ABNORMAL PUERPERIUM PRESENTATION. 6 weeks

Best compiles

1. NAMUBIRU AISHA

2. ABNORMALITIES OF THE PUERPERI UM Puerperal Pyrexia. Puerperal Sepsis. Subinvolution. Urinary complications: UTI, Urinary Retention, Urinary Incontinence, Urinary Suppression Breast Complications: Breast Engorgement, Cracked & Retracted Nipples, Acute Mastitis Puerperal Venous Thrombosis & pulmonary embolism. Puerperal emergencies, obstetric palsies, Psychiatric disorders during puerperium.

3. PUERPERAL PYREXIA “ A rise of temperature reaching 100.4 degree F or more (Measured orally) on two separate occasions 24 hours apart (excluding first 24 hours) within the first 10 days following delivery is called Puerperal pyrexia ” In some countries postabortal fever is also included.

4. CAU SES : - I n f e c ti on: LSCS wound P u lmona r y infection

5. 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.

6. INC E D E NCE There is a marked decline in puerperal sepsis during the past few years due to:- Improved obstetric care Availability of wider range of antibiotics

7. CAU SES : - Combination of all is called Pelvic Cellulitis

8. PREDISPOSING FACTORS Damage of Cervicovaginal mucous membrane Large placental wound surface area Blood clots presents at placental site ANTEPARTUM FACTORS: Malnutrition and an a emia Preterm labour PROM Chronic illness Prolonged rupture of membrane >18 hours

9. INTRAPARTUM FACTORS: Repeated vaginal examinations Prolonged rupture of membranes Dehydration and keto- acidosis during labour Traumatic operative delivery H a emorrhage Retained bits of placenta or membranes Placenta previa C a esarean Section delivery

10. MICRO-ORGANISMS RESPONSIBLE FOR PUERPERL SEPSIS AEROBIC :- Streptococcus hemolytic group- A Streptococcus hemolytic group - B Others: Streptococcus pyogenus , aureus, E coli, Pseudomonas, chlamydia ANAEROBIC:- Streptococcus, peptococcus , bacteriodes

11. 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.

12. CLINICAL FEATURES:-

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

14. 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

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

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

17. 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

18. 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

19. GENERAL CARE:- Isolation of the patient . Adequate fluid and calorie (IV) . C orrected anaemia. Progress chart should be maintained . T R EA T M E N T

20. 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 Metr o nidazole 0.5 g IV, 8 hourly continue atleast 7-8 days

21. 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 wound closure may be done on later date . SURGICAL TREATMENT

22. RETAINED UTERINE PRODUCTS:- With diameter of 3 cm or less may be disregarded or left alone Ot her wise surgical evacuation after antibiotic coverage for 24 hours should be done to avoid risk of septicemia SEPTIC THROMBOPHLEBITIS:- IV Heparin for 7-10 days

23. PELVIC ABCESS:- Drainage by colpotomy under ultrasound guidance WOUND DEHISCENCE: Dehiscence of episiotomy or abdominal wound following c a esarean section:- Scrubbing the wound Debridement of all necrotic tissues Secondary suture

24. LAP A ROTOMY: 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

25. NECROTYSING FA S CITIS: Wound scrubbing Debridement of all necrotic tissues U se of effective antimicrobial agents BACTEREMIC OR SEPTIC SHOCK: Fluid and electrolyte balance Respiratory supports Circulatory support (dopamine/ dobutamine) Infection control

26. SUBINVOLUTION

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

28. CAU SES PREDISPOSING FACTORS: Grand multipara Over distention of uterus Maternal ill health C a esarean section Prolapse of the uterus Retroversion Uterine fibroid

29. CAU SES AGGRAVATING FACTORS:- Retained products of conception Uterine sepsis (Endometritis)

30. SY M P TO M S May be asymptomatic sometimes Abnormal l ochial d ischarge : e xcessive or prolonged Irregular at times e xcessive u terine b leeding Irregular c ramp like p ain Rise of t emperature in case of s epsis

31. S IGNS Fundal height Greater than Postnatal Day Uterus feels Boggy and Softer Displaced Bladder or Loaded Rectum

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

33. URINARY COMPLICATIONS IN PUERPERIUM

34. URINARY TRACT INFECTION Most common cause of puerperal pyrexia . Inc i dence 1-5 % . May be because of consequences of: Reccurence of previous cystitis or pyel onephri tis, asymptomatic bacteriuria . Or f irst time because of: Frequent catheterization, stasis of urine .

35. ORGANISMS RESPONSIBLE:- S t re p t o coccal aureus

36. CLINICAL FETURES: F ev er Pus, blood clots in urine A c u te pain Burning mit u ri t i o n

37. MANAGEMENT: IV fluids

38. RETENTION OF URINE Common complication in early puerperium. CAUSES: Bruising Edema of bladder neck Reflex from the perineal injury An accust o mi s ed position

39. TR E AT M E NT Indwelling catheter for 48 hours Following removal of a 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

40. INCONTENENCE OF URINE Not a common symptom following birth It may be:- Stress incontenence (late puerperium) O verflow incontenence ( following retention of urine) True incontenence (soon following labour)

41. SUPRESSION OF URINE “If the 24 hours urine excretion is less than 400 ml or less, supression of urine is d i agnosed.” The cause is to be sought for and appropriate management is instituted.

42. BREAST CO M P LIC A TI O N S

43. COMMON COMPLICATIONS Breast engorgement Cracked and inverted nipple s Mastitis and breast ab s cess Lactation failure

44. 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

45. 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)

46. S Y M P T O M S Consi d e rable pain and feeling of tendernes or heaviness G e n e r a l ized malaise Painful breast fe e d i n g Rise of t e mpe r ature

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

48. 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 Warm compression

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

50. CAU SES :

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

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

53. 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

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

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

56. ACUTE MASTITIS Incidence of mastitis is 2-5 % in lactating women Less than 1% in nonlactating . Organisms involved are... Streptococcus aureus, S. epidermidis and Streptococci viridans

57. 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 s to development of primary mammary adenitis

58. 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 occur after several weeks also

59. CLINICAL FEATURES S Y M P T O M S INCLUDE: G e ne r a li z ed malaise and headache Fever ( 102 degree F) Severe pain and tender swelling

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

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

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

63. 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 Penicillins like flucloxacillin are is the drug s of choice. 500 mg 6 hourly. erythromycin is alternative

64. Antibiotic therapy is to continue up to 7 days Analgesics Milk flow is maintained by feeding the baby It will prevent prol i feration of staphylococcus in the stagnant milk The ingested staphylococcus will be digested without any harm

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

66. MANAGEMENT Incision and drainage under general an a esthesia 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

67. 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 hours by a smaller pack Continue till it heals up Ab s cess can also be drained by serial percutaneous niddle aspiration under ultrasound guidance Surgical draiange is commonly done

68. Breast feeding is cont i nued at uninvolved side The infected side is mechanically expressed by pump every two hour s and with every let down Recurrence risk is about 10 % Once cellulitis has resolved breast feeding from the involved side may be resumed

69. BREAST PAIN May be due to.... Engorgement Infection ( candida albicans) Nipple trauma Mastitis Occasionally on l a tching-on or let down reflex

70. 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

71. 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

72. MANAGEMENT ANTENATAL: Counsell mother regading benefits of nursing her baby To take care of any breast abnormality.. breast engorgement Maintaining adequate breast hygiene e specially in the last two months of pregnancy

73. PUERPERIUM: Encourage adequate fluid intake To nurse the baby regularly Treat the painfull local lesions to prevent nursing phobia Metoclopramide 10 m g thrice daily, intranasal oxytocin and sulpiride ( selective dopamine intagonist) has been found to increase milk production. They act by stimulating prolactin secretion

74. P U L M O NAR Y VEN O US THROMBOSIS

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

76. 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

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

78. 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

79. INVESTIGATIONS Doppler utrasound VUS- venous utrasonography Venography MRI

80. PELVIC THROMBOPHLEBITIS Originates in the thrombosed veins at placental site by organism s such as an anaerobic streptococci or bacteriosides When localised in the pelvis its called pelvic thrombophlebitis . There is specific features but it is suspected when there is constatnt fever in spite of antibiotics administration .

81. 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)

82. 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

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

84. 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 Administration of fibrinolytic agents Venous thrombectomy

85. PULMONARY EMBOLISM 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

86. Important signs... Tachypnea Dyspn o ea Pleuritis- chest pain Cough Tachycardia H a emoptysis Rise in temperature

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

88. MANAGEMENT Prophylactic measures Active treatment: Resuscitation: cardiac massage, oxygen therapy, heparin bolus IV of 5000 units and morphine 15 mg IV fluids Incase of recurrent .. embolectomy, placement of caval filters, ligation of inferior vana cava and ovarian veins

89. 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

90. 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

91. Condition is usually mild May pass 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

92. Management of damaged lumbosacral nerve roots is same as that of the proplapsed intervertebral disc in consultation with an orthop aedic surgeon. Paraplegia due to epidural h a ematoma or abcess is rare.

93. PUERPERAL E M ERGEN C I ES

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

95. Common complications are ; IMMEDIATE: Postpartum h a emorrhage Shock Postpartum pre/ eclampsia Pulmonary embolism Uterine inversion.

96. EARLY (WITHIN A WEEK) . Acute retention of urine Urinary tract infection Puerperal sepsis Breast engorgement Mastitis and breast ab s cess Pulmonary infection Anuria due to AKI following abruptio placenta e , mismatched boold transfusion or pre/ eclampsia

97. DELAYED : Secondary postpartum h a emorrhage Thrombo-embolic manifestation Psychosis Postpartum cardio myo pathy Postpartum h a emolytic uremic syndrome

98. PSYCHIATRIC DISORDERS DURING PUERPERIUM

99. 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

100. HIGH RISK FACTORS PAST HISTORY: Psychiatric illness Puerperal psychiatric illness FAMILY HISTORY: Major psychiatric illness Marital conflicts Lack of social s upport

101. PRESENT PREGNANCY: Young age C a esarean delivery Difficult labour Neonatal complications OTHERS: Unmet expectations

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

103. MANIFESTATIONS ARE: Depression Anxiety Tearfulness 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

104. TREATMENT: Reassurance Psychological support by the family members

105. 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 hypoth a lamo-pitutary - adrenal axis may be a cause

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

107. TREATMENT: Is started early Fluoxetine or paroxetine ( Selective serotonin re uptake inhibitors) General supportive measures

108. 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

109. MANIFESTED BY: Fear Restlessness Confusion followed by hallucination s , delusion s and disorientation Suicidal, infanticidal ideation Temporary seperation and clinical supervision is needed Risk fo r reccurence 20-25%

110. M A NA G E M E N T 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 causes 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

111. 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 also be because of unexcpected hysterectomy, birth of malformed or chronically ill infant Prolonged seperation from chronically ill infant can also cause grief

112. Physician, nurse and attending staff must understand patient's reaction The common maternal somatic symptoms are ; Insomnia Fatigue Sighing respiration Feeling of guilt Anger Hostility ( feeling of opposition)

113. MANAGEMENT OF PERINATAL GRIEVING Facilitating grieving process with consolation (comfort), support, sympathy Others are: S upporting the couple in seeing/ holding/ taking photographs of infant Autopsy requests Planning investigations Follow up visits Plan for subsequent pregnancy

114. THANK YOU