1. Normal & Abnormal
Puerperium
Supervised by:
Prof. Salah Roshdy,MD
Professor of Obstetrics & Gynecology,
Qassim University
Presented by:
Abdulrahman Alsuhaibani

2. Objectives
• Normal Puerperium
– Reproductive organs
– Systemic change
• Abnormal Puerperium
– Postpartum Hemorrhage
– Puerperal fever and sepsis
– Septic Pelvic Thrombophlebitis
– Endocrine Disorders
– Psychiatric Disorders
– Uterine Subinvolution

3. Normal
Puerperium

4. Normal Puerperium
Definition
Period following delivery of baby & placenta
to about 6 weeks post partum
By 6 weeks after delivery, most of the changes
of pregnancy resolved and the body has
regained the non-pregnant state.

5. A- Reproductive organs
1) Abdominal wall
Remains soft and poorly toned for many weeks.
The return to a prepregnant state depends greatly on exercise.
2) Perineum
Swelling & engorgement are completely gone within 1-2 weeks
The muscle tone may return to normal, depending on the
extent of injury.

6. Cont. (Reproductive organs)
3) Uterus
- 1000g  100 – 200 g ( Uterine involution )
- The endometrial lining rapidly regenerates (16 days)
- After delivery  at the level of the umbilicus
- After 2 weeks  midway bw umbilicus & symphysis
- After 4 weeks  the uterus become pelvic organ

8. Cont. (Reproductive organs)
4) Cervix
- Loses its elasticity & regain firmness
- Closed by the end of the 2nd week
5) Vagina
- By 3 weeks  increased vascularity and edema
- At the end of puerperium  Shrinks to a nonpregnant state
- by 6-10 weeks  The vaginal epithelium appears atrophic
on smear and the normal epitheliaum will be restored
Who deliver vaginally  taught her to perform
kegel exercises

9. Cont. (Reproductive organs)
6) Ovaries
- Ovulate as early as 27 days after delivery (not breastfeed).
- The suppression of ovulation is due to the elevation in
prolactin
- Menstruation  returns by 6-8 weeks in women who do not
nurse

10. Cont. (Reproductive organs)
7) Breasts
- Lactogenesis is initially triggered by the delivery of the
placenta drop of placenta H ( esp. estrogen ) &↑prolactin
- In non nursing women  The prolactin levels decrease and
return to normal within 2-3 weeks
Colostrum secreted for 2 days  contain protein , fat , minerals , IgA and IgG
After 3-6 days  replaced by milk (protein , lactose , water and fat )

11. B- Systemic changes
1) Cardiovascular system
• Cardiac output ↑(immediately after delivery) → slowly
declines→ reach normal 2-6 weeks.
• Blood volume returns to nonpregnant levels by the 10th day
of puerperium
2) Hematologic changes :
• Hemoglobin & hematocrit ↑ after delivery
• Coagulation factors remain elevated in early puerperium 
8-12 weeks return to non pregnant level

12. Manifestations
In First 24 hours:
PBL F
• Pain  uterine contraction
• Breast  colostrum
• Lochia
• Fever  not exceed 38 C

13. LOCHIA
it originate from
Lochia:- “vaginal
body of uterus,
discharge along
cervix and vaginal.
with decidua, clots
it is fishy odor.
and membrane
Reaction is
after delivery of
alkaline first and
placenta during
tends to acidic at
puerperium.”
end.
-Lochia discharge continues for 2 to 6 weeks
after delivery .
- Monitor for signs of infection “foul smelling “
 endometritis

14. Stages
Traits Lochia rubra Lochia serosa Lochia alba
Colour Red Yellow or pale Pale white
brown
Composition Mainly RBC, Mainly mucus and Mucus, serous
leucocytes, serum, few RBC exudates, epithelial
decidua, mucus. and leucocytes. cell, leucocytes.
Duration 1-4 days 5-9 days 10-15 days.
Abnormality with lochia:-
1. persistent lochia rubra:- causes secondary PPH due to retained placental
tissue and membrane.
2. Offensive lochia:- puerperal sepsis due to E.coli.
3. Scanty serous lochia:- severe streptococcal infection.
4. Suppression of lochia:- obstruction at internal os by clots

16. Abnormal
Puerperium

17. Abnormal Puerperium
A-Postpartum Hemorrhage (PPH)
B-Puerperal fever and sepsis
-Endometritis - Mastitis
-Wound Infections - UTIs
C-Septic Pelvic Thrombophlebitis
D-Endocrine Disorders
-Postpartum thyroiditis - PP Graves disease
-Sheehan syndrome - Lymphocytic hypophysitis
E-Psychiatric Disorders
-Postpartum blues - Postpartum depression (PPD)
-Postpartum psychosis
F- UTERINE SUBINVOLUTION

18. Sequence of events in abnormal
puerperium
• At 2nd OR 3rd day  Endometritis
• At 4th day  Mastitis OR Wound infection
• At 7th day  Thrombophlebitis

19. Puerperal fever
A temperature rise above 38°C on any of the
first 10 days after delivery .
Differential diagnosis:
1. Endometritis
2. Wound or chest Infections
3. Mastitis
4. UTIs
5. Thrombophlebitis
6. Any general cause of fever

20. 1) Endometritis
Endometritis is the primary cause of postpartum
infection.
The causative agents are usually normal vaginal
flora or enteric bacteria.

21. Cont. (Endometritis)
Risk factors 4Ps 3Ms 1C
1. Cesarean delivery
2. Prolonged labor
3. Preexisting infection of the lower genital tract
4. Placement of an intrauterine catheter
5. Prolonged rupture of membranes
6. Multiple vaginal examinations
7. Multiple pregnancy (Twin delivery)
8. Manual removal of placenta

22. Cont. (Endometritis)
Diagnosis (After excluding other causes)
A. History of fever, chills, lower abdominal pain,
malodorous lochia, increased vaginal bleeding, anorexia,
and malaise.
B. Physical Examination showing a fever of
38°C, tachycardia, and fundal tenderness.
C. Laboratory tests CBC, ESR , CRP , blood
cultures , urinalysis and microscopic culture of discharge .

23. ROLE of F (Endometritis)
First Exclude
Foul smelling lochia
oFFensive vaginal bleeding
Fever > 38 ᴼC
Fundal tenderness

24. Cont. (Endometritis)
Treatment
IV antibiotics (Gentamicin & clindamycin have
a cure rate of approximately 90%)
Parenteral antibiotics are usually stopped once
the patient is afebrile for 24-48 hours,
tolerating a regular diet, and ambulating
without difficulty

25. 2) Wound Infection
Include infections of the perineum developing
at the site of an episiotomy or laceration, as
well as abdominal incision after a cesarean
birth.
Diagnosis based on presence of erythema,
induration, warmth, tenderness, and purulent
drainage from the incision site (expolortion),
with or without fever.

26. Cont. (Wound Infection)
Perineal infections are rare appears on the
third or fourth postpartum day.
• Risk factors include infected lochia, fecal
contamination of the wound, and poor hygiene.
Abdominal wound infections
S aureus, is isolated in 25% of these infections.
Treatment :
Abscesses must be drained, and broad-spectrum
antibiotics may be initiated.

27. 3) Mastitis
- It is an inflammation of the mammary gland
(parenchyma) .
- Develops during the first 3 months.
- Milk stasis and cracked nipples, which
contribute to the influx of skin flora, are the
underlying factors associated with the
development of mastitis.
- The most common causative organism is
S.aureus
• Risk factors  primiparity, incomplete emptying
of the breast, and improper nursing technique.

28. Cont. (Mastitis)
Diagnosis
A. History of fever, chills, and malaise.
B. Physical Examination
- Should Focus on looking for other sources of infection.
- Typical findings include an area of the breast that is
swollen, warm, red, and tender.
- When the exam reveals a tender, hard, possibly fluctuant
mass with overlying erythema, an abscess should be
considered.

29. Cont. (Mastitis)
Treatment
• Milk stasis can be treated with moist heat,
massage, fluids, rest, proper positioning of the infant
during lactation, manual expression of milk, and
analgesics.
• Penicillinase-resistant penicillins and
cephalosporins, such as dicloxacillin or cephalexin,
are the drugs of choice.
• Erythromycin, clindamycin, and vancomycin may be
used for patients who are resistant to penicillin.
• Resolution usually occurs 48 hours after the onset of
antimicrobial therapy.

30. 4) UTIs
- The most common pathogen is E coli. In pregnancy
- Risk factors Cesarean delivery, forceps delivery, vacum
delivery, induction of labor, maternal renal disease,
preeclampsia, eclampsia, epidural anesthesia, bladder
catheterization, length of hospital stay, and previous UTI
during pregnancy.
Diagnosis
History (frequency, urgency, dysuria, hematuria)
Physical examination (febrile patient, Suprapubic tenderness)
Laboratory tests (urinalysis, urine culture and CBC)
Treatment
Empirical  culture  selective (3-7 Days)

31. C) Septic Pelvic Thrombophlebitis
(SPT)
- It is a venous inflammation with thrombus
formation in association with fevers
unresponsive to antibiotic therapy.
- Bacterial infection of the endometrium seeds
organisms into the venous circulation, which
damages the vascular endothelium and in
turn results in thrombus formation.
- The thrombus acts as a suitable medium for
proliferation of anaerobic bacteria.

32. Cont. (SPT)
Diagnosis
A. History
• It usually accompanies endometritis
• Pts with OVT may describe lower abdominal pain, with or
without radiation to the flank, groin, or upper abdomen.
B. Physical Examination
- Should focus on looking for other sources of infection.
- Fever, tachycardia
- On abdominal examination, 50-70% of pts with ovarian
vein thrombosis have a tender, palpable, ropelike mass.
C. CT and MRI are the studies of choice

34. Cont. (SPT)
Treatment
• IV heparin for 7-10 days.
• Antibiotic therapy is most commonly with
gentamicin and clindamycin

35. D) Endocrine Disorders
Clinical or laboratory dysfunction occurs in 5-10% of
postpartum women
Caused by
A. Primary disorders of the thyroid, such as
1) Postpartum thyroiditis (PPT)
2) Graves disease,
B. Secondary disorders of the hypothalamic-
pituitary axis, such as
1) Sheehan syndrome
2) Lymphocytic hypophysitis.
(pituitary enlargement+Hypopitutarism  ↓TSH  HR)

36. PostPartum Thyroiditis (PPT)
- It is a transient autoimmune destructive
lymphocytic thyroiditis.
- Can occur any time in the 1st postpartum year.
It has 2 phases
1) 1-4 mo PP  thyrotoxicosis (↓TSH)
 If sever ß-blocker
2) 4-8 mo PP  hypothyroidism (↑TSH)
 If sever Thyroxin

37. E) Psychiatric Disorders
1- Postpartum blues - 50-70%
• Mild, self limited, arises during the first 2 weeks PP
• TTT: Support & education
2- Postpartum depression (PPD) - 10-15%.
• More prolonged (3-6 months)
• TTT: Supportive care and reassurance, SSRI
3- Postpartum psychosis- 0.14-0.26%.
• Generally lasts only 2-3 months. Need psychiatrist.
• Better prognosis than nonpuerperal psychosis.

38. Any prolonged episodes of
depression during or after
pregnancy should receive
urgent attention.

39. F) Uterine Subinvolution
It is a transient autoimmune destructive
lymphocytic thyroiditis.
Causes: Endometritis, retained placental
fragments, pelvic infection and uterine fibroids
Signs and Symptoms
1) Prolonged lochial flow.
2) Profuse vaginal bleeding.
3) Large, flabby uterus.

40. Cont. (Uterine Subinvolution )
Treatment:
1- Administration of oxytocic medication to
improve uterine muscle tone, includes:
(a) Methergine - a drug of choice (PO)
(b) Pitocin.
(c) Ergotrate.
2- Dilation and curettage (D&C) to remove any
placental fragments.
3- Antimicrobial therapy for endometritis

41. Summary
Repro. 7
General 2

42. Summary
PPH
Puerperal fever & sepsis 4
SPT
Endocrine Disorders 4
Psychiatric Disorders. 4
Uterine Subinvolution

43. References

44. Any Question ?