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1. Abnormal PUERPERIUM 12/5/2023 Kassa Ketsela 1

2. Abnormal Puerperium Common puerperal problems include PPH Hypertensive disorders Infections Thromboembolism Bladder problems Perinea discomfort Lactation failure Psychiatric disorders Pelvic pains Hemorrhoids Constipation Back aches 12/5/2023 Kassa Ketsela 2

3. Uterine Subinvolution Uterine Subinvolution Arrest/retardation of uterine involution Cause - Retained products of conception or - Infections Manifestations UX Softer &larger than expected on bimanual exam Persistent lochia Excessive bleeding Treatment - Methylergonovine 0.2 mg every 3 to 4 hours for 24 to 48 hours, but its efficacy is questionable. Bacterial metritis ( Chlamydia trachomatis causes third of cases ) responds to oral antimicrobial therapy with Azithromycin or doxycycline therapy is appropriate empirical therapy. 12/5/2023 Kassa Ketsela 3

4. Late PPH Late /2 PPH Bleeding from 24 hrs – 12 weeks post partum ( ACOG 2006) Clinically worrisome uterine hemorrhage develops within 1 to 2 weeks in perhaps 1 % of women. Causes Abnormal Placental site involution Retained placental fragment - Usually the retained piece undergoes necrosis with deposition of fibrin & may eventually form placental polyp . - As the eschar of the polyp detaches from the myometrium, hemorrhage may be brisk ( occurs days 7-14, usually self limiting ) Bleeding disorders (von Willebrand disease) Infection 12/5/2023 Kassa Ketsela 4

5. Late PPH Contd. Management of Late PPH Uterotonics - for a stable patient, with empty uterus by ultrasound - (oxytocin, methylergonovine, or a PG analog) Antimicrobials - if uterine infection is suspected Suction or sharp curettage for RPC indicated if Large clots are seen in the uterine cavity. Bleeding persists or Recurs after medical management. 12/5/2023 Kassa Ketsela 5

6. Puerperal Infections Puerperal infection: is a general term used to describe any bacterial infection of the genital tract after delivery Puerperal Fever - A temperature of 38.0°C (100.4°F) or higher—in the puerperium. - Oral T o > 38.0°C (100.4°F) on any 2 of the first 10 days after delivery, exclusive of the first 24hrs 12/5/2023 Kassa Ketsela 6

7. Puerperal Infections Contd. Of those febrile in the first 24 hrs of delivery Pelvic infection was diagnosed subsequently in 20% of SVDs 70% of Cesarean deliveries Spiking fevers of > 39 c suspect Group A Streptococcal pelvic infection  fatal TSS = Toxic Shock Syndrome Early onset necrotizing fasciitis 12/5/2023 Kassa Ketsela 7

8. DDx of Puerperal Fever 1. Uterine Infection The most common 2. Urinary tract infection, 3. Lower genital tract infection, 4. Wound infections 5. Pulmonary infections, 6. Thrombophlebitis, and 7. Mastitis Puerperal Infections Contd. 12/5/2023 Kassa Ketsela 8

9. Uterine Infection Has different names Endometritis Endomyometritis Endoparametritis Metritis With Pelvic Cellulitis-more inclusive & preferred 12/5/2023 Kassa Ketsela 9

10. Uterine Infection Contd. Risk factors of Metritis With Pelvic Cellulitis Route of delivery CS > vaginal Is the single most significant risk factor Prolonged labor ROM Intrapartal chorioamnionitis Multiple cervical examinations Internal fetal monitoring Manual removal of placenta Multifetal gestation Young age & nulliparity Induction Obesity Meconium-stained amnionic fluid Bacterial colonization of lower GT - Group B streptococcus Chlamydia T, Mycoplasma , Ureaplasma u,& Gardnerella V. Low socioeconomic status 12/5/2023 Kassa Ketsela 10

11. Uterine Infection Contd. Bacteriology common vaginal and cervical flora Polymicrobial Virulence is promoted by Polymicrobial infection  bacterial synergy Hematoma and Devitalized tissues Routine pretreatment genital tract cultures are of little clinical use and add significant costs Routine blood cultures seldom modify care 12/5/2023 Kassa Ketsela 11

12. Bacteria Commonly Responsible for Female Genital Infections Aerobes Gram-positive cocci—group A, B, and D streptococci, enterococcus, Staphylococcus aureus, Staphylococcus epidermidis Gram-negative bacteria— Escherichia coli, Klebsiella,Proteus species Gram-variable— Gardnerella vaginalis Others Mycoplasma and Chlamydia species, Neisseria gonorrhoeae Anaerobes Cocci— Peptostreptococcus and Peptococcus species Others— Clostridium and Fusobacterium species Mobiluncus species 12/5/2023 Kassa Ketsela 12

13. Clinical Features Fever – Commonly 38-39C O most important criterion for the dx of post partal metritis Chills that accompany fever suggest bacteremia Lower Abdominal pain Uterine tenderness Parametrial tenderness Offensive lochia Group A Strept infection-scanty odorless lochia Leukocytosis 15-30,000 – no significance Uterine Infection Contd. 12/5/2023 Kassa Ketsela 13

14. Treatment Mild disease – oral antimicrobials as outpatient - 90% respond for Ampicillin + Gentamycin Moderate- severe disease- - Admit - IV antibiotics - 90% respond in 48- 72 hrs - Can be discharged after being afebrile at least for 24 hrs - Further oral antimicrobial therapy is not needed Uterine Infection Contd. 12/5/2023 Kassa Ketsela 14

15. Antimicrobial Regimens for Pelvic Infection Following Cesarean Delivery Regimen Comments Clindamycin 900 mg +  Gentamicin 1.5 mg/kg, q8h intravenously "Gold standard," 90–97% efficacy, once-daily gentamicin dosing acceptable + Ampicillin added to regimen with sepsis syndrome or suspected enterococcal infection Ceftriaxone 1gm IV BID + Metronidazole 500 mg IV TID What we use here Ampicilin2gm IV QID + Gentamicin 1.5 mg/kg, q8h intravenously + Metronidazole 500 mg IV TID What we use here Clindamycin +  aztreonam Gentamicin substitute with renal insufficiency Extended-spectrum penicillins Piperacillin , ampicillin / sulbactam Extended-spectrum cephalosporins Cefotetan, cefoxitin, cefotaxime Imipenem + cilastatin Reserved for special indications 12/5/2023 Kassa Ketsela 15

16. Prevention of Postpartum Infection of 1. Perioperative Antimicrobial Prophylaxis antimicrobial prophylaxis at the time of cesarean delivery has remarkably reduced the rate of postoperative pelvic and wound infections. The observed benefit applies to both elective and nonelective cesarean delivery and also includes a reduction in abdominal incisional infections Single-dose prophylaxis with Ampicillin(2gm Iv stat before skin incision ) or a first-generation cephalosporin is ideal, and both are as effective as broad-spectrum agents or a multiple-dose regimen Uterine Infection Contd. 12/5/2023 Kassa Ketsela 16

17. Uterine Infection Contd. Persistent fever despite antibiotic treatment of metritis may be 2 to Wound infection, dehiscence, abscess Parametrial phlegmon Pelvic abscess Adnexal infections Peritonitis uterine incision necrosis and dehiscence ,ruptured ovarian/ parametrial abscess 6. Necrotizing fasciitis 7. Septic pelvic thrombophlebitis 12/5/2023 Kassa Ketsela 17

18. Uterine Infection Contd. Wound Infections When prophylactic antimicrobials are given the incidence of abdominal incisional infections following cesarean delivery is <2 % . Wound infection is a common cause of persistent fever in women treated for metritis. Other risk factors for wound infections include obesity, diabetes, corticosteroid therapy, immunosuppression, anemia, hypertension, and inadequate hemostasis with hematoma formation. Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for its persistence beginning about the fourth day. Wound erythema and drainage are present . Treatment includes antimicrobials and surgical drainage, and wound care with careful inspection to ensure that the fascia is intact. 12/5/2023 Kassa Ketsela 18

19. Wound Dehiscence Disruption or dehiscence refers to separation of the fascial layer. Serious complication &requires relaparatomy There could concurrent fascial infection and tissue necrosis . Most disruptions manifested on about the fifth postoperative day and are accompanied by a serosanguineous discharge Uterine Infection Contd. 12/5/2023 Kassa Ketsela 19

20. Necrotizing Fasciitis This uncommon, severe wound infection is associated with high mortality . In obstetrics, necrotizing fasciitis may involve abdominal incisions, or it may complicate episiotomy or other perineal lacerations. There is significant tissue necrosis . Three risk factors of these— diabetes , obesity , & hypertension —are relatively common in pregnant women. Is polymicrobial infections of normal vaginal flora. In some cases, however, infection is caused by a single virulent bacterial species such as group A -hemolytic streptococcus . Treatment - broad-spectrum antibiotics along with prompt - wide fascial debridement until healthy bleeding tissue is encountered . Uterine Infection Contd. 12/5/2023 Kassa Ketsela 20

21. Peritonitis It is unusual for peritonitis to develop following cesarean delivery. It is almost invariably preceded by metritis & uterine incisional necrosis and dehiscence. Other cases may be due to - Inadvertent bowel injury at cesarean delivery - Rupture of a parametrial or adnexal abscess . - Rarely be encountered after vaginal delivery. Abdominal rigidity may not be prominent with puerperal peritonitis because of abdominal wall laxity from pregnancy . Treatment: laparatomy . Uterine Infection Contd. 12/5/2023 Kassa Ketsela 21

22. Adnexal Infections An ovarian abscess rarely develops in the puerperium. These are presumably caused by bacterial invasion through a rent in the ovarian capsule. The abscess is usually unilateral, and women typically present 1 to 2 weeks after delivery . Rupture is common and peritonitis may be severe. Uterine Infection Contd. 12/5/2023 Kassa Ketsela 22

23. Parametrial Phlegmon In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of induration, or phlegmon , within the leaves of the broad ligament. Phlegmons are usually unilateral, & they frequently are limited to the parametrial area at the base of the broad ligament. If the inflammatory reaction is more intense, cellulitis extends along natural lines of cleavage. The most common form of extension is laterally along the broad ligament, with a tendency to extend to the pelvic sidewall . Occasionally, posterior extension may involve the rectovagin al septum, producing a firm mass posterior to the cervix. Severe cellulitis of the uterine incision may lead to necrosis and separation. Extrusion of purulent material commonly leads to peritonitis. Uterine Infection Contd. 12/5/2023 Kassa Ketsela 23

24. DX Palpable mass on bimanual & or rectovaginal exam MRI- parametrial edema RX In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen. Typically, fever resolves in 5 to 7 days , but in some cases, it is longer. Uterine Infection Contd. 12/5/2023 Kassa Ketsela 24

25. Absorption of the induration may require several days to weeks. Surgery is reserved for women in whom uterine incisional necrosis is suspected. In rare cases, uterine debridement and resuturing of the incision are feasible . For most, hysterectomy and surgical debridement are needed and are predictably difficult. Uterine Infection Contd. 12/5/2023 Kassa Ketsela 25

26. Uterine Incision site cellulitis and necrosis Uterine debridement and resuturing Hysterectomy with debridement Pelvic Abscess- suppurating phlegmon Colpotomy CT guided drainage Uterine Infection Contd. 12/5/2023 Kassa Ketsela 26

27. Septic Pelvic Thrombophlebitis This was a common complication in the preantibotic era. Puerperal infection may extend along venous routes and cause thrombosis Lymphangitis often coexists The ovarian become involved because they drain the upper uterus and therefore, the placental implantation site Hematogenous extension of Pelvic infection thrombosis in pelvic veins Uterine Veins  ovarian veins ( particularly ROV )  Internal Iliac Vein Common Iliac Vein  Inferior venacava Occurs in 1/3000 deliveries 12/5/2023 Kassa Ketsela 27

28. Thrombophlebitis Contd. Clinical manifestation Women with septic thrombophlebitis usually have clinical improvement of pelvic infection with antimicrobial treatment, however, they continue to have fever. Although there occasionally is pain in one or both lower quadrants, patients are usually asymptomatic except for chills DX- Clinical Pelvic CT, MRI, Rx. Continued the antibiotic already started. Anticoagulation has no proven efficacy 12/5/2023 Kassa Ketsela 28

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30. Toxic Shock Syndrome This acute febrile illness with severe multisystem derangement has a case-fatality rate of 10 to 15 percent. There is usually fever, headache, mental confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, watery diarrhea, and marked hemoconcentration . Renal failure followed by hepatic failure, disseminated intravascular coagulation, and circulatory collapse may follow in rapid sequence. During recovery, the rash-covered areas undergo desquamation. Staphylococcus aureus has been recovered from almost all afflicted persons. Specifically, a staphylococcal exotoxin, termed toxic shock syndrome toxin-1 —TSST-1—causes the clinical manifestations by provoking profound endothelial injury. A very small amount of TSST-1 has been shown to activate 5 to 30 percent of T cells to create a "cytokine storm" as described by Que (2005) and Heying (2007) and their colleagues 12/5/2023 Kassa Ketsela 30

31. Toxic Shock Syndrome In some cases, infection is not apparent, and colonization of a mucosal surface is the presumed source. From 10 to 20 percent of pregnant women have vaginal colonization with S. aureus , and thus it is not surprising that the disease develops in postpartum women (Chen and colleagues, 2006; Guerinot and co-workers, 1982). Infection is complicated in some cases by streptococcal toxic shock syndrome produced when pyrogenic exotoxin is elaborated. Serotypes M1 and M3 are particularly virulent ( Beres and associates, 2004; Okumura and colleagues, 2004 ). 12/5/2023 Kassa Ketsela 31

32. Toxic Shock Syndrome Delayed diagnosis and treatment may be associated with fetal or maternal mortality (Crum and colleagues 2002; Schummer and Schummer 2002). Principal therapy for toxic shock is supportive, while allowing reversal of capillary endothelial injury (see Chap. 42, Management). Antimicrobial therapy to include staphylococcal and streptococcal coverage is given. With evidence of pelvic infection, antimicrobial therapy must also include agents used for polymicrobial infections. Women with these infections often require extensive wound debridement and possibly hysterectomy. Because the toxin is so potent, the mortality rate is correspondingly high (Hotchkiss and Karl, 2003). 12/5/2023 Kassa Ketsela 32

33. UTI Predisposing Factors Urinary stasis Catheterization, Prolonged labor Frequent pelvic examination In 3-4% post partum women Clinical Dysuria, frequency, urgency, and low-grade fever; Urinary retention, hematuria, pyuria Pyelonephritis-fever, chills, malaise,Nausea & Vomiting UA- WBC, RBC, Bacteria E.coli- most common etiology (~75%) 12/5/2023 Kassa Ketsela 33

34. UTI Treatment Antimicrobials specific against the isolated etiology Lower UTI- PO Nitrofurantoin Trimethoprim-sulfamethoxazole Cephalosporins (cephalexin, cephradine) Amoxicillin- Clavullinate Pyelonephritis – IV antibiotics Eg .- Ceftriaxone 1 gm IV BID or - Ampicilin 2gm IV QID + Gentamycin 1.5mg/Kg TID Response in 48 hrs, continue po medication for ~10 days 12/5/2023 Kassa Ketsela 34

35. Milk Fever (congestive Mastitis) Breast engorgement + fever Low grade fever in the 1 st few days pp Seldom lasts for > 24hr 15% of non breast feeding women Less severe& less common in breast feeding women RX- Ice packs, analgesics ,Tight Pressure (for non BF), milk expression after Breast feeding Pharmacologic suppression- not recommended Exclude other causes 12/5/2023 Kassa Ketsela 35

36. M astitis Mammary gland parenchyma infection Rare ~<1% Usually after 3 rd -4 th week post partum Invariably unilateral Marked engorgement followed by inflammation Hard, reddened, painful breast Chills, rigor, fever, tachycardia 12/5/2023 Kassa Ketsela 36

37. Mastitis Contd. Etiology S. aureus, MERSA (Community & hospital acquierd ) Coagulase negative S. aureus, Viridae streptococci Source – infant nose and throat Bacteria enter the breast through the nipple at the site of a fissure or small abrasion Treatment Milk expression and Continued BF Prevents stasis Empirically – Dicloxacilin , Cloxacillin / Erythromyci n With milk culture & sensitivity Rx for 10-14 days 12/5/2023 Kassa Ketsela 37

38. Breast Abscess In ~ 10 % of mastitis Dx Palpable fluctuating mass , Ultrasound No improvement in 48-72hrs of mastitis treatment RX Incision and drainage, pack Ultrasound guided needle aspiration (80-90% success) Antibiotics 12/5/2023 Kassa Ketsela 38

39. Galactocele Occasionally a milk duct becomes obstructed by inspissated secretions, and milk may accumulate in one or more mammary lobes. The amount is ordinarily limited, but an excess may form a fluctuant mass—a galactocele —that may cause pressure symptoms and have the appearance of an abscess. It may resolve spontaneously or require aspiration 12/5/2023 Kassa Ketsela 39

40. Accessory Breast Tissue Accessory Breast Tissue Extra breasts— polymastia , or extra nipples— polythelia , may develop along the former embryonic mammary ridge. Also termed the milk line , this line extends from the axilla to the groin bilaterally The incidence of accessory breast tissue ranges from 0.22 to 6 percent in the general population. Nipples Occasionally lactiferous ducts open directly into a depression at the center of the areola. With these depressed nipples, nursing is difficult. Abnormalities of Secretion There are marked individual variations in the amount of milk secreted. Many of these are dependent not on general maternal health but on breast glandular development. Rarely, there is complete lack of mammary secretion— agalactia . Occasionally, mammary secretion is excessive— polygalactia . 12/5/2023 Kassa Ketsela 40

41. Venous Thromboembolism (VTE) Puerperium is - Hypercoagulable state High fibrinogen level, Vascular injury, Immobility Increased platelet activity Incidence 1 in 500 to 1 in 2000 pregnancies Pulmonary Embolism in 25% untreated cases DVT Commonly lower extremity veins- often left leg Ilio - femoral and deep calf veins Isolated iliac vein 12/5/2023 Kassa Ketsela 41

42. VTE Contd. Risk factors Cesarean delivery Instrumental delivery Thrombophilias Early ambulation- protective DX and treatment Superficial vein thrombosis Supportive treatment-analgesia, elastic support, and rest. 12/5/2023 Kassa Ketsela 42

43. Postpartum Thyroiditis Autoimmune ( In ~10% ) DM – increased risk Hypo/ Hyperthyroid features Evaluation- TFT RX Hypo – Thyroxine supplementation Hyper-- β -blockers, PTU Sequelae Permanen t hypothyroidism (5-30% of PPT) 12/5/2023 Kassa Ketsela 43

44. Psychiatric Disorders Postpartum Blues Mild and transient mood disturbances- Affects 40-80% of post partum women Usually in the 1 st 10 days Self limiting Treatment  Reassurance, support 12/5/2023 Kassa Ketsela 44

45. Postpartal Depression More protracted depressive mood, Usual onset > 1month postpartum symptoms In~12-20% post partum women DX ( DSM V Peripartal Depression) Suicidal /Homicidal ideation- psychiatric emergency Rx : Psycohtherapy , antidepressants Recurrence ~25% 12/5/2023 Kassa Ketsela 45

46. Psychiatric Disorders Post Partal Psychosis in 0.1-0.2% of all postpartum women; symptoms usual onset b/n 1 st and 2 nd week cannot be distinguished from other psychoses anxiety, restlessness, Manic paranoid thoughts or delusions . Abnormal reaction towards family members. Admission to a psychiatric clinic ;. 12/5/2023 Kassa Ketsela 46

47. Obstetric Neuropathies Injury to branches of lumbosacral plexus by Fetal head Inappropriate legging Forceps Usually after prolonged 2 nd stage of labor Crampy leg pain ( uni or bilateral) Variable degree of Sensory or motor deficit Foot drop Resolve in 2wks- 18 mths (median duration~~2mths) 12/5/2023 Kassa Ketsela 47

48. Management of the Puerperium Immediate postpartal care (Hospital Care) VS, Vaginal bleeding, uterine contraction, Urinary retention encourage voiding, catheter Perineal discomfort look for hematoma Ice pack to reduce edema over episiotomy/laceration Help with breast feeding Encourage early ambulation Minimal bladder and bowel complaints, ↓ TE risk 12/5/2023 Kassa Ketsela 48

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50. Management Contd. Discharge within 24- 48hrs) for uncomplicated SVD 2-4 days for uncomplicated CS Instruction on Normal/ physiologic changes Danger signs (fever, excessive vaginal bleeding, or leg pain, swelling, or tenderness. Shortness of breath or chest pain, mood problems.) Diet , activity, perineal and breast care , 12/5/2023 Kassa Ketsela 50

51. Management Contd. Subsequent follow up Care 3-6days infections, postpartum depression, and problems with infant care and feeding, coitus, contraceptive 6weeks PP Recovery, Anemia, contraception, complaints 6months General health, any morbidity 12/5/2023 Kassa Ketsela 51

52. Postpartal Contraception Options LAM Barrier Hormonal IUDs Sterilization 12/5/2023 Kassa Ketsela 52

53. Contraception Contd. LAM Progestin only-POP, Implants, Injectable After 6weeks PP ( ACOG, WHO ) IUCD Both copper and LNG can be used Timing Post placental (~10min of placental delivery)  increased risk of expulsion 4-6weeks postpartum( after co mplete involution ) Female sterilization 24hrs - 07 days postpartum 6weeks postpartum 12/5/2023 Kassa Ketsela 53

54. Thank you 12/5/2023 Kassa Ketsela 54