It is ridiculous to hear that man from Peru complaining about America’s poverty. Peru has twice as much poverty

1. Post partal sepsis
By: Andualem Gezahegn (MSc)
Lecturer, SLU
May-2022

2. Puerperal sepsis
 Infection of the genital tract that occurs at any time between the rupture
of membrane in labor and 6 weeks following delivery.
 In which two or more of the following are present:
 Pelvic pain
 Temperature of 38.5 0C or more in any one occasion
 Abnormal vaginal discharge
 Delay in involution of uterus(<2cm/day)
Abnormal odor of the discharge

3. Etiology
Endogenous bacteria
It is usually an ascending infection by the normal polymicrobial flora of the
vagina and the gastrointestinal tract.
Exogenous bacteria
The most frequently identified organisms are :
Group B Streptococcus.

4. Mycoplasma species.
*Gram +ve
-beta-hemolytic streptococcus group A,B,D
-staphylococcus aureus.
-staphylococcus faecalis.
*Gram –ve
-Hemophilus influenza.
-gardenella vaginalis.
*Anaerobes
-Bactroides fragilis.
* Chlamydia trachomatis

5. Risk factors
Route of delivery risk is 5-8 times higher in cesarean delivery than
vaginal delivery
Prolonged rupture of membranes of >12 hours
Prolonged labor of 12 hours
Multiple pelvic examinations
Manual removal of the placenta
Retained products of conception & blood clots

6. Diagnosis
Fever, rigors, malaise, headache
Abdominal discomfort
Offensive or foul-smelling lochia
Pyrexia and tachycardia
Uterus is large and tender
Infected wounds as CS or perineal lacerations
Laboratory investigations

7. Types of puerperal sepsis
Endometritis
 Infection of endometrium.
 Commonest form of puerperal sepsis
 Give a combination of antibiotics until the woman is fever-free for 48 hours
• Ampicillin 2 g IV every 6 hours;
• PLUS gentamicin 5 mg/kg body weight IV every 24 hours;
• PLUS metronidazole 500 mg IV every 8 hours

8. Prevention
Aseptic technique
Avoid traumatic delivery
Avoid repeated pelvic examinations
Prevent prolonged labor by using partograph.
Prophylactic antibiotics especially in emergency CS.
Proper 3rd stage management of labor.

9. Wound infections
 Episiotomy site infections
 Infections of lower genital tract tears
 C/S infections

10. Management
Prior to attempting early repair of surgical site dehiscence, the
surgical wound must be properly cleaned and free of infection.
Removal of sutures and drain abscess
Postoperative care includes provision of local wound care, and
nothing per vagina until healed.

11. Breast engorgement:
is the medical term to occur when the breasts get too full of milk.
It can make the breast feel full and firm and can cause pain and
tenderness.
It may occur due to:
Excessive production of milk,
Obstruction to outflow of milk or
Poor sucking of milk by the baby.
It usually starts after the milk secretion
Breast complications

12. Symptoms:
Both breast feels tender, tense and firm.
Nipples become edematous and flushed.
The veins over the breasts become engorged and prominent.
Generalized malaise and Rise of temperature by up to 0.5 degree
centigrade.
Painful breast feeding.

13. Preventive measures
 Initiate breast feeding early and feeding at regular intervals.
 Exclusive breast feeding on demand.
 Feeding in correct position.
Management
 Support the breast with binder or brassiere.
 Manual expression of remaining milk.
 Keeping the intervals short between the feeds
 The cause of poor suckling is corrected.
 Analgesics for pain.

14. Binder or brassiere

15. Cracked nipples:
 The nipple may become painful due to:
Loss of surface epithelium with the formation of raw area on the
nipple or
A fissure situated at the tip or base of the nipple.
 These two conditions often co-exists , which are referred to as the
cracked nipple.

16. Causes
 Inadequate hygiene
 Retracted nipple.
 Vigorous sucking and an inadequate milk flow.
Symptoms
 Soreness and pain at the site of the fissure
 Fissure may infected, it spreads to the deeper tissues producing mastitis.

17. Prevention
 Local cleanliness during pregnancy and puerperium before and after each
feeding.
Treatment
 Application of Tincture Benzoin after the night feeding.
 Nipples is to be kept dry and exposed to air.
 Manual expression of milk.
 If infected, Antiseptic cream is applied locally.
 If it fails to heal , breast feeding from the affected breast is stopped for 24
hrs.

18. Mastitis:
 Is the inflammation of breast tissue.
 S. aureus is the most common etiological organism.

19. Clinical features:
Breast tenderness or warmth to the touch
General malaise or feeling ill
Swelling of the breast
Pain or a burning sensation
Skin redness, flushed skin and feel tense & tender
If not treated, lead to breast abscess.

20. Treatment
Prophylactic:
Prevention of engorgement and isolation of the infected baby.
Curative:
Isolation of mother and baby
Suspension of breast feeding on the affected side until it is
controlled.
The affected breast is supported with breast binder.
Antibiotics and anti pain

21. Breast abscess
It is a painful infection.
It is a hollow space in the breast that becomes filled with pus from
the infected milk ducts in the presence of severe mastitis

22. Common symptoms of breast abscess:
Breast engorgement.
Breast pain.
Itching.
Nipple discharge.
Nipple tenderness.
Swelling, warmth & redness of the breast tissue.
Tender or enlarged lymph nodes.

23. Serious symptoms
 Confusion or loss of consciousness
 Difficulty breathing or rapid breathing.
 High fever
Risk factors:
 Not staying on a consistent feeding schedule.
 Pressure on the milk ducts from a too-tight brassiere.
 Stress and exhaustion.
 Weaning the baby too quickly

24. Treatment:
 Medical management
Investigations like WBC and sample of milk.
Broad spectrum antibiotics (like Cephalosporins, Erythromycin,
Penicillins)

25. Surgical management:
Incision and drainage :

26. Postpartum psychiatric disorders
During the postpartum period, up to 85% of women suffer from some
type of mood disturbance. For most women, symptoms are transient
and relatively mild (I e, postpartum blues).
However, 10-15% of women experience a more disabling and
persistent form of mood disturbance (e g, postpartum depression,
postpartum psychosis).

27. Postpartum psychiatric illness was initially conceptualized as a
group of disorders specifically linked to pregnancy and childbirth.
Thus was considered diagnostically distinct from other types of
psychiatric illness.

28. Risk factors
 Unintended pregnancy
 Feeling unloved by mate
 Unmarried
 Low self-esteem
 Dissatisfaction with extent of education
 Economic problems
 Limited parental support
 Past or present evidence of emotional problems

29. Types
 Postpartum Blues:
 Up to 85% of women experience postpartum affective instability.
 Rapidly fluctuating mood, tearfulness, irritability, and anxiety are
common symptoms.
 Transient disorder(lasting only for a short time),
 Lasts hours to weeks

30.  Characterized by:
o Bouts of crying and sadness
o self-limiting
o Commonly in the first 2 weeks
 Symptoms do not interfere with a mother's ability to function and
to care for her child.

31. Treatment of Postpartum Blues
 Often resolves by postpartum day 10
 No pharmacotherapy is indicated
 Provide support and education

32. Postpartum depression
 Postpartum depression is more persistent and debilitating than
postpartum blues.
 Signs and symptoms are clinically indistinguishable from major
depression that occurs in women at other times.
 Is more severe and longer-lasting than the blues.

33. Signs and symptoms
 Insomnia
 Lethargy(a lack of energy and enthusiasm (intense enjoyment, interest, or
approval)
 Anxiety
 Loss of libido (sexual desire)
 Suicidal thoughts
 Diminished appetite
 Pessimism (lack of hope or confidence in the future)

34. Treatment
Non pharmacological treatment strategies are useful for women
with mild-to-moderate depressive symptoms.
Psycho educational groups may be helpful.
Pharmacological strategies are indicated for moderate-to-severe
depressive symptoms or when a woman fails to respond to Non
pharmacological treatment.

35. Selective serotonin reuptake inhibitors (SSRIs) are first-line
agents and are effective in women with postpartum depression.
Use standard antidepressant dosages, eg, fluoxetine 10-60 mg/d,
sertraline 50-200 mg/d, paroxetine 20-60 mg/d, or citalopram 20-
60 mg/d.

36.  Postpartum Psychosis
 Psychosis is a general term used to describe a mind in which the
patient is out of touch with reality.
 Postpartum psychosis is the most severe form of postpartum
psychiatric illness
 In most women, symptoms develop within the first 2 postpartum
weeks.

37.  The condition resembles a rapidly evolving manic episode with
symptoms such as:
- restlessness and insomnia
- irritability
- rapidly shifting depressed or elated mood and
- disorganized behavior.

38.  The mother may have delusional beliefs that relate to the infant (e.g.
she may have auditory hallucinations that instruct her to harm
herself or her infant.
 Risks for infanticide and suicide are high among women with this
disorder.

39. Pathophysiology
Hormonal factors
-Levels of estrogen and progesterone fall dramatically within 48
hours after delivery.
Psychosocial factors
–Women who report inadequate social supports, marital discord
or dissatisfaction, or recent negative life events are more likely
to experience postpartum depression.

40. Biologic vulnerability
–Women with prior history of depression or family history of a
mood disorder are at increased risk for postpartum depression.
–Women with a prior history of postpartum depression or
psychosis have up to 90% risk of recurrence.

41. Management
Puerperal psychosis is a psychiatric emergency that typically
requires inpatient treatment.
Psychotherapy, antipsychotic treatment and isolation of the
neonate from the mother.

42. Thromboembolism
The condition in which a blood clot (thrombus), formed at one
point in the circulation, becomes detached and lodges at another
point.
 The risk of Thromboembolism in otherwise healthy women is
considered highest during pregnancy and the puerperium.
The 2 manifestations of venous thromboembolism (VTE) are deep
venous thrombosis (DVT) and pulmonary embolus (PE).

43. Although most reports suggest that VTE can occur at any trimester
in pregnancy.
Signs and symptoms
The signs and symptoms of VTE are nonspecific and common in
pregnancy.
Diagnosis of VTE by physical examination is frequently
inaccurate,
Even though 80% of pregnant women with DVT experience pain
and swelling of the lower extremity.

44. Clinical signs and symptoms of PE are rarely encountered together;
 The classic symptoms are as follows:
 Dyspnea
Abrupt onset of chest pain
Cough
The most common presenting signs of PE are as follows:
 Tachypnea
Crackles
Tachycardia

45. Patients with massive PE may present with the following:
 Syncope
Hypotension
Pulseless cardiac electrical activity
Death

46. Diagnosis
Imaging studies:
 Imaging for DVT is the best means of screening and evaluation for these
conditions.
 The current initial test of choice in the evaluation of VTE is compression
ultrasonography (CUS) of the lower extremity veins.
 Imaging studies used in the diagnosis of PE include the following:
Chest radiography: Recommended prior to the evaluation for PE to
determine whether other etiologies may explain the patient’s symptoms
(eg, pneumonia, atelectasis) and to identify the next appropriate imaging
test.

47. Management
Once the diagnosis of VTE is made, therapeutic anticoagulation
should be initiated in the absence of contraindications.
The common classes of anticoagulation drugs are as follows:
Indirect thrombin inhibitors: heparin and low molecular-weight
heparin (LMWH),
Direct thrombin inhibitors: Include argatroban, lepirudin, and
bivalirudin
Vitamin K antagonist: Warfarin is included in this class

48. ……..ends!