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ABNORMAL PUERPERIUM PRESENTATION. 6 weeks
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- 2. ABNORMALITIES OF THEPUERPERIUM • Puerperal Pyrexia. • Puerperal Sepsis. • Subinvolution. • Urinary complications: UTI, Urinary Retention, Urinary Incontinence, Urinary Suppression • Breast Complications: Breast Engorgement, Cracked & Retracted Nipples, Acute Mastitis • Puerperal Venous Thrombosis & pulmonary embolism. • Puerperal emergencies, obstetric palsies, Psychiatric disorders during puerperium.
- 3. PUERPERAL PYREXIA • “A rise of temperature reaching 100.4 degree F or more (Measured orally) on two separate occasions 24 hours apart (excluding first 24 hours) within the first 10 days following delivery is called Puerperal pyrexia” • In some countries postabortal fever is also included.
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- 5. PUERPERAL SEPSIS • “Aninfection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis.” • Puerperal pyrexia is considered to be due to genital tract infection unless proved otherwise.
- 6. INCEDENCE • There isa marked decline in puerperal sepsis during the past few years due to:- • Improved obstetric care • Availability of wider range of antibiotics
- 7. CAUSES:- Combination of all iscalled Pelvic Cellulitis
- 8. PREDISPOSING FACTORS • Damageof Cervicovaginal mucous membrane • Large placental wound surface area • Blood clots presents at placental site ANTEPARTUM FACTORS: • Malnutrition and anaemia • Preterm labour • PROM • Chronic illness • Prolonged rupture of membrane >18 hours
- 9. INTRAPARTUM FACTORS: • Repeatedvaginal examinations • Prolonged rupture of membranes • Dehydration and keto- acidosis during labour • Traumatic operative delivery • Haemorrhage • Retained bits of placenta or membranes • Placenta previa • Caesarean Section delivery
- 10. MICRO-ORGANISMS RESPONSIBLE FOR PUERPERLSEPSIS •AEROBIC:- •Streptococcus hemolytic group- A •Streptococcus hemolytic group - B •Others: Streptococcus pyogenus, aureus, E coli, Pseudomonas, chlamydia •ANAEROBIC:- •Streptococcus, peptococcus, bacteriodes
- 11. MODE OF INFECTION •Puerperal sepsis is essentially a wound infection • Placental site, lacerations of the genital tract or cesarean section wounds • It may get infected by ENDOGENOUS or EXOGENOUS organisms.
- 12.
- 13. 1. LOCAL INFECTION •Slight temperature rise • Generalized malaise • Headache • Redness and swelling to local wound • Pus formation
- 14. 2. UTERINE INFECTION MILD:- •Rise in temperature and pulse rate • Offensive and copious lochial discharge • Subinvoluted and tender uterus • SEVERE:- • Acute onset with high grade temperature with chills and rigor • Rapid pulse rate • Scanty and orderless lochia
- 15. 3. SPREADING INFECTION •Parametritis • Pelvic pritonitis • General peritonitis • Thrombophlebit is • Septicemia
- 16. INVESTIGATION History, Clinical examination Highvaginal endocervical swab Blood examination Pelvic ultrasound CT scan, MRI
- 17. PROPHYLAXIS ANTENATAL: • Improvement ofnutritional status • Eradication of any septic status • INTRANATAL: • Full surgical asepsis during labour • Prophylactic antibiotics: Cefriaxone 1g IV immediate after cord clamping and second dose: after 8 hour is recommended
- 18. POSTNATAL: • Aseptic precautionsatleast one week following delivery • Too many visitors are restricted • Sterilized senitory pads are to be used • Infected babies and mothers should be in isolated room
- 19. GENERAL CARE:- • Isolationof the patient. • Adequate fluid and calorie (IV). • Corrected anaemia. • Progress chart should be maintained. TREATMENT
- 20. ANTIBIOTICS • Gentamicin, 2mg/kg IV loading dose followed by 1.5 mg/kg IV every 8 hours • Ampicillin, 1g IV every 6 hours • Clindamycin 900 mg, IV every 8 hours • Cefotaxime 1 g, 8 hourly IV is an alternative • Metronidazole 0.5 g IV, 8 hourly
- 21. PERINEAL WOUND:- • Stichesof perineal wound may have to be removed to facilitate drainage of pus and relieve pain. • Wound has to be cleaned with sitz bath several times per day and dressed with antiseptic ointment or powder. • After the infection is controlled, secondary wound closure may be done on later date. SURGICAL TREATMENT
- 22. RETAINED UTERINE PRODUCTS:- •With diameter of 3 cm or less may be disregarded or left alone • Other wise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid risk of septicemia • SEPTIC THROMBOPHLEBITIS:- • IV Heparin for 7-10 days
- 23. PELVIC ABCESS:- • Drainageby colpotomy under ultrasound guidance WOUND DEHISCENCE: • Dehiscence of episiotomy or abdominal wound following caesarean section:- • Scrubbing the wound • Debridement of all necrotic tissues • Secondary suture
- 24. • LAPAROTOMY: • Hasgot limited indications • IV fluids and antibiotics usually controls the peritonitis • When the peritonitis is unresponsible to antibiotics laprotomy is indicated • HYSTERECTOMY: • In case of uterine rupture or perforation • Multiple abcess, gangrenous uterus • Ruptured tubo-ovarian abcess
- 25. NECROTYSING FASCITIS: • Woundscrubbing • Debridement of all necrotic tissues • Use of effective antimicrobial agents • BACTEREMIC OR SEPTIC SHOCK: • Fluid and electrolyte balance • Respiratory supports • Circulatory support (dopamine/ dobutamine) • Infection control
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- 27. DEFINITION • “When theinvolution is impaired or retarded it is called subinvolution” • The uterus is the most common organ
- 28. CAUSES PREDISPOSING FACTORS: • Grandmultipara • Over distention of uterus • Maternal ill health • Caesarean section • Prolapse of the uterus • Retroversion • Uterine fibroid
- 29. CAUSES AGGRAVATING FACTORS:- • Retainedproducts of conception • Uterine sepsis (Endometritis)
- 30. SYMPTOMS • May beasymptomatic sometimes • Abnormal lochial discharge : excessive or prolonged • Irregular at times excessive uterine bleeding • Irregular cramp like pain • Rise of temperature in case of sepsis
- 31. SIGNS Fundal height Greater than Postnatal Day Uterus feels Boggyand Softer Displaced Bladder or Loaded Rectum
- 32. MANAGEMENT • Antibiotics incase of infection • Exploration of uterus for retained products • Pessary in prolapse or retroversion • Methergine to enhance involution process
- 33.
- 34. URINARY TRACT INFECTION •Most common cause of puerperal pyrexia. • Incidence 1-5 %. • May be because of consequences of: Reccurence of previous cystitis or pyelonephritis, asymptomatic bacteriuria. • Or first time because of: Frequent catheterization, stasis of urine.
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- 38. RETENTION OF URINE Commoncomplication in early puerperium. CAUSES: • Bruising • Edema of bladder neck • Reflex from the perineal injury • An accustomised position
- 39. TREATMENT • Indwelling catheterfor 48 hours • Following removal of a catheter recidual urine is to be measured • If it is more than 100 ml drainage is resumed • Appropriate urinary antiseptics up to 5-7 days
- 40. INCONTENENCE OF URINE •Not a common symptom following birth • It may be:- • Stress incontenence (late puerperium) • Overflow incontenence ( following retention of urine) • True incontenence (soon
- 41. SUPRESSION OF URINE •“If the 24 hours urine excretion is less than 400 ml or less, supression of urine is diagnosed.” • The cause is to be sought for and appropriate management is instituted.
- 42.
- 43. COMMON COMPLICATIONS Breast engorgement Crackedand inverted nipples Mastitis and breast abscess Lactation failure
- 44. BREAST ENGORGEMENT • Breastengorgement is due to exaggerated normal venous and lymphatic engorgement of the breasts which precedes lactation. • This in turn prevents escape of milk from the lacteal system
- 45. • The primiparouspatient and the patient with inelastic breasts are more likely develop breast engorgement • Engorgement is an indication that the baby is not in step with stage of lactation ONSET: • It usually manifests after the milk secretion starts ( 3r dand 4t hday postpartm)
- 46. SYMPTOMS Considerable pain and feeling of tendernesor heaviness Generalized malaise Painful breast feeding Rise of temperature
- 47. PREVENTION: • Avoid prelectealfeeds • Initiate early breast feeding • Exclusive breast feeding on demand • Feeding in correct position
- 48. TREATMENT: • Support withthe binders • Mannual expression of milk • Administer analgesics for pain • Frequently and regular feeding the baby • In severe cases gentle use of breast • Warm compression
- 49. CRACKED AND RETRACTED NIPPLE Thenipple may become painful due to:
- 50.
- 51. SYMPTOMS • Condition mayremain asymptomatic • Sometimes painful when feeding the baby • When infected, the infection may spread to the deeper tissue proceding mastitis
- 52. PROPHYLAXIS • Local cleanlinessduring pregnancy and puerperium • Clean the crusts before and after feeding • Application of lotion to soothen the epithelium
- 53. TREATMENT • Correct attachementduring feeding • Purified lanonin with mother's milk applied 3 or 4 times a day for healing • In severe cases expression of milk by breast pump
- 54. • For inflammed nippleand areola miconazole lotion is applied • Apply nipple shields • If persistant... biopsy is needed
- 55. RETRACTED AND FLATNIPPLE • Commonly seen in primiparous mother • Manual expression of milk is initiated • Correction of retracted nipple
- 57. ACUTE MASTITIS • Incidenceof mastitis is 2-5 % in lactating women • Less than 1% in nonlactating. • Organisms involved are... • Streptococcus aureus, • S. epidermidis and • Streptococci viridans
- 59. Mode of infection: Twodifferent types of mastitis based on location of infection. • Infection that involves the breast paranchymal tissues leading to cellulitis. (lacteal system remains unaffected) • Infection up to lactefarous ducts...leads to development of primary mammary adenitis
- 60. • Source ofinfection : infant's nose/mouth • Noninfected mastitis is due to milk stasis. • Feeding from the affected breast can solve the problem • ONSET: • In superficial cellulitis, onset is acute during first 2-4 weeks postpartum • However it may occur after several weeks also
- 61. CLINICAL FEATURES SYMPTOMS INCLUDE: •Generalized malaise and headache • Fever ( 102 degree F) • Severe pain and tender swelling
- 62. CLINICAL FEATURES SIGNS INCLUDE: •Presence of toxic features • Redness of overlying skin and swelling • Warm and flushy
- 63. COMPLICATION • Due tovariable distruction of breast tissues, it leads to the formation of a breast abcess.
- 64. PROPHYLAXIS • Hand washingbefore and after each feed, maintaing hygiene, keep the breast and nipple dry
- 65. MANAGEMENT • Support bybinders • Plenty of oral fluids • Good attachment when feeding the baby • Initiate feeding from uninfected breast first to establish let down • The infected site is emptied manually with each feed • Penicillins like flucloxacillin are is the drugs of choice. 500 mg 6 hourly. erythromycin is alternative
- 66. • Antibiotic therapyis to continue up to 7 days • Analgesics • Milk flow is maintained by feeding the baby • It will prevent proliferation of staphylococcus in the stagnant milk • The ingested staphylococcus will be digested without any harm
- 67. BREAST ABCESS FEATURES ARE: •Flushed breasts not responding to antibiotics • Browny edema on the overlying skin • Marked tenderness with fluctuation • Swinging temperature
- 68. MANAGEMENT • Incision anddrainage under general anaesthesia • Deep radial incision extending from near the areolar margin to prevent injury of the lacteferous ducts • Incision perpendicular to the lactiferous duct can increase the risk of fistula formation and ductal occlusion
- 69. • Finger explorationhas to be done to break the walls of loculi. • The cavilty is loosely packed with gause which should be replaced after 24 hours by a smaller pack • Continue till it heals up • Abscess can also be drained by serial percutaneous niddle aspiration under ultrasound guidance • Surgical draiange is commonly done
- 70. • Breast feedingis continued at uninvolved side • The infected side is mechanically expressed by pump every two hours and with every let down • Recurrence risk is about 10 % • Once cellulitis has resolved breast feeding from the involved side may be resumed
- 71. BREAST PAIN May bedue to.... • Engorgement • Infection ( candida albicans) • Nipple trauma • Mastitis • Occasionally on latching-on or let down reflex
- 72. MANAGEMENT • Appropriate nursingtechnique • Positioning • Breast care • Use of myconazole oral lotion or gel on the nipples and in infant's mouth thrice daily for two weeks are helpful
- 73. LACTATION FAILURE CAUSES ARE: •Infrequent suckling • Depression or anxiety state in puerperium • Unwilling to nursing • Ill development of nipples • Endogenous supression of prolactin • Prolactin inhibition
- 74. MANAGEMENT ANTENATAL: • Counsell motherregading benefits of nursing her baby • To take care of any breast abnormality.. breast engorgement • Maintaining adequate breast hygiene especially in the last two months of pregnancy
- 75. PUERPERIUM: • Encourage adequatefluid intake • To nurse the baby regularly • Treat the painfull local lesions to prevent nursing phobia • Metoclopramide 10 mg thrice daily, intranasal oxytocin and sulpiride ( selective dopamine intagonist) has been found to increase milk production. • They act by stimulating prolactin secretion
- 76.
- 77. PREVALENCE Thrombosis of leg veinand pelvic vein is most common However, the prevalence is less
- 78. RISK FACTORS •Vascular stasis Hypercoagulopathyof blood Vascular endothelial trauma •Other pregnancy related factors •Venous thrombo-embolic disease like.. deep vein thrombosis, thrombophlebitis, pulmonary embolism
- 79. This stasis causesdamage to the endothelial cells Thrombophilias are hypercoaguable states in pregnancy that increase the risk of venous thrombosis (inherited / acquired)
- 80. DEEP VEIN THROMBOSIS •Clinical diagnosis is unreliable. • In majority it remains asymptomatic • SYMPTOMS INCLUDE: • Pain in the caff muscles • On examination asymmentric leg edema • A positive Homan's sign
- 81. INVESTIGATIONS • Doppler utrasound •VUS- venous utrasonography • Venography • MRI
- 82. PELVIC THROMBOPHLEBITIS • Originatesin the thrombosed veins at placental site by organisms such as an anaerobic streptococci or bacteriosides • When localised in the pelvis its called pelvic thrombophlebitis. • There is specific features but it is suspected when there is constatnt fever inspite of antibiotics administration.
- 83. EXTRA PELVIC SPREAD •Through the right ovarian vein to inferior vana cava and hence to the lungs • Through left ovarian vein to left renal vein and hence to the left kidney • Retrograde extension to iliofemoral veins to produce the clinical pathological entity called “phlegmasia alba dolens” ( adjacent cellulitis in femoral vein)
- 84. CLINICAL FEATURES: • Usuallydevelops in second week of puerperium • Mild pyrexia • High grade fever with chills and rigor • Constitutional disturbances like... headache, malaise, rising pulse rate • Swelling, pain, white , cold over affected leg
- 85. PROPHYLAXIS • PREVENTIVE MEASURES: •Prevention of trauma, sepsis, anemia, dehydration • Use of elastic compression stocking • Leg exercise, Early ambulation
- 86. MANAGEMENT • Bed restwith foot end kept higher to heart level • Pain management • Antibiotics • Anticoagulants- Heparin- 15000 units IV followed by 10,000 units 6-8 hourly for 4 to 6 injections. up to 7 to 10 days • Administration of fibrinolytic agents • Venous thrombectomy
- 87. PULMONARY EMBOLISM • Classicalsymptoms of massive pulmonary embolism are... • Sudden collapse • Acute chest pain • Air hunger • Death usually occurs within short time from shock and vagal inhibition
- 88. Important signs... • Tachypnea •Dyspnoea • Pleuritis- chest pain • Cough • Tachycardia • Haemoptysis • Rise in temperature
- 89. DIAGNOSIS • ECG • Arterialblood gas • D-Dimer: value (More than 500 ng/ mL) • Doppler utrasound • Lung scans • Pulmonary CT angiography • MRA: Magnetic resonance angiography
- 90. MANAGEMENT • Prophylactic measures •Active treatment: • Resuscitation: cardiac massage, oxygen therapy, heparin bolus IV of 5000 units and morphine 15 mg • IV fluids • Incase of recurrent.. embolectomy, placement of caval filters, ligation of inferior vana cava and ovarian veins
- 91. OBSTETRIC PALSIES (Syn.POSTPARTUM TRAUMATICNEURITIS) • The commonest form of obstetric palsy encountered in puerperium is... “FOOT DROP” • Usually unilateral • Appears shortly after delivery/ first day postpartum
- 92. • It isdue to stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L5 and S1 • Backward rotation of the sacrum during labour may also be a contributory factor • Direct pressure either by fetal head or forcep blade on the lumbosacral cord or sacral plexus
- 94. • Condition isusually mild • May pass unnoticed • Neurological examination reveals lower motor neurone type of lesions with placcidity and wasting of muscles in areas supplied by femoral nerve or lumbosacral plexus • Secondary loss is always present
- 95. • Management ofdamaged lumbosacral nerve roots is same as that of the proplapsed intervertebral disc in consultation with an orthopaedic surgeon. • Paraplegia due to epidural haematoma or abcess is rare.
- 96.
- 97. • There aremany acute complications • Majority of them are alarming complications • Arises immediately after delivery • Except pulmonary embolism
- 98. Common complications are; IMMEDIATE: •Postpartum haemorrhage • Shock • Postpartum pre/eclampsia • Pulmonary embolism • Uterine inversion.
- 99. EARLY (WITHIN AWEEK). • Acute retention of urine • Urinary tract infection • Puerperal sepsis • Breast engorgement • Mastitis and breast abscess • Pulmonary infection • Anuria due to AKI following abruptio placentae, mismatched boold transfusion or pre/eclampsia
- 100. DELAYED: • Secondary postpartum haemorrhage •Thrombo-embolic manifestation • Psychosis • Postpartum cardiomyopathy • Postpartum haemolytic uremic syndrome
- 101.
- 102. INTRODUCTION • In thefirst 3 months after delivery, the incidence of mental illness is high. • Overall incidence is about 15-20%. • Sleep deprivation, hormone elevation near the end of gestation and massive postpartum withdrawal contribute to the high risk
- 103. HIGH RISK FACTORS PASTHISTORY: • Psychiatric illness • Puerperal psychiatric illness FAMILY HISTORY: • Major psychiatric illness • Marital conflicts • Lack of social support
- 104. PRESENT PREGNANCY: • Youngage • Caesarean delivery • Difficult labour • Neonatal complications OTHERS: • Unmet expectations
- 105. PUERPERAL BLUES • Itis transient state of mental illness observed 4-5 days after delivery • Lasts for few days • Incidence is 50 %
- 106. MANIFESTATIONS ARE: • Depression •Anxiety • Tearfulness • Insomnia • Helplessness • Negative feelings towards the infant • No specific metabolic or endocrine abnormalities detected • But lowered troptophan (neurotransmitor serotonin) level is observed. it indicats altered neurotransmitter function
- 107. TREATMENT: • Reassurance • Psychologicalsupport by the family members
- 108. POSTPARTUM DEPRESSION • Observedin 10-20 % of mothers • More gradual in onset over the first 4-6 months following delivery or abortion • Changes in the hypothalamo- pitutary- adrenal axis may be a cause
- 109. MANIFESTED BY: • Lossof energy • Loss of appetite • Insomnia • Social withdrawal • Irritability • Suicidal ideation • Risk of reccurence is 50-100% in subsequence pregnancies
- 110. TREATMENT: • Is startedearly • Fluoxetine or paroxetine (Selective serotonin reuptake inhibitors) • General supportive measures
- 111. POSTPARTUM PSYCHOSIS • Observedin 0.14-0.26 % of mothers • Commonly seen in women with past history and family history • Onset is relatively sudden • Lasts for 4 days
- 112. MANIFESTED BY: • Fear •Restlessness • Confusion followed by hallucinations, delusions and disorientation • Suicidal, infanticidal ideation • Temporary seperation and clinical supervision is needed • Risk for reccurence 20-25%
- 113. MANAGEMENT • A psychiatristmust be consulted urgently • Hospitalization is needed • Chlopramazine 150 mg stat and 50-150 mg three time /day is started • Sublingual estradiol 1 mg TDS causes significant improvement • Electro convulsive therapy if remains unresponsive or in depressive psychosis • Lithium in manic depressive psychosis • Breast feeding is restricted in case of lithium administration
- 114. PSYCHOLOGICAL RESPONSES TOTHE PERINATAL DEATHS AND MANAGEMENT • Most perinatal events are joyful • But when a fetal /neonatal death occurs, social attention must be given to grieving parents and family • It may also be because of unexcpected hysterectomy, birth of malformed or chronically ill infant • Prolonged seperation from chronically ill infant can also cause grief
- 115. Physician, nurse andattending staff must understand patient's reaction The common maternal somatic symptoms are; • Insomnia • Fatigue • Sighing respiration • Feeling of guilt • Anger • Hostility ( feeling of opposition)
- 116. MANAGEMENT OF PERINATAL GRIEVING •Facilitating grieving process with consolation (comfort), support, sympathy • Others are: • Supporting the couple in seeing/ holding/ taking photographs of infant • Autopsy requests • Planning investigations • Follow up visits • Plan for subsequent pregnancy
- 117.