This topic contains detail information about all abnormalities during puerperium like puerperial pyrexia, sepsis, subinvolution, breast complications, urinary complications, puerperal venous thrombosis, pulmonary embolism, obstetric palsies, puerperal emergencies, psychiatric disroders, perinatal management
5. PUERPERAL PYREXIA
“ A rise of temperature reaching 100.4
degree F or more (Measured orally) on
two seperate occassions at 24 hours
apart (excluding first 24 hours) within
first 10 days following delivery is called
Puerperal pyrexia”
In some countries postabortal fever is
also included.
7. PUERPERAL SEPSIS
“An infection 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.
8. INCEDENCE
There had been marked decline in
puerperal sepsis during the past few years
due to:-
Improved obstetric care
Availability of wider range of antibiotics
10. PREDISPOSING FACTORS
Damage of Cervicovaginal mucous
membrane
Large placental wound surface area
Blood clots presents at placental site
ANTEPARTUM FACTORS:
Malnutrition and anemia
Preterm labour
PROM
Chronic illness
Prolonged rupture of membrane >18 hours
11. INTRAPARTUM FACTORS:
Repeated vaginal examinations
Prolonged rupture of membranes
Dehydration and keto- acidosis during
labour
Traumatic operative delivery
Hemorrhage
Retained bits of placenta or membranes
Placenta previa
Cesarean Section delivery
13. AEROBIC:-
Streptococcus hemolytic group- A
Streptococcus hemolytic group - B
Others: Streptococcus pyogenus, aureus,
E coli, Pseudomonas, chlamydia
ANAEROBIC:-
Streptococcus, peptococcus, bacteriodes
14. 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.
16. 1. LOCAL INFECTION
Slight temperature rise
Generalized malaise
Headache
Redness and swelling to local wound
Pus formation
17. 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
20. PROPHYLAXIS
ANTENATAL:
Improvement of nutritional 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
21. POSTNATAL:
Aseptic precautions atleast 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
22. GENERAL CARE:-
Isolation of the patient
Adequate fluid and calorie (IV)
Anemia is to be corrected
Progress chart should be maintained
TREATMENT
24. ANTIBIOTICS
Gentamicin, 2 mg/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
Metrinidazole 0.5 g IV, 8 hourly
continue atleast 7-8 days
26. PERINEAL WOUND:-
Stiches of 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 suture may be given on later
date
SURGICAL TREATMENT
27. RETAINED UTERINE PRODUCTS:-
With diameter of 3 cm or less may be
disregarded or left alone
Otherwise surgical evacuation after
antibiotic coverage for 24 hours should be
done to avoid risk of septicemia
SEPTIC THROMBOPHLEBITIS:-
IV Heparin for 7-10 days
28. PELVIC ABCESS:-
Drainage by colpotomy under ultrasound
guidance
WOUND DEHISCENCE:
Dehiscence of episiotomy or abdominal wound
following cesarean section:-
Scrubbing the wound
Debridement of all necrotic tissues
Secondary suture
29. LAPROTOMY:
Has got 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
30. NECROTYSING FACITIS:
Wound scrubbing
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
35. SYMPTOMS
May be asymptomatic sometimes
Abnormal Lochial Discharge : Excessive or
prolonged
Irregular at times Excessive Uterine Bleeding
Irregular Cramp like Pain (Retained bits)
Rise of Temperature in case of Sepsis
37. MANAGEMENT
Antibiotics in case of infection
Exploration of uterus for retained
products
Pessary in prolapse or retroversion
Methargin to enhance involution
process
39. URINARY TRACT INFECTION
Most common cause of puerperal
pyrexia
Incedence 1-5 %
May be because of consequences of:
Reccurence of previous cystitis or
pyelitis, asymptomatic bacteriuria
First time because of: Frequent
catheterization, stasis of urine
43. RETENTION OF URINE
Common complication in early
puerperium.
CAUSES:
Bruising
Edema of bladder neck
Reflex from the perineal injury
Anaccustamized position
44. TREATMENT
Indwelling catheter for 48 hours
Following removal 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
45. 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 following
labour)
46. SUPRESSION OF URINE
“If the 24 hours urine excretion is less
than 400 ml or less, supression of urine
is dagnosed.”
The cause is to be sought for and
appropriate management is instituted.
49. BREAST ENGORGEMENT
Breast engorgement 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
50. The primiparous patient 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 ( 3rd
and 4th
day
postpartm)
53. TREATMENT:
Support with the binders
Mannual expression of milk
Administer analgesics for pain
Frequently and regular feeding the
baby
In severe cases gentle use of breast
pump
Hot application
56. SYMPTOMS
Condition may remain asymptomatic
Sometimes painful when feeding the
baby
When infected, the infection may
spread to the deeper tissue proceding
mastitis
57. PROPHYLAXIS
Local cleanliness during pregnancy
and puerperium
Clean the crusts before and after
feeding
Application of lotion to soothen the
epithelium
58. TREATMENT
Correct attachement during 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
59. For inflammed
nipple and areola
miconazole lotion
is applied
Apply nipple
shields
If persistant...
biopsy is needed
60. RETRACTED AND FLAT NIPPLE
Commonly seen in primiparous mother
Manual expression of milk is initiated
Correction of retracted nipple
61.
62. ACUTE MASTITIS
Incidence of mastitis is 2-5 % in
lactating
Less than 1% in nonlactating mother
Organisms involved are...
Streptococcus aureus,
S. epidermidis and
Streptococci viridans
63.
64. Mode of infection:-
Two different types of mastitis based on
location of infection.
1.Infection that involves the breast
paranchymal tissues leading to cellulitis.
(lacteal system remains unaffected)
2.Infection up to lactefarous ducts...lead
to development of primary mammary
adenitis
65. Source of infection : 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 occurs after several
weeks also
70. MANAGEMENT
Support by binders
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
Dicloxacilin is the drug of choice. 500
mg 6 hourly. erythromycin is
71. • Antibiotic therapy is to continue up to 7
days
• Analgesics
• Milk flow is maintained by feeding the
baby
• It will prevent proloferation of
staphylococcus in the stagnant milk
• The ingested staphylococcus will
digested without any harm
72. BREAST ABCESS
FEATURES ARE:
Flushed breasts not responding to
antibiotics
Browny edema on the overlying skin
Marked tenderness with fluctuation
Swinging temperature
73. MANAGEMENT
Incision and drainage under general
anesthesia
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
74. Finger exploration has to be done to
break the walls of loculi.
The cavilty is loosely packed with
gause which should be replaced after
24 hoursby a smaller pack
Continue till it heals up
Abcess can also be drained by serial
percutaneous niddle aspiration under
ultrasound guidance
Surgical draiange is commonly done
75. Breast feeding is contonued at
uninvolved side
The infected side is mechanically
expressed by pump every two hourly
and with every let down
Reccurence risk is about 10 %
Once cellulitis resolved breast feeding
from the involved side may be resumed
76. BREAST PAIN
May be due to....
Engorgement
Infection ( candida albicans)
Nipple trauma
Mastitis
Occasionally on letching-on or let
down reflex
78. 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
79. MANAGEMENT
ANTENATAL:
Counsell mother regading benefits of
nursing her baby
To take care of any breast abnormality..
breast engorgement
Maintaining adequate breast hygiene
specially in last two months of
pregnancy
80. PUERPERIUM:
Encourage adequate fluid intake
To nurse the baby regularly
Treat the painfull local lesions to
prevent nursing phobia
Metoclopramide 10 g thrice daily,
intranasal oxytocin and sulpiride
( selective dopamine intagonist) has
been found to increase milk production.
They act by stimulating prolactin
secretion
83. RISK FACTORS
Vascular stasis
Hypercoagulopathy of blood
Vascular endothelial trauma
Other pregnancy related factors
Venous thrombo-embolic disease like..
deep vein thrombosis, thrombophlebitis,
pulmonary embolism
84. This stasis causes damage to the
endothelial cells
Thrombophilias are hypercoaguable states
in pregnancy that increase the risk of
venous thrombosis (inheritate/ acquired)
85. OTHER ACQUIRED RISK FACTORS
Advanced age and
parity
Operative delivery
Obesity
Anemia
Heart disease
Infection- pevic celluitis
Trauma to the venous
wall
Immobility and smoking
86. 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
88. PELVIC THROMBOPHLEBITIS
Originates in the thrombosed veins at
placental site by organism such as an
anaerobic streptococci or
bacteriosides
When localised in the pelvis called
pelvic thrombophlebitis.
There is specific features but it is
suspected when there is constatnt
fever instead of antibiotics
administration
89. 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)
90. CLINICAL FEATURES:
Usually develops 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
92. MANAGEMENT
Bed rest with 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
Administartion of fibrinolytic agents
Venous thrombectomy
93. PULMONARY EMBOLISM
Most leading cause of maternal deaths
Classical symptoms of massive
pulmonary embolism are...
Sudden collapse
Acute chest pain
Air hunger
Death usually occurs within short time
from shock and vagal inhibition
96. MANAGEMENT
Prophylactic measures
Active treatment:
Resuscitation: cardiac massage, oxygen
therapy, heparin bolus IVof 5000 units and
morphine 15 mg
IV fluids
Incase of recurrent .. embolectomy,
placement of caval filters, ligation of inferior
vana cava and ovarian veins
97. OBSTETRIC PALSIES
(Syn.POSTPARTUM TRAUMATIC NEURITIS)
The commonest form of obstetric palsy
encountered in puerperium is...
“FOOT DROP”
Usually unilateral
Appears shortly after delivery/ first day
postpartum
98. It is due 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
99.
100. Condition is usually mild
May passed 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
101. Management of damaged lumbosacral
nerve roots is same as that of the
proplapsed intervertebral disc in
consultation with an orthopedist
Paraplegia due to epidural hematoma
or abcess is rare.
105. EARLY (WITHIN A WEEK):
–Acute retention of urine
–Urinary tract infection
–Puerperal sepsis
–Breast engorgement
–Mastitis and breast abcess
–Pulmonary infection
–Anuria following abruptio placenta,
mismatched boold transfusion or
eclampsia
108. INTRODUCTION
In the first 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
114. POSTPARTUM DEPRESSION
Observed in 10-20 % of mothers
More gradual in onset over the first 4-6
months following delivery or abortion
Changes in the hypothelamo-pitutary-
adrenal axis may be a cause
115. MANIFESTED BY:
Loss of energy
Loss of appetite
Insomnia
Social withdrawal
Irritability
Suicidal attitude
Risk of reccurence is 50-100% in
subsequence pregnancies
117. POSTPARTUM PSYCHOSIS
Observed in 0.14-0.26 % of mothers
Commonly seen in women with past
history and family history
Onset is relatively sudden
Lasts for 4 days
118. MANIFESTED BY:
Fear
Restlessness
Confusion followed by hallucination,
delusion and disorientation
Suicidal, infanticidal impulses
Temporary seperation and clinical
supervision is needed
Risk foe reccurence 20-25%
119. MANAGEMENT:
A psychiatrist must be consulted urgently
Hospitalization is needed
Chlopramazine 150 mg stat and 50-150 mg
three time /day is started
Sublingual estradiol 1 mg TDS in
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
120. PSYCHOLOGICAL RESPONSES TO THE
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 be because of unexcpected
hysterectomy, birth of malformed or
chronically ill infant
Prolonged seperation from chronically
ill infant can also cause grief
121. Physician, nurse and attending staff
must understand patient's reaction
The common maternal somatic
symptoms are...
Insomnnia
Fatigue
Sighing respiration
Feeling of guilt
Anger
Hostility ( feeling of opposition)
122. MANAGEMENT OF PERINATAL GRIEVING
Facilitating grieving process with
consolation (comfort), support, sympathy
Others are:
1. supporting the couple in seeing/ holding/
taking photographs of infant
2. Autopsy requests
3. Planning investigations
4. Follow up visits
5. Plan for subsequent pregnancy