12.1.Puerperium-1.pptx

Dr Alazar W.
THE PUERPERIUM
Normal & Abnormal
10/01/2017
1 The Puerperium - Normal and Abnormal

Normal
 Defn: a period 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

Anatomic changes
 Pelvic organs:
 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

Cervix:- open for few 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

 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

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

PHYSIOLOGICAL CHANGES
CVS:
- Heart axis 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

Weight loss :-Conceptus
:- fluid loss
:- involution
At the end of purperiem nearly pre pregnant weight
attained.
1/27/2024

Ovulation and menstruation
1/27/2024
The Puerperium - 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

ABNORMAL PUERPERIUM
 Any deviation 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

 Uterine sub involution:
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

INFECTIONS DURING
PUERPERIUM
 Puerperal febrile 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

I.Puerperal infection: puerperal sepsis
- 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

Puerperal infection: puerperal sepsis…
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

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

Investigations:- CBC
- B/F
- U/A
- Ultra sound for RPC
1/27/2024

Management
1 Mild cases after 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

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

 If there is 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

II. C/S wound infection:
 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

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

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

V. Urinary tract infections:-
- 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

Postpartum Psychiatric Disorders
(PPD)
Maternity blue
 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.

 Importantly symptoms are 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.

Postpartum Depression…
 In nearly 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-Jan-24
Dilayehu B.
27
Criteria
1.Depressed mood 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.

 At least 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.

Course and Treatment
 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.

Supportive treatment alone is 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.
27-Jan-24
30 Dilayehu B.

Postpartum psychosis
 This is 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.

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.

Postpartum psychosis…
Course and Treatment
 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.

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

12.1.Puerperium-1.pptx

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