Puerperium and lactation

it describes in detail about puerperium and lactation and their associated complications and management.

1. PUERPERIUM AND LACTATION DR. AYESHA SHERZADA FCPS R1

2. OBJECTIVES D efinition of puerperium, physiological changes in body during puerperium. Management of puerperium. Complications. Importance of breastfeeding. Mental health during puerperium.

3. PUERPERIUM The puerperium is the period from the delivery of he placenta to 6 weeks after the delivery.

4. PHYSIOLOGY O F PUERPERIUM Two major physiological events occur during the puerperium: the establishment of the lactation the return of the physiological changes of pregnancy to the non-pregnant state. During first two weeks----some changes are rapid. Others take 6-12 weeks to complete.

5. CHANGES DURING PUERPERIUM Involution of uterus. Lochia Ovulation and menstruation. Cervical changes. Cardiovascular and coagulation. Urinary tract. Weight loss. Thyroid functions. Hair loss.

6. UTERINE INVOLUTION Pregnant uterus at term weighing about 1 kg returns to pre-pregnant state of < 100gms. Uterine fundus is no longer palpable abdominally by 10 days after delivery, and uterus returns to normal size by 6 weeks. Involution is by autolysis, muscle cells diminish in size, not in numbers. Involution appears to be accelerated by oxytocin in breastfeeding.

7. CAUSES OF DELAYED INVOLUTION Full bladder Loaded rectum Uterine infection Retained products of conception Fibroids Broad ligament hematoma.

8. LOCHIA Blood stained uterine discharge comprised of blood and necrotic decidua. Basal layer is involved in regeneration of new endometrium after necrotic decidua is sloughed off. Regeneration is completed by 3 rd week. Persistence of red or offensive lochia is suggestive of pathology, should be manage accordingly.

9. OVARIAN FUNCTION In non-lactating women, ovulation occur as early as 27days after delivery---mean time is approx. 70-75 days. In lactating women, mean time to ovulation is 6 months. Menstruation resumes by 12 weeks after birth in 70% non-lactating women, mean time is 7-9 weeks. Risk of ovulation within 6 months after delivery in lactating women is 1-5%. Reason of ovulation suppression in lactating women is ----prolactin.

10. CARDIOVASCULAR & COAGULATION SYS. Changes in the cardiovascular and coagulation systems during the puerperium cardiovascular Early puerperium Late puerperium Heart rate Falls 14% by 48hrs Normal by 2wks Stroke vol. Rises over 48hrs Normal by 2wks Cardiac output Remains elevated & then falls over 48hrs Normal by 24wks Blood pressure Rises over 4days Normal by 6wks Plasma vol. Initial increases then falls. Progressive decline in 1 st wk.

11. CARDIOVASCULAR & COAGULATION SYS. coagulation Early puerperium Late puerperium fibrinogen Rises in 1 st wk Normal by 6wks Clotting factors Most remains elevated Normal by 3wks Platelets count Falls and then rises Normal by 6wks fibrinolysis Rapid reversal of pregnancy inhibition of tissue plasminogen activator. Normal by 3wks

12. OTHER SYSTEMS Urinary tract: Bladder and urethra may show mild trauma sustained at delivery & are associated with localized edema. Completely returns to normal in 6-8wks. Thyroid function: Thyroid vol. inc by 30% during pregnancy. Returns to normal over 12wks. Thyroid hormones return to normal within 4wks.

13. OTHER SYSTEMS Weight loss: Immediate loss of 4.5-5kgs after delivery. 28 % women returns to pre-pregnancy weight by 6wks. Women with excessive weight gain 0f >15kg, still have 5kgs net gain at 6 months. Breastfeeding has no effect on postpartum weight loss unless lactation cont. for 6months. Diet and exercise have no effect on growth of infant. Hair loss: This is transient phenomenon, more hair is lost than regrown.

14. MANAGEMENT OF NORMAL PUERPERIUM

15. DAILY ROUND SHOULD INCLUDE VITALS: pulse, BP, temp, resp rate. CHEST: auscultate in all pts , esp post C/S. BREASTS : examine for engorgement and signs of infection . UTERUS : palpate uterine fundus to evaluate level & tone. ABDOMEN : examine for distention, especially postoperatively. LOCHIA : for quality and unusual odor. PERINEUM : inspected for hematoma formation, signs of infection, or wound breakdown .

16. DAILY ROUND SHOULD INCLUDE BLADDER : function may be abnormal after traumatic delivery or epidural anesthesia. ( catheter may be left in place for 24hrs, if there is marked periurethral edema or repair .) EXTREMITIES : because postpartum patients are at increase risk of DVT, especially post C/S.

17. ADVISE AFTER DELIVERY Encourage for breastfeeding. Encourage for early mobilization after C/S. Counsel for effective contraception. Postpartum immunization in Rh-ve women. Health and nutrition education: Calories intake should be individualized on women’s BMI and activity level. Care of nipples and areola. Sexual intercourse can be resumed 6 weeks after delivery. Immunization of child.

18. COMPLICATIONS OF THE PUERPERIUM The most serious complications are thromboembolism, infections and hemorrhage, as well as mental disorders and breast problems.

19. PERINEAL COMPLICATIONS Pain in about 80% of women in 1 st 3 days of delivery. Discomfort is greatest in those who sustain spontaneous tears, episiotomy or instrumental delivery. Sitz bath, oral diclofenac or paracetamol, topical analgesics----for pain relief. Spontaneous opening of repaired perineal tears and episiotomies ------sec. infections. Avoid surgical repair------allow to heal by sec. intention. Sec . repair-----no exudate and cellulitis & granulation tissue present.

20. URINARY COMPLICATIONS

21. URINARY COMPLICATIONS Urinary retention. Causes--- painful episiotomy, epidural anesthesia, instrumental deliver. Avoid urinary retention in immediate postnatal period, as over-distension may leads to atonic bladder. After epidural anesthesia bladder may take up to 8 hrs. to regain normal sensation. Fluid overloading prior to epidural + antidiuretic effect of high conc. of oxytocin + inc. postpartum diuresis + inc. fluid intake by lactating mother =inc. urine production in puerperium.

22. URINARY COMPLICATIONS Minimize the risk of over-distention of the bladder after C/S & epidural anesthesia by leaving catheter in situ for 12-24 hrs. Investigate any incontinence to exclude vesico-vaginal, urethro-vaginal and uretero-vaginal fistula. Prolonged obstructed labour----pressure necrosis and incontinence. 15 % of women have urinary incontinence that persists for 3 months.

23. BOWEL PROBLEMS 35% of women develop anal sphincter injury after 1 st vaginal delivery. In 10%, it persists for 3 months. Common cause is instrumental (forceps> vaccum ) delivery. Incidence of 3 rd & 4 th degree tears varies from centre to centre .

24. BOWEL PROBLEMS Constipation is common problem in puerperium, causes are---interruption of normal diet, dehydration, fear of pain d/t sutured perineum, prolapsed haemorrhoids , anal fissures. Constipation can be prevent by giving lactulose, ispaghol husk or methylcellulose immediately after repair, for 2wks period.

25. THROMBOSIS AND EMBOLISM CEMACH shows that pulmonary embolism is still a major cause of death in the puerperium. Risk of thromboembolism rises 5 fold during pregnancy and puerperium. Three major risk factors are inc maternal age, obesity & family hx . Can be avoid by early mobilization, DVT stockings, and LMW heparin.

26. PUERPERAL PYREXIA Defined as temperature of 38C or higher on any two occasions of the first 10 days postpartum, exclusive of the first 24hrs.

27. GENITAL TRACT INFECTIONS Pu erperal sepsis syn with older descriptions of puerperal fever, milk fever & childbed fever. Sepsis in the puerperium remains an important cause of maternal death, accounting for around 10 deaths per year in the UK.

28. RISK FACTORS Obesity Impaired glucose tolerance/diabetes Impaired immunity / immunosuppressant medication Anaemia Vaginal discharge History of pelvic infection Amniocentesis and other invasive procedures Cervical cerclage Prolonged spontaneous rupture of membranes Vaginal trauma, caesarean section, wound haematoma Retained products of conception GAS infection in close contacts / family members Black or minority ethnic group origin

29. COMMON PATHOGENS The major pathogens causing sepsis in the puerperium are: GAS, also known as Streptococcus pyogenes Escherichia coli Staphylococcus aureus Streptococcus pneumoniae meticillin -resistant S. aureus (MRSA), Clostridium septicum and Morganella morganii

30. OTHER CAUSES OF SEPSIS Mastitis, urinary tract infection pneumonia skin and soft-tissue infection gastroenteritis and pharyngitis are likely causes of sepsis other than the genital tract . Rarer causes include bacterial meningitis.

31. SYMPTOMS OF PUERPERAL SEPSIS Fever rigors (persistent spiking temperature suggests abscess). Beware: normal temperature may be attributable to antipyretics or NSAIDs Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock) Breast engorgement / redness Rash ( generalised maculopapular rash ) Abdominal /pelvic pain and tenderness Wound infection – spreading cellulitis or discharge Offensive vaginal discharge (smelly: suggestive of anaerobes; serosanguinous : suggestive of streptococcal infection) Productive cough Urinary symptoms Delay in uterine involution heavy lochia General – non-specific signs such as lethargy, reduced appetite

32. SIGNS OF PUERPERAL SEPSIS Pyrexia Hypothermia Tachycardia Tachypnea Hypoxia Hypotension Oligouria Impaired consciousness & failure to respond o treatment.

33. MANAGMENT The focus of infection should be sought and dealt with . Administration of intravenous broad-spectrum antibiotics, till sensitivity report is awaited. Breastfeeding limits the use of some antimicrobials. The presence of shock or other organ dysfunction in the woman is an indication for admission to the ICU

34. Antimicrobial choices and limitations of antimicrobials Antimicrobial Limitations Co- amoxiclav Does not cover MRSA, Pseudomonas or ESBL-producing organisms Metronidazole Only covers anaerobes Clindamycin Covers most streptococci and staphylococci, including many MRSA, and switches off exotoxin production with significantly decreased mortality. Not renally excreted or nephrotoxic Piperacillin / tazobactam and carbapenems Covers most organisms except MRSA and are renal sparing (in contrast to aminoglycosides) Piperacillin / tazobactam does not cover ESBL producers Gentamicin (as a single dose of 3–5 mg/kg) Poses no problem in normal renal function but if doses are to be given regularly serum levels must be monitored

35. PREVENTION OF PUERPERAL SEPSIS Increase awareness of the principles of general hygiene. Good surgical approach and use of aseptic techniques. Prophylactic antibiotics in cesarean section.

36. SECONDARY POSTPARTUM HAEMORRHAGE Fresh bleeding from the genital tract btw 24hrs & 6wks after delivery . Causes are; Endometritis . RPOCs Subinvolution of placental implantation site. Bleeding disorders

37. SPPH MANAGEMENT Assessment of vaginal microbiology(vaginal/ endocervical ). Appropriate use of antimicrobial therapy, when endometritis is suspected. Pelvic ultrasound to exclude RPOCs. Surgical evacuation of retained placental tissue, if present.

38. PUERPERAL PSYCHOLOGICAL DISORDERS. Most common are; Postpartum blues Postnatal depression. Puerperal psychosis .

39. POSTPARTUM BLUES The transient experience of tearfulness, anxiety and irritability, frequently occur in 1 st few days following delivery. Occur in 70% of women, and resolved by day 10 after delivery. May be associated with disrupted sleep pattern, adaptation & anxiety of having newborn baby. No therapy is needed.

40. POSTNATAL DEPRESSION It does not differ from depression at other times of life, but is associated with childbirth. Occurs in 8-15% of women. Vary in severity from mild to suicidal depression. 50% recurrence in subsequent pregnancies. Treatment includes cognitive- behavioural therapy & anti-depressants (SSRI). Risk factors for postnatal depression includes; unmarried, age <20yrs, brought up by single parent, poor parental support in childhood, poor relationship with partner, socially disadvantaged, poor achievement e ducationally, low self esteem, previous emotional problems, previous depressive illness.

41. POSTNATAL DEPRESSION Risk factors for postnatal depression includes; Unmarried age < 20yrs brought up by single parent poor parental support in childhood poor relationship with partner socially disadvantaged poor achievement educationally low self esteem previous emotional problems previous depressive illness.

42. PUERPERAL PSYCHOSIS Occur in 0.1% of women. A severe mental disorder occurring in 1 st 4 weeks after delivery, characterized by presence of irrational ideas & unusual reaction to the baby. Should be immediately referred to a psychiatrist, & transfer to a mother & baby unit for better care. 5% risk of suicide. 5% risk of infanticide, if not treated. Treatment includes antidepressants, neuroleptics and sometimes electro-convulsive therapy.

43. INFANT FEEDING The major physiological event of the puerperium is the establishment of lactation. ADVANTAGES OF LACTATION: Nutritional aspects of breast milk. Protection against infection. Helps in neurological development. Helps to prevent atopic illness. Reduce risk of diseases later in life. Reduce risk of breast cancer. Effect on fertility. Effects on obesity.

44. COMPARISON OF HUMAN & COW’S MILK constituent Human milk Cow’s milk Energy (kcal/100ml) 75 66 Protein (g/100ml) 1.1 3.5 Fat (g/100ml) 4.5 3.7 Lactose (g/100ml) 6.8 4.9 Sodium ( mmol /l) 7 2.2

45. PATHWAY INVOLVED IN SECRETION OF IgA IN BREAST MILK BY ENTEROMAMMARY CIRCULATION.

46. REFRENCES Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives:reviewing maternal deaths to make motherhood safer: 2006–08.The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom.BJOG 2011;118 Suppl 1:1–203 . Lewis G (editor).The Confidential Enquiry into Maternal and Child Health (CEMACH). Saving Mothers’ Lives:Reviewing Maternal Deaths to Make Motherhood Safer 2003–2005.The Seventh Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. London:CEMACH ; 2007. Dellinger RP, Levy MM,Carlet JM,Bion J, Parker MM,Jaeschke R, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock.Crit Care Med 2008;36:296–327.Erratum in Crit Care Med 2008;36:1394–6 Barnham MR,Weightman NC.Bacteraemic Streptococcus pyogenes in the peri -partum period:now a rare disease and prior carriage by the patient may be important.J Infect 2001;43:173–6 . Stevens DL. Streptococcal toxic shock syndrome.Clin Microbiol Infect 2002;83:133–6 Kovacs GT (1985) Post partum fertility – a review.Clin Reprod Fertil 3, 107–14. Greer IA(2003) Prevention of venous thromboembolism in pregnancy. Best Pract Res Clin Haematol 16, 261–78. Rooney BL& Schauberger CW (2002) Excess pregnancy weight gain and long-term obesity: one decade later. Obstet Gynecol 100, 245–52. Dewey KG (2004) Impact of breast feeding on maternal nutritional status. Adv Exp Med Biol 554, 91–100. Confidential Enquiry into Maternal and Child Health (2004) Why Mothers Die 2000–2002. London: RCOG Press

47. MCQs An 18 year old patient finally delivered a 4kg infant vaginally. Her prenatal course was complicated by anemia, poor weight gain and maternal obesity. Her labour was protracted, including a 3hrs 2 nd stage, a mid-forceps delivery with a sulcus laceration, and a third degree tear.

48. Q1: which of the following is the greatest predisposing cause of puerperal infection in this patient? A) coitus during late pregnancy B) iron deficiency C) obesity D) Tissue trauma

49. Q2: she developes a persistent fever of 101F on the 3 rd day postpartum.What is most likely etiology? A) cholecystitis B) endometritis C) mastitis D) pneumonia E) thrombophlebitis

50. Q3: if this infection spreads to include the supporting connective tissues of the uterus, what is it called? A) parametritis B) peritonitis C) phlebothrombosis D) pyemia E) thrombophlebitis

51. Q4: puerperal infection may be spread by several routes. Which of the following is the most common route that results in serious complication of a septic thrombophlebitis? A) arterial B) direct extension C) fomites D) lymphatic E) venous

52. ANSWERS Q1---E Q2---B Q3---A Q4---E

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