Subinvolution

Subinvolution

1. SUBINVOLUTION BREAST COMPLICATIONS & THROMBOPHELEBITIS Mrs.Jagadeeswari.J M.Sc Nursing

2. SUBINVOLUTION DEFINITION: When the involution is impaired or retarded it is called Subinvolution. D.C.DUTTA

3. CAUSES OF SUBINVOLUTION PREDISPOSING FACTORS Grand multiparty Over distension of uterus as in twins and hydramnios Maternal ill health Caesarean section Prolapse of the uterus Retroversion after the uterus become pelvic organ Uterine fibroid.

4. AGGRAVATING FACTORS Retained products of conception Uterine sepsis(Endometritis)

5. CLINICAL FEATURES SYMPTOMS 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

6. SIGNS 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.

7. MANAGEMENT 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 . Ergometrine Is prescribed to enhance the involution process by reducing the blood flow to the uterus

8. BREAST ENGORGEMENT DEFINITION Swelling of the breast due to an increase in blood and lymph supply as a precursor to lactation. D.C.DUTTA

9. CAUSES OF BREAST ENGORGEMENT Due to exaggerated normal venous and lymphatic engorgement . Prevent the escape of milk from lacteal system . Primiparas patients and patients with inelastic breast are likely to be involved Engorgement is an indication that the baby is not in step with the stage of lactation

10. ONSET Usually manifests after the milk secretion starts 3 rd or 4 th postpartum

11. SYMPTOMS Pain and feeling of tenderness or Heaviness in both breast Generalised Malaise Transient Rise of temperature Painful breast feeding

12. PREVENTIVE MEASURES Avoid prelacteal feeding Initiate breast feeding early and unrestricted Exclusive breast feeding on demand Feeding in correct position

13. TREATMENT-NURSING CARE To support breast with a binder or brassiere. Frequent suckling and manual expression of any remaining milk after each feed. To administer analgesics for pain. The baby should be put to the breast regularly at frequent intervals. In a severe case gentle use of a breast pump this will reduce the tension in the breast without causing excess milk production. Gentle hand expression of milk to make the breast soft so that the infant can latch on. Provide moist heat and cold compress to relieve oedema.

14. MASTITIS DEFINITION Mastitis is inflammation of tissue in one or both mammary glands inside the breast .

15. ONSET AND CAUSATIVE ORGANISMS The incidence of mastitis is 2.5% in lactating and less than 1% in non lactating women. The common organisms involved are Staphylococcus Aureus , S.Epidermidis and Streptococci. Acute mastitis usually occurs during late first week or by end of second week or even after several week after the delivery

16. RISK FACTORS The risk factors for mastitis are poor nursing and cracked nipples.

17. CLINICAL FEATURES SYMPTOMS: Generalized malaise and headache Fever (102 F or more ) with chills Severe pain and tender swelling in one quadrant of the breast SIGN: Presence of toxic features Presence of a wedge shaped swelling on the breast with its apex at the nipple The overlying skin is red, hot and flushed and feels tense and tender.

18. MODE OF INFECTIONS There are two different types of mastitis depending upon the site of infection Infection that involves the breast parenchymal tissues leading to cellutitis.The lacteal system remains unaffected. Infection gains access through the lactiferous duct leading to development of primary mammary adenitis.

19. PREVENTION Through hand washing before each feed Cleaning the nipples before and after each feed Keeping them dry

20. TREATMENT-NURSING CARE Breast support Consuming plenty of oral fluids Continuous breast feeding with good attachment Unaffected side is nursed first to establish let down Infected side is emptied manually with each feed Flucloxacillin is the drug of choice or Erythromycin is alternative drug for patients with allergy to Penicillin Antibiotic therapy is continued for 7days Analgesics(ibuprofen) are given for pain

21. BREAST ABSCESS DEFINITION Localized collection of pus that forms in the breast is called breast abscess.

22. CAUSES Most breast abscesses occur as a complication of mastitis, which is a bacterial infection that causes the breast to become red and inflamed

23. CLINICAL FEATURES Flushed breast not responding to antibiotics promptly Brawny edema of the overlying skin Marked tenderness with fluctuation Swinging temperature

24. TREATMENT Abscess is drained by radical incision done under general anesthesia Abscess can be also drained by using needle and syringe Breast feeding is continued in the uninvolved side The infected breast is mechanical pumped every two hours and with every let down Antibiotics given depending upon the culture and sensitivity report of pus Antibiotic therapy is given for 7 days

25. THROMBOPHELEBITIS DEFINITION Thrombhophelebitis is the inflammation of a vein with blood clot formed inside the vein at the side of the inflammation.

26. ETIOPATHOGENESIS In normal pregnancy there is rise in concentration of coagulation factors I,II,VII,VIII,IX.X,XII. Plasma fibrinolytic inhibitors produced by placenta and the level of protein S is marked decreased. Alteration in blood constituents- increased number of platelet & their adhesiveness. Venous stasis is increased due to compression of gravid uterus to IVC & iliac veins. This stasis cause damage to endothelial cells.

27. Cont… Thrombophilias are hypercoagulable states in pregnancy that increase the risk of venous thrombosis Other acquired risk factors for thrombosis are advanced age and parity, operative delivery(10 times more),obesity , anemia, heart disease, infection of pelvic cellulitis and trauma to the venous wall.

28. SIGNS AND SYMPTOMS Fever Abdominal pain, usually localized and restricted to the Side of the affected vein but may spread into the groin, Upper abdomen, or flank Abdominal bloating and tenderness A tender, sausage-shaped mass near the umbilicus Decreased or absent bowel sounds Nausea, vomiting and increased pulse rate HOMANS signs –Pain in the calf region

29. INVESTIGATIONS Doppler ultrasound Venography Fibrinogen scanning CT scan or MRI

30. PROPHYLACTIC MEASURES Avoid pressure behind the knees Avoid prolonged sitting Avoid constructive clothing Avoid crossing the legs Elevate legs including foot of the bed Never massage the leg Ambulate as soon possible Apply compression stockings Prophylactic anticoagulants therapy should be started

31. MANAGEMENT Complete bed rest with foot end raised above heart level Analgesics for pain Antibiotics therapy Anti coagulants Heparin 15000IU /IV 4to 6 hourly for 7-10days should be given Apply elastic stockings are fitted on the affected leg before mobilization Venous Thrombectomy

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