Abnormal puerperium


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Abnormal puerperium

  1. 1. Continued……. Abnormal puerperium Dilip Kumar H.R. VIII Term
  2. 2. • Puerperal venous thrombosis • Pulmonary embolism • Obstetric palsies • Psychiatric disorder during puerperium • Psychological response to perinatal death. 2
  3. 3. Puerperal Thrombosis
  4. 4. Puerperal Thrombosis Leg vein & pelvic vein is one of the complication in western countries.  However the prevalence is low in Asians & Africans. Etiopathogenesis In normal pregnancy there is rise in concentration of coagulation factors 1, 2, 7, 8, 9, 10, 12. plasma fibrinolytic inhibitors produced by placenta. Alteration in blood constituents- increased number of platelet & their adhesiveness.
  5. 5. Venous stasis is increased due to compression of gravid uterus to IVC & iliac veins. This stasis cause damage to endothelial cells. Thrombophilias are the genetic condition associated with deficiencies of antithrombin3 protein C . Acquired thrombophilias are due to presence lups anticoagulant & antiphospholipids antibodies.
  6. 6. Risk factors: Advanced age & parity Operative delivery Obesity Anemia & heart disease. Trauma to venous vessel wall. Infections DVT. C/F: Asymptomatic,pain in calf muscle, edema of leg, rise skin temperature. Homan’s sign.
  7. 7. Investigations: Doppler ultrasound. Duplex Doppler ultrasound. Venography. Pelvic Thrombophlibits.  C/F:usually develop after 2nd weeks of puerperium.  Fever with chills & rigors. Feature of toxemia i.e. headache, malaise & rising pulse. Affected leg is painful, swollen & cold. Polymorph nuclear leucocytosis.
  8. 8. Prophylaxis for VTEPreventive measures.  low & high risk woman. Management  bed rest & foot is raised.  Analgesics, Abs  Anticoagulants  Gentle movements of the leg after relief of pain.  Vena caval fillers  Fibrinolytic agents  Venous thrombectomy.
  9. 9. Pulmonary Embolism. ..............
  10. 10. 10 Pulmonary Embolism. It is leading cause of maternal death. Because of decline of maternal mortality due to hemorrhage, hypertension & sepsis. Death occurs with in short time from shock & vagal inhibition.
  11. 11. Clinical feature Sudden collapse, acute chest pain & air hunger these are classical symptoms of massive pulmonary embolism. Tachyponea,dysponea,pleuritic chest pain, cough , tachycardia, haemoptysis & rise in temperature > 37 degree Celsius 11
  12. 12. Diagnosis X-ray of the chest shows decreased vascular marking in area of infraction, elevation of dome of diaphragm & often pleural effusion. It is useful to rule out pnemonia,atelactasis. ECG:tachycardia.  Doppler ultrasound : ? DVT. 12
  13. 13. Lung scan : ? Area of diminished blood flow.Diminised in perfusion with maintenance ventilation indicate PE. MRI: risk of radiation is absent. Pulmonary angiography: most accurate method of diagnosis. 13
  14. 14. Treatment Resuscitation I.V.fluid support Thrombolytic therapy Digitalis Recurrent attack require embolectomy. 14
  15. 15. ……………….. Obstetric palsies
  16. 16. 1 Obstetric palsies • The commonest form of palsy encountered in puerperium is FOOT DROP. • It is usually unilateral & appears shortly after the delivery. Etiology • Streching of the lumbo-sacral trunk by prolapsed inter vertebral disc b/w L5&s1.
  17. 17. • Backward rotation of the sacrum during labour • Direct pressure by fetal head or by forceps blade on lumbosacral cord. Clinical feature. 1.Asymptomatic. 2.Flacidity & wasting of muscle. 3.Loss sensation. 2
  18. 18. • Management • Bed rest for 6 wks. • A splint is applied to prevent damage of over stretch muscle. • Massage & electric stimulation of the muscle.
  19. 19. Psychiatric disorder during Puerperium
  20. 20. 20  1st 3 month after delivery the incidence of mental illness is high.  Overall incidence is 15-20% Risk factors:  Past H/O: mental illness, puerperal psychiatric illness.  Family H/O: psychiatric illness, marital conflict.  Present pregnancy: Caesarean section, difficult labour, neonatal complication.  Idiopathic.
  21. 21. Puerperal BLUES  It is transient state of mental illness observed 4-5 days after delivery & it last for few days.  50% of the postpartum women suffer from problem.  Clinical manifestation:  Depression, anxiety, tearfulness, insomnia, helplessness & negative feelings towards infant.  No specific metabolic or endocrine abnormalities have been detected. But lowered tryptophan level is observed.  It suggest altered neurotransmitter function.  Treatment reassurance & psychological support by the family.
  22. 22. Postpartum DEPRESSION It is seen 10-20% of mothers. It is more gradual onset, occurs 1st 4-6 months after delivery or abortion. Changes in HypoThalamopitutaryarenal axis may the cause. Manifested by loss appetite, insomnia, social withdrawal, irritability & even suicidal tendency. Risk of recurrence is high (50-100%) in subsequent pregnancy .
  23. 23. Treatment Fluoxetin or paroxetine. General support is essential. Overall prognosis is good.
  24. 24. SCHIZOPHRENIA About 1in 500-1000 mothers.  Seen in woman with past H/O psychosis or with positive family H/o.  Relatively sudden in onset with in 4 days after delivery.  Manifestation:  Fear, restless, confusion followed by hallucination, delusion and disorientation.  Suicidal, infanticidal impulse may be present.  Risk of recurrence in subsequent pregnancy is 20-20%.
  25. 25. Treatment Psychiatrist consulted urgently. Admission needed. Chlorpromazine 150mg stat & 50-150mg thrice daily. ECT: needed if unresponsive case. Lithium is indicated in manic depressive psychosis & breast feeding contraindicated.
  26. 26. Psychological response to perinatal death.
  27. 27. Psychological response to perinatal death. Most perinatal events are joyful. But when perinatal death occurs special attention must given to grieving patient & her family. Perinatal grieving may also be due to unexpected hysterectomy, birth malformed, critically ill infant. Obstetrician, nurse & attending staff must understand the patient reaction.
  28. 28. Management. Facilitating the grieving process, support & sympathy. Supporting the couple in holding or taking photograph of the infant . Requesting for autopsy . Follow up visits & plan for subsequent pregnancy.