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12.1.Puerperium-1.pptx
- 1. Dr Alazar W. THEPUERPERIUM Normal & Abnormal 10/01/2017 1 The Puerperium - Normal and Abnormal
- 2. Normal Defn: aperiod of time starting from immediately after delivery up to 6 weeks postpartum. : Anatomical and physiological changes of pregnancy returns back to pre-pregnant state 1/27/2024 2 The Puerperium - Normal and Abnormal
- 3. Anatomic changes Pelvicorgans: UTERUS :- Involution Body: Immediately after delivery - Just below the umbilicus - Weigh 1kg - Highly vascular After 2 days –starts to shrink,1 finger/d At the 10th day not palpable per abd. In 2 weeks –in the pelvis, 300 gm. In 4 weeks –pre-pregnant size End of puerperium-100gm 1/27/2024 3 The Puerperium - Normal and Abnormal
- 4. Cervix:- open forfew days gradually closes - lacerations heals Endometrium:- regeneration from decidua basalis starts in 2-3 days Vagina:- gradually shortens, rugae reappears Pelvic muscles, ligaments and fascia: progressively gains strength 1/27/2024 4 The Puerperium - Normal and Abnormal
- 5. Lochia :-decidua, RBC, epithelial cells & bacteria. :-persists up to 3 weeks :- Normally shouldn’t have offensive odor Three types:- Rubra-red for 1-4days Serosa- watery for 5-9days Alba -white, thick after 10 - 15 days 1/27/2024 5 The Puerperium - Normal and Abnormal
- 6. OTHER ORGANS Breast :-colostrum – 1st 2 days, high in Immunolglobulins :- milk Lungs:-returns to normal position Glands:- pitutary- after the first week postpartum the pituitary gland returns rapidly to its normal size in both lactating and nonlactating women. thyroid – shrinks after delivery Urinary: -Kidney, ureters:-Dilated ureters and renal pelvis returns to normal with in 8 wks 1/27/2024 6 The Puerperium - Normal and Abnormal
- 7. PHYSIOLOGICAL CHANGES CVS: - Heartaxis returns to prepregnant state - plasma volume- ↓, non pregnant vol by 2 wks - HR-↑for few hrs after delivery then settles down to normal in the 2nd day -BP- Maintained normal Hematology:-Hct returns to normal by the end of the first week as hemodilution disapears :-WBC - leukocytosis which occur in labor, upto 30,000/ml :-Platelets & coagulation factors 1/27/2024 7 The Puerperium - Normal and Abnormal
- 8. Weight loss :-Conceptus :-fluid loss :- involution At the end of purperiem nearly pre pregnant weight attained. 1/27/2024 8 The Puerperium - Normal and Abnormal
- 9. Ovulation and menstruation 1/27/2024 ThePuerperium - Normal and Abnormal 9 Ovulation occurs as early as 27 days after delivery, with a mean time of 70–75 days in nonlactating women and 6 months in lactating women Menstruation returns as soon as 7 weeks in 70% and by 12 weeks in all nonlactating mothers, and as late as 36 months in 70% of breastfeeding mothers
- 10. ABNORMAL PUERPERIUM Anydeviation from the normal course of puerperium Could be either anatomic or physiologic or both May involve either pelvic organs or other organs or both 1/27/2024 10 The Puerperium - Normal and Abnormal
- 11. Uterine subinvolution: Causes: 1-RPC:-Placenta tissue or membrane Sign & Symptoms - Uterine sub involution - Late PPH - Open cervix - Sn/Sx of endo myometritis 2-Puerperal infections:- -tender uterus -offensive lochia -s/s of bacterial infection 1/27/2024 11 The Puerperium - Normal and Abnormal
- 12. INFECTIONS DURING PUERPERIUM Puerperalfebrile morbidity:- Defn:-Oral Temp.> 38 oC, at least 2 times (at least 24hrs apart) in the 1st 10 days postpartum excluding the 1st 24hrs. Causes:- Purperal sepsis(Genital tract infection) Infection of CS wound Mastitis Pulumunary infection, atelectasis UTI DVT 1/27/2024 12 The Puerperium - Normal and Abnormal
- 13. I.Puerperal infection: puerperalsepsis - is a general term used to describe any bacterial infection of genital tract after delivery - is one of lethal triads along with obstetric hemorrhage and hypertension Uterine infections:- endometritis, - myometritis, - parametritis or - combination Infection starts at placenta implantation site, then progresses to myometrium & parametrium. Loss of protective mechanisms – open cx, absent cx mucus, raw endometrium – leads to colonization by vaginal 1/27/2024 13 The Puerperium - Normal and Abnormal
- 14. Puerperal infection: puerperalsepsis… Risk factors (predisposing factors) :- 1 Rout of delivery:-most important risk factor C/S > Vaginal delivery 2 Duration of labor:-prolonged 3 Prolonged PROM:->24hr 4 Chorioamnionitis 5 Repeated PV 6 Use of internal fetal monitor & pressure catheter 7 Low socio economic status, malnutrition, anemia 8 Coitus near delivery, vaginal colonization - bacterial vaginosis, C.trachomatis etc. 1/27/2024 14 The Puerperium - Normal and Abnormal
- 15. Puerperal infection: puerperalsepsis… Microbiology:- Polymicrobial - Aerobs, anaerobs; Gm-ve, Gm+ve - Normal vaginal flora Clinical Sn/Sx:- Fever, High PR, Offensive lochia Sub involuted, tender uterus Open Cx, Offensive discharge If pelvic peritonitis:- the above s/s + direct and rebound tenderness of lower abdomen & pouch of douglas If pelvic abscess :- pelvic mass, bulged pouch :-diarrhea 1/27/2024 15 The Puerperium - Normal and Abnormal
- 16. Puerperal infection: puerperalsepsis… Investigations:- CBC - B/F - U/A - Ultra sound for RPC 1/27/2024 16 The Puerperium - Normal and Abnormal
- 17. Management 1 Mild casesafter vaginal delivery:- If there is no RPC:- Out patient with oral combination of antibiotics. 2 Moderate to severe cases and those after C/S with out RPC or pelvic abscess :- Admit to the wards I V Fluids I V antibiotics :-combination :-Clindamycin & Gentamycin - best but expensive :-other combinations:- Amp., CAF (or metronidazol), Genta :- Cephalosporins & metronidazol Follow response with: T, PR Q 4 hrs 1/27/2024 17 The Puerperium - Normal and Abnormal Puerperal infection: puerperal sepsis…
- 18. Management…. 1/27/2024 The Puerperium -Normal and Abnormal 18 Response Usu. resolves in 48-72 hrs If no response in 48-72 hrs suspect :- RPC :- parametrial cellulits or parametrial phlegmon :- pelvic abscess, wound abscess :- resistant strains- rare
- 19. If thereis RPC:-E & C with postpartum curret (blunt) or MVA under umbrella of oxytocin after IV antibiotics at least for an hour. If pelvic abscess: surgical drainage, laparatomy or posterior colpotomy (if localized, central & dissecting recto-vaginal septum) 1/27/2024 19 The Puerperium - Normal and Abnormal
- 20. II. C/S woundinfection: 3-15% of C/S Risk factors: -Chorioamnionitis, obesity, DM, low socio eco. status, low immunity, anemia, steroids, poor surgical technique Prevention:-prophylactic antibiotics. - delayed primary or 2nd closure Management:-wound care :-antibiotics :-2nd closure 1/27/2024 20 The Puerperium - Normal and Abnormal
- 21. Complete wound dehiscence Fascia separated; abdominal organs eviscerates High mortality Causes :-intra abd.infection, high intra abd pressure( ex coughing, etc) type of incision, technique of closure, suture materials used Mgt:- surgical Episiotomy wound infection - rare b/c of good perineal blood supply - Mgt is wound care( sitz bath) and 2nd closure sitz bath- a bath in which the hips and buttocks are immersed in hot water for the therapeutic effect of moist heat in the perineal and anal regions 1/27/2024 21 The Puerperium - Normal and Abnormal
- 22. III. Mastitis &breast engorgement: Engorgement:-Causes, clinical features, treatement. Mastitis:- Etiology, clinical findings, Dx and treatement IV. Respiratory infections:- a. atelectasis: b. aspiration pneumonia:- c. bacterial pneumonia:- 1/27/2024 22 The Puerperium - Normal and Abnormal
- 23. V. Urinary tractinfections:- - affects 1-5 % of all deliveries - stasis of urine during early purperium contributes to it - Commen organisms- E.coli, Proteius and S. Aureus Upper UTI:- Lower UTI:- VII. Septic pelvic thrombophlebitis:- Predisposing factors:- Prolonged labor, immobilization, operative delivery( esp. C/S), hematologic causes, etc Clinical S/S:-Engimatic fever 1/27/2024 23 The Puerperium - Normal and Abnormal
- 24. Postpartum Psychiatric Disorders (PPD) Maternityblue This is a mood disturbance experienced by approximately 50-80% of women within 3 to 6 days after parturition . There is evidence that blues are precipitated by progesterone withdrawal(Not proven) Might be adjustment disorder Core feature include insomnia, weepiness, poor concentration. irritability and rapid mood changes. 27-Jan-24 24 Dilayehu B.
- 25. Importantly symptomsare mild and usually only last b/n a few hrs to a few days. Supportive treatment indicated and mother can be reassured that the dysphoria is transient and most likely due to biochemical changes. They should be monitored for development of more severe psychiatric disturbances including postpartum depression and psychosis Maternity blue… 27-Jan-24 25 Dilayehu B.
- 26. Postpartum Depression… Innearly all respects postpartum depression is similar to other major and minor depression that develop at any time Typically depression is considered postpartum if it begins with in 3-6 month after child birth Affects 10 -20 % of mothers 27-Jan-24 26 Dilayehu B.
- 27. Postpartum Depression… 27-Jan-24 Dilayehu B. 27 Criteria 1.Depressedmood most of the day 2.Markedly diminished interest or pleasure in all or almost all activities most of the day. 3.Significant weight loss or weight gain when not dieting or decrease or increase in appetite. 4.Insomnia or hypersomnia 5. Psychomotor agitation retardation 6. Fatigue or loss of energy 7. Feeling or loss of energy. 8. Diminished ability to think or concentrate 9. Recurrent thoughts of death recurrent suicidal ideation without a specific plan or a suicidal attempt.
- 28. Postpartum Depression… Atleast five of the symptoms for 2 week period ,one symptom must be either depressed mood or loss of interest or pleasure nearly everyday In severe case may be accompanied by psychosis bizarre or paranoid thought. 27-Jan-24 28 Dilayehu B.
- 29. Postpartum Depression… Course andTreatment Usually begins in the 2nd to 3rd wks The natural course is one of gradual improvement over the 6 months after delivery The prospect for full recovery are generally good. 27-Jan-24 29 Dilayehu B.
- 30. Supportive treatment aloneis not sufficient for major postpartum depression. Pharmacological intervention is needed in most instances and affected women should be managed in conjunction with psychiatrist Treatment option include. Antidepressant ( f.e.g.- Fluxothene) Anxiolytic agents (Not recommended in breast feeding) Electro convulsive therapy. Postpartum Depression… 27-Jan-24 30 Dilayehu B.
- 31. Postpartum psychosis Thisis the most worrisome and severe puerperal mental disorder. It is estimated to occur in 1 to 4 of 1000 births.(0.1%) Women with postpartum psychosis lose touch with reality Frequently noted symptoms are confusion, disorientation , delusion and halucination Women with preexisting psychotic illness are at highest risk with bipolar disorder and schizoafective disorder being the most strongly associated. 27-Jan-24 31 Dilayehu B.
- 32. Postpartum psychosis… 27-Jan-24 Dilayehu B. 32 Other risk factors are biologically related and include Younger age ,Prim parity ,Family history & Psychiatric illness. The peak onset of psychotic symptoms is 10- 14 days after parturition but the risk remain high for months after delivery The women who is psychotic usually will have difficulty in caring for her infants and may have delusions leading to thoughts of self harm or harm of infant.
- 33. Postpartum psychosis… Course andTreatment The course is variable depend up on the type of underlying illness Patients should be hospitalized (Decreases the chance of suicide/Infanticide) The earlier the initiation of treatment, the better the prognosis Often small doses(2-5mg) of antipsychotics such as haloperidol improves the symptoms 27-Jan-24 33 Dilayehu B.
- 34. Other Purperal abnormities CVS:-post partum pre-eclampsia - peripartum cardiomyopathy - hypotension 2nd to blood loss - CHF sec. to existing cardiac disease Hematologic:- anemia - coagulopathy - DVT - Pelvic vein thrombosis - PTE Urinary:- Renal failure- as a complication of APH or PPH. :- Obstetric fistulas 1/27/2024 34 The Puerperium - Normal and Abnormal
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