rarely Often Almost always in psychosis stageFeelings of guilt, inadequacy Absent or mild Often and excessive Often and excessive 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 32
  33. 33. OTHER PROBLEMS • HaemorrhageType Timescale Presentation Predisposing factorsPrimary In the first 24 Fresh bleeding, often severely Uterine atony [90%]haemorrhage hours heavy. Uterus may be soft and Trauma, vaginal or poorly contracted with the cervical fundus still above the lacerations, labial umbilicus tears Coagulation disordersSecondary After 24 hours and May be fresh loss or old, Retained products ofhaemorrhage up to 6 weeks altered blood, often conception malodorous. The Endometritis uterus may feel soft, poorly Dysfunctional contracted and possibly bleeding tender, with the cervical os open 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 33
  34. 34. OTHER PROBLEMS• Bowel problems – Haemorrhoids are a common problem after childbirth, exacerbated by bearing down during the second stage of labour. –Treatment: Local application of 5% lidocaine gel or anusol (hydrocortisone) cream together with bulking agents (eg. Psyllium, fiber) to soften the motions.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 34
  35. 35. OTHER PROBLEMS• Musculoskeletal problems – Painless divarication (spreading apart) of the recti can occur antenatally due to the enlarging uterus that exerts pressure on the recti, causing them to separate. – Treatment involves exercises that increase muscle tone.7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 35
  36. 36. OTHER PROBLEMS • Musculoskeletal problems – In pregnancy the pelvic ligaments become more lax and the symphysis pubis will separate to some extent. This is beneficial as the anterior-posterior diameter is increased. –In extreme situations the hemi-pelvices can be widely separated causing severe pain making walking difficult. –Treatment: Milder cases: Analgesic and orthopaedic belt Severe cases: Zimmer frame and bed rest7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 36
  37. 37. Normal non-pregnant pelvisTotal gap width of up to 9mm is normal Abnormal gap is considered to be ≥10mm. during pregnancy Note misalignment. 7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 37
  38. 38. REFERENCES• Obstetrics by Ten Teachers, 18th edition• Danforth’s Obstetrics and Gynaecology, 10th Edition• Obstetrics and Gynecology An Illustrated Colour Text, 1st Edition• Kaplan and Sadock’s Synopsis of Psychiatry- Behavioral Sciences/Clinical Psychiatry, 10th Edition7/31/2012 NORMAL AND ABNORMAL PUERPERIUM 38