Abnormal puerpeium....................pptx

NA

1. NORMAL PUERPERIUM

2. ABNORMALITIES OF THE PUERPERIUM Puerperal Pyrexia Puerperal Sepsis Subinvolution Urinary complications: UTI, Urinary Retention, Urinary Incontinence, Urinary Suppression Breast Complications: Breast Engorgement, Cracked & Retracted Nipple, Acute Mastitis Puerperal Venous Thrombosis & Pulmonary Embolism Puerperal Emergencies, Obstetric palsies, Psychiatric Disorders during puerperium

3. PUERPERAL PYREXIA

4. 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.

5. CAUSES:- Infection: LSCS wound Pulmonary infection

6. 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.

7. 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

8. CAUSES:- Combination of all called as Pelvic Cellulitis

9. 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

10. 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

11. MICRO-ORGANISMS RESPONSIBLE FOR PUERPERL SEPSIS

12. AEROBIC :- Streptococcus hemolytic group- A Streptococcus hemolytic group - B Others: Streptococcus pyogenus, aureus, E coli, Pseudomonas, chlamydia ANAEROBIC:- Streptococcus, peptococcus, bacteriodes

13. 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.

14. CLINICAL FEATURES:-

15. 1. LOCAL INFECTION Slight temperature rise Generalized malaise Headache Redness and swelling to local wound Pus formation

16. 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

17. 3. SPREADING INFECTION Parametritis Pelvic pritonitis General peritonitis Thrombophlebitis Septicemia

18. INVESTIGATION High vaginal endocervical swab Blood examination History, Clinical examination Pelvic ultrasound CT scan, MRI

19. 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

20. 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

21. GENERAL CARE:- Isolation of the patient Adequate fluid and calorie (IV) Anemia is to be corrected Progress chart should be maintained TREATMENT

22. ANTIBIOTICS

23. 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

24. SURGICAL TREATMENT

25. 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

26. 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

27. 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

28. 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

29. 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

30. SUBINVOLUTION

31. DEFINITION “When the involution is impaired or retarded it is called subinvolution” The uterus is the most common organ

32. CAUSES PREDISPOSING FACTORS: Grand multipara Over distention of uterus Maternal ill health Cesarean section Prolapse of the uterus Retroversion Uterine fibroid

33. CAUSES AGGREAVATING FACTORS:- Retained products of conception Uterine sepsis (Endometritis)

34. 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

35. SIGNS Fundal height Greater than Postnatal Day Uterus feels Boggy and Softer Displaced Bladder or Loaded Rectum

36. MANAGEMENT Antibiotics in case of infection Exploration of uterus for retained products Pessary in prolapse or retroversion Methargin to enhance involution process

37. URINARY COMPLICATIONS IN PUERPERIUM

38. 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

39. ORGANISMS RESPONSIBLE:- Streptococcal aureus

40. CLINICAL FETURES: Fever Pus, blood clots in urine Acute pain Burning miturition

41. MANAGEMENT: IV fluids

42. RETENTION OF URINE Common complication in early puerperium. CAUSES: Bruising Edema of bladder neck Reflex from the perineal injury Anaccustamized position

43. 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

44. 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)

45. 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.

46. BREAST COMPLICATIONS

47. COMMON COMPLICATIONS Mastitis and breast abcess Lactation failure Cracked and inverted nipple Breast engorgement

48. 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

49. 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 ( 3 rd and 4 th day postpartm)

50. SYMPTOMS: Considerable pain and feeling of tendernes or heaviness Generalized malaise Painful breast feeding Rise of temperature

51. PREVENTION: Avoid prelecteal feeds Initiate early breast feeding Exclusive breast feeding on demand Feeding in correct position

52. 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

53. CRACKED AND RETRACTED NIPPLE The nipple may become painful due to:

54. CAUSES:-

55. SYMPTOMS Condition may remain asymptomatic Sometimes painful when feeding the baby When infected, the infection may spread to the deeper tissue proceding mastitis

56. PROPHYLAXIS Local cleanliness during pregnancy and puerperium Clean the crusts before and after feeding Application of lotion to soothen the epithelium

57. 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

58. For inflammed nipple and areola miconazole lotion is applied Apply nipple shields If persistant... biopsy is needed

59. RETRACTED AND FLAT NIPPLE Commonly seen in primiparous mother Manual expression of milk is initiated Correction of retracted nipple

60. 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

61. Mode of infection:- Two different 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 ...lead to development of primary mammary adenitis

62. 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

63. CLINICAL FEATURES SYMPTOMS INCLUDE: Generalized malaise and headache Fever ( 102 degree F) Severe pain and tender swelling

64. CLINICAL FEATURES SIGNS INCLUDE: Presence of toxic features Redness of overlying skin and swelling Warm and flushy

65. COMPLICATION Due to variable distruction of breast tissues, it leads to the formation of a breast abcess.

66. PROPHYLAXIS Hand washing before and after each feed, maintaing hygiene, keep the breast and nipple dry

67. 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 alternative

68. 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

69. BREAST ABCESS FEATURES ARE: Flushed breasts not responding to antibiotics Browny edema on the overlying skin Marked tenderness with fluctuation Swinging temperature

70. 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

71. 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

72. 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

73. BREAST PAIN May be due to.... Engorgement Infection ( candida albicans) Nipple trauma Mastitis Occasionally on letching-on or let down reflex

74. MANAGEMENT Appropriate nursing technique 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

75. 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

76. 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

77. 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

78. PULMONARY VENOUS THROMBOSIS

79. PREVALENCE Thrombosis of leg vein and pelvic vein is most common However, the prevalence is less

80. 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

81. This stasis causes damage to the endothelial cells Thrombophilias are hypercoaguable states in pregnancy that increase the risk of venous thrombosis (inheritate/ acquired)

82. 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

83. 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

84. INVESTIGATIONS Doppler utrasound VUS- venous utrasonography Venography MRI

85. 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

86. 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)

87. 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

88. PROPHYLAXIS PREVENTIVE MEASURES: Prevention of trauma, sepsis, anemia, dehydration Use of elastic compression stocking Leg exercise, Early ambulation

89. 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

90. 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

91. Important signs... Tachypnea Dyspnea Pleuritis- chest pain Cough Tachycardia Hemoptysis Rise in temperature

92. DIAGNOSIS ECG Arterial blood gas D-Dimer: value (More than 500 ng/ mL) Doppler utrasound Lung scans Pulmonary angiography Spital CT MRA: Magnetic resonance angiography

93. 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

94. 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

95. It is due to stretching of the lumbosacral trunk by the prolapsed intervertebral disc between L 5 and S 1 B ackward 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

96. 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

97. 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.

98. PUERPERAL EMERGENCIES

99. There are many acute complications Majority of them are alarming complications Arises immediately after delivery Except pulmonary embolism

100. Common complications are ..... IMMEDIATE: Postpartum hemorrhage Shock Postpartum eclapmsia Pulmonary embolism Inversion

101. 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

102. DELAYED : Secondary postpartum hemorrhage Thrombo-embolic manifestation Psychosis Postpartum cardiopathy Postpartum hemolytic uremic syndrome

103. PSYCHIATRIC DISORDERS DURING PUERPERIUM

104. 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

105. HIGH RISK FACTORS PAST HISTORY: Psychiatric illness Puerperal psychiatric illness FAMILY HISTORY: Major psychiatric illness Marital conflicts Poor social situation

106. PRESENT PREGNANCY: Young age Cesarean delivery Difficult labour Neonatal complications OTHERS: Unmet expectations

107. PUERPERAL BLUES It is transient state of mental illness observed 4-5 days after delivery Lasts for few days Incidence is 50 %

108. MANIFESTATIONS ARE: Depression Anxiety Tearfullness 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

109. TREATMENT: Reassurance Psychological support by the family members

110. 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

111. MANIFESTED BY: Loss of energy Loss of appetite Insomnia Social withdrawal Irritability Suicidal attitude Risk of reccurence is 50-100% in subsequence pregnancies

112. TREATMENT: Is started early Fluoxentine or paroxetine (serotonin uptake inhibitors) General supportive measures

113. 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

114. 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%

115. 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

116. 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

117. 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)

118. 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