Abnormal puerperium

Abnormal puerperium

1. ABNORMALITIES OF THE PUERPERIUM

2. PUERPERAL PYREXIA

3. A rise of temperature reaching 100 F (38 C) or more (measured orally) on 2 separate occasions at 24 hrs apart (excluding first 24 hours) within first 10 days following delivery is called Puerperal pyrexia. DEFINITION

4. PUERPERAL SEPSIS URINARY TRACT INFECTION MASTITIS CAUSES…

5. INFECTION OF CAESAREAN SECTION WOUND PULMONARY INFECTION A RECRUDESCENCE OF MALARIA / PULMONARY TUBERCULOSIS

6. PUERPERAL SEPSIS

7. An infection of the genital tract which occurs as a complication of delivery is termed puerperal sepsis Definition

8. Marked decline in cases: Improved obstetric care Availability of wider range of antibiotics Incidence

9. Endometritis Endomyometritis Endoparametritis common causes of sepsis

10. Causative organism Doderlein bacillus (60-70%) Yeast like fungus – candida albicans (25%) Staphylococcus albus or aureus Streptococcus – anerobic common E.coli Clostridium welchii

11. Predisposing factor

12. Pathogenic factor for vaginal flora The cervicovaginal mucous membrane is damaged even in normal delivery and the uterine surface too, specially at the placental site is converted into open wound by the seperation of the placenta which takes place during third stage of labor the blood clots present at the placental site are excellent media for the growth of the bacteria.

13. Antepartum factor Malnutrition and anemia Preterm labor Premature rupture of membrane Chronic debilitating illness (HIV) Prolonged rupture of membrane >18hrs Diabetes

14. Intrapartum factor Repeated vaginal examination Traumatic operative delivery Retained bits of placental tissue or membrane. Prolonged labour Hemorrhage Caesarean delivery

15. pathology Puerperal infection is an wound infection. The primary sites of the infection are:- Perineum Vagina Cervix Uterus

16. Perineum Laceration of the perineum are likely to be infected. The wound edges become red and swollen. There may be collection of purulent discharge resulting in complete disruption of the wound.

17. Vagina Vaginal laceration are infected directly or by extension from the perineal infection . The mucosa is swollen and hyperaemic , resulting in necrosis and sloughing

18. Cervix:- The cervical laceration becomes the site of infection Uterus :- The uterus is most common site of infection Decidua (placental site) is common site and infected first The infection usually manifests between 3 rd and 6 th day of delivery

19. Spread of infection Pelvic cellulitis:- ( lymphatics /blood route) Causes exudation n formation of indurated mass confined to one side of the uterus

20. Salpingitis :- (lymphatic spread) infection of the fallopian tube and ovaries with the formation of tubo ovarian mass Peritonitis :- Localised pelvic abscess

21. Thrombophelebitis :- Ovarian vein of one side is usually involved Uterine vein may also involved Suppuration n embolism to other organs Septicemia and pyemia :- These may lead to endocarditis , pericarditis , Renal abscess, lung abscess, meningitis or artheritis . “These are rare these days with advent of potent antibiotic”

22. Clinical features Local infection- Slight rise in temperature, generalised malaise and headache. Redness and the swelling of the local wound Pus formation and disruption of wound Uterine infection- Mild: Pyrexia of variable degree and tachycardia. Red, copius and offensive lochia. Subinvoluted , tender and soft uterus.

23. Sever infection- Fever with chills and rigor Rapid pulse Scanty, odorless lochia S ubinvoluted uterus Parametritis - Sustained rise in temperature (7 th to 10 th day) Constant pelvic pain Tenderness on either side of the hypogastrium Unilateral, tender mass felt on vaginal examination

24. Pelvic peritonitis:- Pyrexia with increased pulse rate Lower abdominal pain and tenderness Collection of the pus in pouch of douglas

25. Generalised peritonitis:- High fever with rapid pulse Vomiting Abdominal pain Tender and distended abdomen Thrombophelebitis – swinging fever with chills and rigor Features of pyemia

26. Septicemia- High temperature with rigor Rapid pulse Headache, insomnia or mental confusion Positive blood culture Sign/symptoms of infection in the lungs, meninges or joint

27. investigation Bacteriological study- Smear Culture and antibiotic sensitivity of purulent material High vaginal and cervial swabs Peritoneal fluids Blood culture

28. Urine :- Routine and microscopic examination Culture if infection is suspected Complete blood count-

29. Ultrasonography - For diagnosis of pelvic masses Pelvic abscess Pelvic peritonitis Retained bits of placenta and/ or membrane

30. Other specific investigation X – ray Blood for malaria parasite

31. SUBINVOLUTION

32. When the involution is impaired or retarded it is called subinvolution . DEFINITION

33. Grand multiparity , twins and hydramnios , Maternal ill health , Cesarean section , Prolapse of the uterus, Uterine fibroid. CAUSES:

34. The condition may be asymptomatic. Abnormal lochial discharge either excessive or prolonged , Irregular or at times excessive uterine bleeding , Irregular cramp like pain in cases of retained products or rise of temperature in sepsis SYMPTOMS:

35. The uterine height is greater than the normal for the particular day of puerperium . It feels boggy and softer. Presence of features responsible for subinvolution may be evident. SIGNS:

36. Appropriate therapy is to be instituted only when subinvolution is found to be a mere sign of some local pathology: Antibiotics in endometritis , Exploration of the uterus in retained products, Pessary in prolapse or retroversion. MANAGEMENT

37. Urinary tract infection

38. It is an infection of the urinary organs such as kidney, ureter, urinary bladder and urethra.

39. Causative organism E. coli Klebsiella Proteus Staphylococcus aureus

40. Other causes are:- Recurrence of previous cystitis and pyelitis Infection contracted for the first time during pregnancy is due to E ffect of frequent catheterization either during labor or in early puerperium to relative retention of urine. Stasis of urine during early puerperium due to lack of bladder tone and less desire to pass urine.

41. Incidence It is one of the common cause of puerperal pyrexia, the incidence being 1- 5 % of all deliveries .

42. Diagnosis UTI is confirmed by examination of an uncontaminated midstream clean catch sample for urinalysis and culture and antibiotic sensitivity test.

43. Management High fluid intake Adequate drainage of urine Appropriate antimicrobial therapy.

44. BREAST ENGORGEMENT

45. CAUSES Due to exaggerated normal venous and lymphatic engorgement. Prevent the escape of milk from lacteal system.

46. INCIDENCE In primiparous

47. ONSET Third and forth day postpartum

48. SYMPTOMS Pain Heaviness in both breast Malaise Rise of temperature Painful breast feeding

49. PREVENTION Avoid prelacteal feeding Initiate breast feeding early and unrestricted Exclusive breast feeding on demand Feeding in correct position

50. TREATMENT Breast supports Manual expression of remaining milk after each feed In severe condition use breast pump

51. CRACKED AND RETRACTED NIPPLES

52. it occurs due to loss of surface epithelium or due to a fissure situated at the tip or base of the nipple

53. CAUSE Crust formation over nipple due to unhygiene Retracted nipple Trauma from baby's mouth

54. SYMPTOMS Asymptomatic condition pain while feeding

55. PROPHYLAXIS Local cleanliness during pregnancy and in puerperium before and after each feeding

56. COMPLICATION Mastitis

57. TREATMENT Correct attachment will provide immediate relief from healing and pain Fresh human milk and saliva have got an healing property breast pumps in severe cases