Normal & Abnormal Puerperium

Supervised by:

Prof. Salah Roshdy,MD

Professor of Obstetrics & Gynecology,

Qassim University

Presented by:

Abdulrahman Alsuhaibani

• Normal Puerperium – Reproductive organs

– Systemic change

• Abnormal Puerperium – Postpartum Hemorrhage

– Puerperal fever and sepsis

– Septic Pelvic Thrombophlebitis

– Endocrine Disorders

– Psychiatric Disorders

– Uterine Subinvolution

Objectives

Normal

Puerperium

Definition

Period following delivery of baby & placenta to about 6 weeks post partum

By 6 weeks after delivery, most of the changes of pregnancy resolved and the body has regained the non-pregnant state.

Normal Puerperium

1) Abdominal wall Remains soft and poorly toned for many weeks. The return to a prepregnant state depends greatly on exercise.

2) Perineum Swelling & engorgement are completely gone within 1-2 weeks The muscle tone may return to normal, depending on the

extent of injury.

A- Reproductive organs

3) Uterus - 1000g 100 – 200 g ( Uterine involution ) - The endometrial lining rapidly regenerates (16 days)

- After delivery at the level of the umbilicus - After 2 weeks midway b\w umbilicus & symphysis - After 4 weeks the uterus become pelvic organ

Cont. (Reproductive organs)

4) Cervix - Loses its elasticity & regain firmness - Closed by the end of the 2nd week

5) Vagina - By 3 weeks increased vascularity and edema - At the end of puerperium Shrinks to a nonpregnant state - by 6-10 weeks The vaginal epithelium appears atrophic

on smear and the normal epitheliaum will be restored

Who deliver vaginally taught her to perform kegel exercises

Cont. (Reproductive organs)

6) Ovaries - Ovulate as early as 27 days after delivery (not breastfeed). - The suppression of ovulation is due to the elevation in

prolactin - Menstruation returns by 6-8 weeks in women who do not

nurse

Cont. (Reproductive organs)

Cont. (Reproductive organs)

7) Breasts - Lactogenesis is initially triggered by the delivery of the

placenta drop of placenta H ( esp. estrogen ) &↑prolactin - In non nursing women The prolactin levels decrease and

return to normal within 2-3 weeks

Colostrum secreted for 2 days contain protein , fat , minerals , IgA and IgG After 3-6 days replaced by milk (protein , lactose , water and fat )

1) Cardiovascular system • Cardiac output ↑(immediately after delivery) → slowly

declines→ reach normal 2-6 weeks. • Blood volume returns to nonpregnant levels by the 10th day

of puerperium

2) Hematologic changes : • Hemoglobin & hematocrit ↑ after delivery • Coagulation factors remain elevated in early puerperium

8-12 weeks return to non pregnant level

B- Systemic changes

Manifestations

In First 24 hours:

PBL F • Pain uterine contraction • Breast colostrum • Lochia • Fever not exceed 38 C

LOCHIA

Lochia:- “vaginal discharge along with decidua, clots and membrane after delivery of placenta during puerperium.”

it originate from body of uterus,

cervix and vaginal. it is fishy odor.

Reaction is alkaline first and tends to acidic at

end.

-Lochia discharge continues for 2 to 6 weeks after delivery . - Monitor for signs of infection “foul smelling “ endometritis

Traits Lochia rubra Lochia serosa Lochia alba

Colour Red Yellow or pale brown

Pale white

Composition Mainly RBC, leucocytes, decidua, mucus.

Mainly mucus and serum, few RBC and leucocytes.

Mucus, serous exudates, epithelial cell, leucocytes.

Duration 1-4 days 5-9 days 10-15 days.

Stages

Abnormality with lochia:- 1. persistent lochia rubra:- causes secondary PPH due to retained placental

tissue and membrane. 2. Offensive lochia:- puerperal sepsis due to E.coli. 3. Scanty serous lochia:- severe streptococcal infection. 4. Suppression of lochia:- obstruction at internal os by clots

Abnormal

Puerperium

A-Postpartum Hemorrhage (PPH) B-Puerperal fever and sepsis

-Endometritis - Mastitis -Wound Infections - UTIs

C-Septic Pelvic Thrombophlebitis D-Endocrine Disorders

-Postpartum thyroiditis - PP Graves disease -Sheehan syndrome - Lymphocytic hypophysitis

E-Psychiatric Disorders -Postpartum blues - Postpartum depression (PPD) -Postpartum psychosis

F- UTERINE SUBINVOLUTION

Abnormal Puerperium

Sequence of events in abnormal puerperium

•At 2nd OR 3rd day Endometritis

•At 4th day Mastitis OR Wound infection

•At 7th day Thrombophlebitis

Puerperal fever

A temperature rise above 38°C on any of the first 10 days after delivery .

Differential diagnosis: 1. Endometritis 2. Wound or chest Infections 3. Mastitis 4. UTIs 5. Thrombophlebitis 6. Any general cause of fever

1) Endometritis

Endometritis is the primary cause of postpartum infection.

The causative agents are usually normal vaginal flora or enteric bacteria.

Cont. (Endometritis)

Risk factors 1. Cesarean delivery 2. Prolonged labor 3. Preexisting infection of the lower genital tract 4. Placement of an intrauterine catheter 5. Prolonged rupture of membranes 6. Multiple vaginal examinations 7. Multiple pregnancy (Twin delivery) 8. Manual removal of placenta

4Ps 3Ms 1C

Cont. (Endometritis)

Diagnosis (After excluding other causes)

A. History of fever, chills, lower abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and malaise.

B. Physical Examination showing a fever of 38°C, tachycardia, and fundal tenderness.

C. Laboratory tests CBC, ESR , CRP , blood cultures , urinalysis and microscopic culture of discharge .

ROLE of F (Endometritis)

First Exclude

Foul smelling lochia

oFFensive vaginal bleeding

Fever > 38 ᴼC

Fundal tenderness

Cont. (Endometritis)

Treatment IV antibiotics (Gentamicin & clindamycin have

a cure rate of approximately 90%)

Parenteral antibiotics are usually stopped once the patient is afebrile for 24-48 hours, tolerating a regular diet, and ambulating without difficulty

2) Wound Infection Include infections of the perineum developing

at the site of an episiotomy or laceration, as well as abdominal incision after a cesarean birth.

Diagnosis based on presence of erythema, induration, warmth, tenderness, and purulent drainage from the incision site (expolortion), with or without fever.

Cont. (Wound Infection)

Perineal infections are rare appears on the

third or fourth postpartum day.

• Risk factors include infected lochia, fecal contamination of the wound, and poor hygiene.

Abdominal wound infections S aureus, is isolated in 25% of these infections.

Treatment : Abscesses must be drained, and broad-spectrum

antibiotics may be initiated.

3) Mastitis - It is an inflammation of the mammary gland

(parenchyma) . - Develops during the first 3 months. - Milk stasis and cracked nipples, which

contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis.

- The most common causative organism is S.aureus

• Risk factors primiparity, incomplete emptying of the breast, and improper nursing technique.

Cont. (Mastitis)

Diagnosis

A. History of fever, chills, and malaise.

B. Physical Examination - Should Focus on looking for other sources of infection. - Typical findings include an area of the breast that is

swollen, warm, red, and tender. - When the exam reveals a tender, hard, possibly fluctuant

mass with overlying erythema, an abscess should be considered.

Cont. (Mastitis)

Treatment • Milk stasis can be treated with moist heat,

massage, fluids, rest, proper positioning of the infant during lactation, manual expression of milk, and analgesics.

• Penicillinase-resistant penicillins and cephalosporins, such as dicloxacillin or cephalexin, are the drugs of choice.

• Erythromycin, clindamycin, and vancomycin may be used for patients who are resistant to penicillin.

• Resolution usually occurs 48 hours after the onset of antimicrobial therapy.

4) UTIs - The most common pathogen is E coli. In pregnancy

- Risk factors Cesarean delivery, forceps delivery, vacum delivery, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy.

Diagnosis History (frequency, urgency, dysuria, hematuria)

Physical examination (febrile patient, Suprapubic tenderness)

Laboratory tests (urinalysis, urine culture and CBC)

Treatment Empirical culture selective (3-7 Days)

C) Septic Pelvic Thrombophlebitis (SPT)

- It is a venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.

- Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation.

- The thrombus acts as a suitable medium for proliferation of anaerobic bacteria.

Cont. (SPT)

Diagnosis

A. History • It usually accompanies endometritis

• Pts with OVT may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen.

B. Physical Examination - Should focus on looking for other sources of infection. - Fever, tachycardia - On abdominal examination, 50-70% of pts with ovarian

vein thrombosis have a tender, palpable, ropelike mass.

C. CT and MRI are the studies of choice

Cont. (SPT)

Treatment • IV heparin for 7-10 days. • Antibiotic therapy is most commonly with

gentamicin and clindamycin

D) Endocrine Disorders Clinical or laboratory dysfunction occurs in 5-10% of

postpartum women

Caused by A. Primary disorders of the thyroid, such as

1) Postpartum thyroiditis (PPT) 2) Graves disease,

B. Secondary disorders of the hypothalamic-pituitary axis, such as

1) Sheehan syndrome 2) Lymphocytic hypophysitis. (pituitary enlargement+Hypopitutarism ↓TSH HR)

PostPartum Thyroiditis (PPT) - It is a transient autoimmune destructive

lymphocytic thyroiditis. - Can occur any time in the 1st postpartum year.

It has 2 phases

1) 1-4 mo PP thyrotoxicosis (↓TSH)

If sever ß-blocker

2) 4-8 mo PP hypothyroidism (↑TSH)

If sever Thyroxin

E) Psychiatric Disorders 1- Postpartum blues - 50-70%

• Mild, self limited, arises during the first 2 weeks PP

• TTT: Support & education

2- Postpartum depression (PPD) - 10-15%. • More prolonged (3-6 months)

• TTT: Supportive care and reassurance, SSRI

3- Postpartum psychosis- 0.14-0.26%. • Generally lasts only 2-3 months. Need psychiatrist.

• Better prognosis than nonpuerperal psychosis.

Any prolonged episodes of depression during or after pregnancy should receive

urgent attention.

F) Uterine Subinvolution It is a transient autoimmune destructive

lymphocytic thyroiditis.

Causes: Endometritis, retained placental fragments, pelvic infection and uterine fibroids

Signs and Symptoms 1) Prolonged lochial flow.

2) Profuse vaginal bleeding.

3) Large, flabby uterus.

Cont. (Uterine Subinvolution )

Treatment: 1- Administration of oxytocic medication to

improve uterine muscle tone, includes:

(a) Methergine - a drug of choice (PO)

(b) Pitocin.

(c) Ergotrate.

2- Dilation and curettage (D&C) to remove any placental fragments.

3- Antimicrobial therapy for endometritis

Summary

Repro.

General

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2

Summary

PPH

Puerperal fever & sepsis

SPT

Endocrine Disorders

Psychiatric Disorders.

Uterine Subinvolution

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References

Any Question ?