Normal and Abnormal Puerperium Dr nihal harris Department

Normal and Abnormal Puerperium Dr nihal harris Department Obstetrics & Gynecology

Normal Puerperium Definition It is the period following delivery of the baby and placenta to 6 weeks postpartum. It is the period during it , the reproductive organs & maternal physiology returns towards the pregnancy state.

Anatomic and physiologic changes : 1. Uterine Involution 2. Return of Menstruation. 3. Vagina. 4. Cardiovascular System.

(1) Uterine Involution * it rapidly decreases in weight from 1000 g - 100 g in the first 3 weeks postpartum. * lochia =lochia ruba: bloody discharge in the first few days after delivery. =lochia serosa: the discharge becomes pale in color after 3 – 4 days. =lochia alba: uterine discharge assumes a white or yellow-white color by the 10 th day postpartum. NB: foul-smelling lochia suggests endometritis.

(2) Return of menstruation * non-nursing mothers: menstruation returns by 6 – 8 weeks. * nursing mothers: may develop lactating amenorrhea. NB: In all women , although ovulation may not occur for several months , particularly in nursing mothers contraceptive use should be advised during the puerperium to avoid an undesired pregnancy.

(3) Vagina * the supportive tissues of the pelvic floor gradually returns its former tone. * women who deliver vaginally should be taught & encouraged to perform Kegel excercises (4) Cardiovascular system * cardiac output & plasma volume gradually returns to normal during the first 2 weeks. * marked weight loss occurs in the first week as a result of the decrease of plasma volume and the deuresis of the extracellular fluid.

Breastfeeding * Advantages: = inexpensive , in good supply usually, = accelerates uterine involution , because suckling stimulates the release of oxytocin , thus causing increased uterine contractions. = immunologic advantages for the baby , as breast milk contains several types of maternal antibodies, which provides the newborn with passive immunity against certain infectious diseases , until its own immune mechanisms become fully functional by 3 – 4 months.

Correct Wrong

* Complications 1. Fissured Nipples: = nipples may become fissured and nursing become painful and difficult. = breast fissures are a portal of entry for bacteria, so they should be managed aggressively by lanolin breast cream. = further breast feeding should be stopped , milk can be expressed manually until the nipples heal and breastfeeding can be resumed.

2. Mastitis : = uncommon complication usually develops after 2 – 4 weeks. = symptoms & signs low grade fever , chills , indurated , red and painful segment of the breast. = caused by Staphylococcus aureus bacteria from the infant’s oral pharynx.

Mastitis

= mother should start antibiotics immediately, such as dicloxacillin for 7 -10 days. = breastfeeding may be discontinued so, breast pump can be used to maintain lactation. however , suppression of lactation is advisable. = if a breast abscess develops , it should be surgically drained.

3. Drug passage to the newborn: = infant ingest up to 500 ml of breast milk /day. thus , maternally administrated drugs that pass to breast milk may have significant effect. = amount of drug in breast milk depends on: * maternal drug dose. * rate of maternal clearance. * physiochemical properties of the drug. * composition of the breast milk with respect to fat and protein. * infant GA at birth.

Effects of selected drugs on breastfeeding infants: (1) Sedatives diazepam (2) Salicylates (3) Anticonvulsants phenobarbital phenytoin (4) Narcotics heroin methadone (5) Antibiotics penicillin ampicillin erythromycin nitrofurantoin tetracycline Sedation May cause platelet dysfunction. Sedation & decreased suckling. May cause addiction. Infant death. 3 antibiotics modify bowel flora & allergy. may hemolytic anaemia in infants with glucose 6 phosphate dehydrogenase discoloration of teeth& bone growth. .

(6) Thyroid drugs thyroxine propyl thiouracil May interfere with screening for hypoth. Nodular goiter. (7)Drugs have no adverse effects : * antipsychotics as chlorpromazine haloperidol * antihypertensives methyldopa propranolol * Digoxin * analgesics acetaminophen no adverse effects.

Abnormal Puerperium Puerperal Disorders: 1. Puerperal Pyrexia. 2. 2 ry Postpartum Hemorrhage. 3. Thromboembolism. 4. Perineal Complications. 5. Bladder Dysfunction. 6. Bowel Dysfunction.

Puerperal Pyrexia Definition: a temperature of 38 C or > lasts for 2 days or > in the first 10 days postpartum, exclusive of the first 24 h. Fever during puerperium must be regarded as result in from genital tract infection (puerperal sepsis) until prove otherwise.

Causes: 1. genital tract infection ( puerperal sepsis ). 2. milk engorgement , mastitis & breast abscess 3. DVT & PE. 4. 5. 6. 7. UTI. chest infection. CS delivery, wound infection & fasciites. meningitis.

Genital Tract Infection ( Puerperal Sepsis) Incidence: 3% 7% of all direct maternal deaths , excluding deaths after abortion. Etiology: Puerperal infection is usually poly microbial involves contaminants from the bowel that colonize the perineum and lower genital tract.

The most frequently identified organisms are : * Group B Streptococcus. * Mycoplasma species. * others: =Gram +ve -beta-hemolytic streptococcus gr. A, B, D -staphylococcus aureus. -staphylococcus faecalis. =Gram –ve -E coli -Hemophilus influenzae. -gardenella vaginalis. =Anaerobes as; Bactroides fragilis. =Miscellaneous as; Chlamydia trachomatis

Predisposing Factors: 1. manual removal of the placenta. 2. placental separation exposes a large raw area. 3. retained products of conception & blood clots. 4. CS wound , episiotomy and genital tract lacerations.

Risk Factors 1. 2. 3. 4. 5. instrumental delivery. internal fetal monitoring. multiple vaginal examinations. prolonged ROM and chorioamnonitis. cervical cerclage. 6. Non obstetric : . . Obesity. . . DM. . . HIV.

Factors that determine the clinical course & severity of the infection: 1. general health and resistance of the woman. 2. virulence of the causative organisms. 3. presence of predisposing factors as bl. Clots, hematoma or retained products of conception. 4. timing of antibiotic therapy.

Diagnosis A. Clinical Picture symptoms: • fever , rigors, malaise, headache. • vomiting and diarrhoea. • abdominal discomfort. • offensive lochia. • 2 ry PP Hge.

signs: • pyrexia and tachycardia. • uterus is large and tender. • infected wounds as CS or perineal lacerations • peritonism and paralytic ileus (severe cases). • indurated adnexae due to parametritis. • fullness in pelvis due to abscess.

Investigations: 1. FBC 2. Coagulation Profile 3. RFT & Electrolytes anaemia, leukocytosis , thrombocytopenia. DIC. fluid & electrolytes imbalance. acidosis & hypoxia. 4. Arterial blood gas ( septiceamic shock) 5. High vaginal swabs infection. and blood cultures. 6. Pelvic US : =retained products = adnexal mass =pelvic abscess.

Management Prevention: 1. awareness of general hygiene principles. 2. good surgical technique with proper hemostasis. 3. prophylactic antibiotics especially in emergency CS. a single intra operative dose of cephalosporin+ metronidazole.

Treatment A. Mild and Moderate infections : broad spectrum antibiotic as: cephalosporin + metronidazole. in the first 48 h , antibiotic should be given IV. B. Severe infections : septic/endotoxic shock appropriate antibiotics should be aggressively given , any delay could be fatal.

Complications 1. Pelvic abscess salpingo- ophoritis and pelvic peritonitis. This could progress to a generalized peritonitis and the development of pelvic absess. 2. Pelvic Peritonitis metritis and parametitis. 3. Septic Thrombophlebitis spread to distant sites via lymphatics , bl. v to the iliac vessels or directly via the ovarian vessels.

Necrotizing Fasciitis * fatal infection of skin , fascia and muscle. It occurs in the perineal tears, episiotomy sites & CS wounds. * caused by a variety of bacteria including anaerobes. * in addition to signs of infection , there is extensive necrosis which is managed by surgical removal of the necrotic tissue under general anesthesia and split-thickness skin grafts. This is essential to avoid mortality.

(2) Secondary Postpartum Hemorrhage * it is fresh bleeding from the genital tract after the first 24 h. till 6 weeks after delivery. (7 – 14 days). * the most common cause is retained placental reminants. Endometritis is another cause. Then bleeding disorders , hormonal contraception and choriocarcinoma. * associated features are cramps abdominal pain. the uterus is larger than expected and signs of infection as tenderness.

* Management * Diagnosis : US is mandatory. * Treatment : = IV blood transfusion. = Syntocinon infusion. = Antibiotics should be given if placental tissues are found even without evidence of overt infection. = evacuation of the uterus under general anesthesia.

(3) Perineal Complications 1. perineal discomfort * it is the single major problem for mothers in the first 3 days. * discomfort is greatest in the presence of episiotomy , spontaneous tears following instrumental delivery. * treatment • local cooling by crushed ice. • topical anaesthetics as 5% lignocaine gel. • analgesics ; paracetamol or NSAIDs as; diclofenac suppositories at delivery followed by another 12 h latter.

2. perineal infection * uncommon , but if signs of infection occur these must be taken seriously. * caused by bacterial contamination during delivery , thus swabs from infected wounds for culture & antibiotic sensitivity. * treatment. . antibiotics. . . drainage if pus collected by removal of any skin sutures. . . if spontaneous opening of repaired tears or episiotomy , in presence of infection, should be irrigated twice daily & healing is allowed by secondary intention.

(4) Bladder Dysfunction * Voiding difficulty and over-distention of the bladder are not uncommon after delivery , especially , if epidural or spinal anesthesia has been used. * Causes • after epidural anesthesia the bladder may take 8 – 12 h to regain normal sensation. During this time about 1 liter of urine is produced and therefore , urinary retention occurs.

• caused also by pain or peri urethral edema due to traumatic delivery as : instrumental delivery , multiple extended lacerations , vulvo vaginal hematomas. * Distended bladder is diagnosed by being palpated as a suprapubic cystic mass or it may displace the uterus upwards or laterally , so increasing the height of the uterine fundus.

* treatment if regional anesthesia has been used , urinary catheter should be left in situ for the first 12 – 24 h especially if the residual urine in the bladder is > 300 ml. * Important stress incontinence is a rare problem in the puerperium , thus any urine incontinence should be investigated to exclude obstetric fistulae.

(5) Bowel Dysfunction * Constipation is a common problem in the puerperium. It caused either by interruption in the normal diet and dehydration during labor or as a result of fear of evacuation due to pain from a sutured perineum. * Advice on adequate fluid & fiber intake is necessary.

* In repaired 3 rd and 4 th degree perineal tears, avoidance of constipation & straining is very important as it would disrupt the repaired anal sphincter and cause anal incontinence. * It is important to give Lactulose and fibers as; Regulan immediately after repair for 2 weeks.

* Long -term anal incontinence following repair of 3 rd and 4 th degree perineal tears occurs in 5% and recto-vaginal fistula in 3% in the postpatum period. * Occult anal sphincter trauma occurs in 10 -30% of primiparous women , due to disruption of the internal anal sphincter detected by trans anal US.

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