Title: abnormal pueperium
1ABNORMAL PUERPERIUM
- By Dr M.Chiduo
- OBGY Dept
- HKMU
- 2023
2OBJECTIVES
- Definitions Puerperal Pyrexia. Puerperal Sepsis
- Causative microorganisms
- Types of Infection Vulvovaginitis. Endometritis.
Salphingoophoritis Pelvic Abscess.
Thromboflebitis. - Pulmonary Embolism.
- Breast disorders.
- Psychiatric problems
3PUERPERAL PYREXIA AND SEPSIS
- Puerperal Pyrexia
- Is defined as a temperature higher than 38C on
two occasions, at least 4 hours apart, after the
first 24 hours postpartum and during the first
42 days postpartum.
4Puerperal Sepsis
- Infection of genital tract and other organs
related to pregnancy and delivery occurring
during the first 42 days postpartum
5Puerperal pyrexia
- Classification
- Physiological puerperal pyrexia
- Pathological puerperal pyrexia
- Physiological puerperal pyrexia
- Rise of temperature which does not exceed 38
degrees and drops within 24 hours after child
birth (difficult labour)and the 3rd to 5th day
after child birth(due to engorgement of breast).
6Puerperal pyrexia
- Pathological puerperal pyrexia
- Postpartum febrile morbidity defined by the
temperature higher than 380 C on two occasions at
least 4 hours apart after the first 24 hours to
42 days postpartum. - This results from an infection of the female
genital tract or extra genital tract. - Types of Infections in Puerperium
- I. Genital tract infections
- II. Extra-genital tract infections
7I. GENITAL TRACT INFECTIONS
- Involved structures-
- Perineum
- Vagina
- Cervix
- Uterus
- Adnexa
- Parametrium
8II. EXTRA-GENITAL TRACT INFECTIONS
- Involved structures-
- Breast (mastitis)
- Urinary tract system(UTI)
- Superficial Thrombophlebitis or DVT
- Respiratory system(Common cold and
Pharyngitis-after GA) - Septicaemia
9Predisposing Factors for Puerperal Sepsis
- Low socioeconomic status
- Young Primipara
- Obesity
- Antepartum Anaemia
- Antepartum genital tract infections
- Prolonged Labour
- Prolonged Rupture of Membranes
- Induction of labour
- Multiple Per Vaginal/cervical examinations
- Caesarean section
- Manual removal of placenta
10Causative microorganisms
- I. Endogenous organisms
- Microorganisms usually residents of the lower
genital tract. Cause infection when there is loss
of the cervical mucus/prolonged rupture of
membranes during delivery or loss of mucosa
integrity. - The blood and devitalized tissues are good
culture media for multiplication of these
organisms and they become pathogenic. -
11Causative microorganisms..
- II. Exogenous organisms
- Introduced into the genital tract from outside,
during vaginal examination, instrumental delivery
or during Caesarean section. - Transferred by hospital staff from one patient to
another, or from the staff to patient. -
12Microorganisms
- Streptococci Group A,B,D
- Enterococci
- Escherichia coli
- Klebsiella
- Proteus
- Staphylococcus aureus
- Staphylococcus epidermidis
- Gardnerella vaginalis
- Peptococcus species
- Bacteroides fragilis
- Clostridium species
- Fusobacteria species
- Mycoplasma species
- Chlamydia trachomatis
- Neisseria gonorrhoeae
13Favorable Conditions for Sepsis
- Manipulation
- Surgical trauma
- Foreign body
- Devitalized tissues
- Blood and serum collection
14Route of Infection
- Muco-cutaneal
- Connective tissue
- Vascular(blood)
- Clinical Features
- Depend on the type and localization of infection.
15Investigations
- Swab and culture from the cervix and upper
vagina for aerobic and anaerobic cultures. - Blood culture taken at peak of temperature in
case of septicaemia. - Full Blood picture Haemoglobin, WBCs and
Differentials. - Urine analysis and culture midstream or catheter
specimen.
16Investigations
- Blood Grouping Cross matching
- Check LFT, RFT, Electrolytes
- Blood culture in case of suspected septicaemia
- Abdominal pelvic ultrasound
- Chest X-ray
- Echocardiography
17General Management
- Establish IV line and give Ringers lactate
/Normal Saline 2Lts then continue as required - Amoxicillin Clavulanic acid tabs (PO) 625 12
hourly for 5days - Metronidazole tabs (PO) 400mg 8 hourly for 5days
- Gentamycin Inj. (IV) 80mg 12hourly for
24-48hours.
18Management
- Adjust drugs depending on the Culture and
Sensitivity results - Observe specific measures according to the cause
eg. Septic wound, Endometritis etc. - Continue with the above antibiotic for 5-7 days
- If C/S results are not available and there is no
improvement after 3 days of treatment with above
antibiotics switch to 2nd line of treatment
19Management
- Metronidazole Inj. (IV) 500mg 8hourly for 5-7days
- Ceftriaxone Sulbactam Inj. (IV) 1.5g 12hourly
for 5-7 days - OR
- Piperacillin Tazobactam Inj (IV) 4.5g 12hourly
for 5-7days
20Other Antibiotic Options
- Ampicillin Gentamycin
- Cephalosporins (Cefotaxime, Cefoxitin etc)
- Amoxicillin-Clavuronic acid Metronidazole
- Metronidazole Gentamycin Ampicillin
- Metronidazole Kanamycin Ampicillin
- If no Improvement consider complications.
21VULVOVAGINITIS
- Infection of the vulva and vagina.
- Occurs as a result poor observation of asepsia
and antisepsia during labour and delivery as well
as poor attention to tears and episiotomy.
Foreign bodies per vagina. - Features Pussy discharge on the ulcerations,
oedema and tenderness.
22ENDOMETRITIS
- High fever 39C, Chills (bacteremia)
- Lower abdominal pain
- Lochia persistent red or pussy with offensive
smell - Subinvolutioned uterus
- Tender abdomen
- Leucocytosis 15-30,000 cells/µL
- Usually caused by retained products of
conception/blood clots in uterus
23Pathology and Clinical Picture Local and
Generalized infection (Septicaemia)
Localised or Putrid Generalised or Septic
Type of infection is mild. is severe.
Organism virulence is low as anaerobic streptococci. Virulent organism as haemolytic streptococci.
Resistance of the patient is good is low.
Uterus Subinvoluted and soft. Well involuted.
Uterine cavity Offensive retained necrotic parts. Empty but lined with purulent membrane.
Lochia is excessive and offensive. Scanty and not offensive.
Microscopically Well defined zone of leukocytes next to the endometrium preventing spread of infection. Absent or deficient leucocytic zone favouring spread of infection.
Clinical picture 4 days after delivery there is fever, tachycardia, rigors and malaise. 1-2 days after delivery with more severe manifestations.
24Endometritis Management
- Hospitalization
- Analgesics and Antipyretics
- IV fluids
- IV Antibiotics for 48-72 hours
- Uterine cavity revision and evacuation of
remaining products of conception
25Complications
- Parametrial Phlegmon
- Pelvic Cellulitis
- Pelvic Peritonitis
- Pelvic Abscess
- Generalized Peritonitis
- Septic Pelvic Thrombophlebitis
- Infected Haematoma
26PERITONITIS
- Infection extended to pelvic peritoneum
- Occurs post-Caesarean section complicated with
Endometritis with incisional necrosis and
dehiscence - Post Endometritis-Salphingoophoritis
27PERITONITIS
- Clinical Features
- High fever 39C, tachycardia
- Ill looking
- Lower/generalized abdominal pain
- Lochia persistent red or pussy with offensive
smell - Subinvolutioned uterus
- Muscle guarding
28Peritonitis..
- Tender abdomen, rebound tenderness
- Cervix Excitation test positive. Bulging
posterior fornix in Pelvic abscess. - Signs of adynamic ileus
- Post-Caesarean section Peritonitis requires
surgery antibiotics - Peritonitis due to Transvaginal infection, IV
antibiotics suffices.
29PARAMETRIAL PHLEGMON
- Parametrial induration
- To be considered in case of poor/no improvement
/persistent fever - PV palpable firm mass, unilateral base of Broad
ligament
30PELVIC ABSCESS
- Supurated Parametrial phlegmon
- Fluctuating parametrial mass (on Broad ligament)
- Bulging and tender posterior fornix (fluid
collection) - Antibiotics and Colpotomy/Laparotomy
31Endometritis Sequelae
32SEPTIC THROMBOPHLEBITIS
- Extension of puerperal infection via
vascular(venous ) route leading to thrombosis and
lymphangitis - Ovarian vein may be involved drain from fundus of
the uterus placental site - Placental site----Ovarian vein----Inferior vena
cava - Placental site----Uterine vein--- Common illiac
vein
33Thrombophlebitis.
- Persistent fever, chills, pelvic pain on 2nd
3rd day post operative - Diagnosis by CT scan or MRI
- Use Heparin Challenge Test in absence of CT/MRI (
Improved Temp. on IV Heparin administration) - Common in pelvic operations/delivery is Deep
Venous Thrombosis (DVT) - Prevented by early ambulation
- Treat with IV Heparin.
34BREAST DISORDERS
- Retracted and Cracked Nipples
- Breast Engorgement
- Mastitis
- Breast Abscess
- Lactation Failure
35Retracted or flat nipple
- - Most common in primigravidas
- -babies are not able to attach to the breast
correctly and are not able to suck adequately - Management
- Expression of milk manually or by using breast
pump
36CRACKED NIPPLES
- Maybe painful due to-
- Loss of surface epithelium with a formation of
raw area of nipple - A fissure on either the base or tip of the nipple
- Poor hygiene resulting to crust formation over
the nipple - Trauma from babies mouth
- Management
- Correct attachment
- Breast pump
37BREAST ENGORGEMENT
- Is due to exaggerated normal venous and lymphatic
engorgement of the breast which precedes
lactation. - This in turn prevents escape of milk from the
lacteal system - It usually manifests after the milk starts (3rd
or 4th day postpartum) - Common to primiparas
38Breast Engorgment
39 Breast Engorgement.
- Considerable pain and feeling of tenseness or
heaviness in both breasts - Generalized malaise or even transient raise in
temperature - Painful breastfeeding
40 Breast Engorgement.
- Management
- Breast Support by a binder or brassiere
- Manual expression/breast pump after each feeding
- Regular and frequent feeds
- Analgesics for pain
41ACUTE MASTITIS
- The most common micro organisms
- Staphylococcus aureas
- Staphylococcus epidermidis
- Streptococci viridians
- The source of micro organisms is the infants nose
and throat.
42ACUTE MASTITIS..
- Mode of infection
- Infection involving the breast parenchymal tissue
leading to cellulitis - Infection through the lactiferous duct leading to
development of primary mammary adenitis.
43Acute Mastitis ....
- Clinical features
- - General malaise and headache
- - Fever 38 degrees
- - Swollen breasts
- - Severe pain and tenderness of the breasts
- - The overlying skin is red, hot, tense and
tender - Complication Breast Abscess
44Mastitis
45Acute Mastitis Cont
- Management
- Breast support
- Plenty of oral fluids
- Continue breastfeeding
- Antibiotics
- Analgesics
- Breastfeeding to the infants must continue
- The ingested staphylococcus will be digested
without any harm!
46BREAST ABSCESS
- Clinical Features
- Flushed breast not responding promptly to
antibiotics - Browny oedema of the underlying skin
- Marked pain and tenderness with fluctuation.
- Swinging temperatures
47Breast abscess.
- Management
- Incision and drainage under GA
- - a deep incision extending from areolar margin
to prevent injury of the lactiferous ducts - Antibiotics
- Antipyretics
- Analgesics
- Manual /breast pump milk extraction
48Lactation failure (Inadequate milk production)
- By the end of 1st week postpartum expected
amount is gt 500mL/day, - 2nd -3rd week 800 mL and peaks at 1.5 to 2.0
L/day - Frequent breastfeeding maintains milk stores
- In case of reduced milk supply the neonate will
loose weight
49Reduced milk supply.
- Poor nourishment and Psychological stress can
decrease milk supply - Sheehans Syndrome (Postpartum Pituitary
Necrosis) -- agalactia, inability to lactate as
well as lethargy, anorexia, weight loss - Other causes include
- Inadequate suckling
- Reluctance to breast feeding
50Reduced milk supply.
- Ill development of the breasts
- Painful breast lesion
- Endogenous suppression of prolactin
- Prolactin inhibition e.g., Egort preparation,
diuretics, pyridoxine.
51Cont
- Treatment of lactation failure.
- Encourage breastfeeding regularly and frequently
- Advice in advantages of human milk over
artificial milk - Adequate fluid intake
- Treat if any lesions are present
- Drugs e.g. Metoclopramide 10mg tds
- Proper hygiene of the breasts
52URINARY COMPLICATION IN PUERPERIUM
- URINARY TRACT INFECTION
- E.coli, Klebsiella Staphylococcus aureus
- Asymptomatic bacteriuria becomes overt
- Recurrence of previous cystitis or pyelitis
- Effect of frequent catheterization
- Stasis of urine during early puerperium due to
lack of bladder tone and less desire to pass
urine. - Treatment
- Antibiotics
532. RETENSION OF URINE
- Common in early puerperium. Causes
- Bruising and edema of the bladder neck
- Reflex from perineal injury
- Treatment. Catheterization
- 3. Others
- Incontinence of urine
- Suppression of urine lt400mls/24
- Anuria absence of urine in 24hrs (renal failure)
54PUERPERAL VENOUS THROMBOSIS
- DEEP VEIN THROMBOSIS (ileofemoral)
- THROMBOPHLEBITIS (superficial and deep veins)
- SEPTIC PELVIC THROMBOPHLEBITIS
- PULMONARY EMBOLISM
55ETIOPATHOGENESIS
- A rise in coagulation factors during pregnancy
- Alteration in blood constituents
- Venous stasis
- Thrombophilia's
- Others eg.
- - Advanced parity and age
- - Operative delivery (C/S )
- -Heart disease
- -Infection
56DEEP VENOUS THROMBOSIS (DVT)
- Clinical features
- Pain in calf muscles
- Oedema of the legs and rise in skin temperature
- A positive HOMARS sign
- Pain the calf on dorsiflexion of the foot
- Investigation Doppler ultrasound, Venography
and MRI
57DVT
- Management
- Bed rest with foot raised above the heart level
- Antibiotics
- Analgesics
- Anticoagulants eg IV Heparin/ oral Warfarin
- Mobilization after 7days of treatment
58PELVIC THROMBOPHLEBITIS
- Originates from thrombosed veins at the placental
site by organisms such as - Anaerobic streptococci Bacteriodes
- - Should be suspected if pyrexia continues
despite of antibiotic therapy. - Treatment
- Anticoagulants eg Heparin inj. 15,000 units for 7
days - Antibiotics
- Analgesics
59PULMONARY EMBOLISM
- Occurs during or immediately after delivery,
Caesarean section or Rupture of Uterus - Characterized by the penetration of amniotic
fluid or other blood elements into maternal
circulation - Contributes significantly to Maternal mortality
gt80 die ( sudden death) and more than half of
the survivors die some hours later.
60PULMONARY EMBOLISM
- Occurs on both Pre and Full term pregnancies
- Predisposing factors-
- - Parous women (Para 2-4)
- - Polyhydramnios
- - Prelabour rupture of membranes
- - Abruptio placentae
- - Ruptured uterus, Caesarean section
-
61PULMONARY EMBOLISM
- - Prolonged labour
- - Precipitate labour -unusually rapid labour
less than 3hrs. (spontaneous or induced) - - Meconium stained liquor
- - IUFD
62PULMONARY EMBOLISM
- Clinical Features
- Anxiety, Restless, sweating, shivering
- Headache, Vomiting
- Acute chest pain, cough
- Dyspnoea, Crepitations with marked cyanosis
- Shock (not proportional to blood loss)
- Convulsions
- Coagulopathy and Cardiac Arrest
63PULMONARY EMBOLISM
- Investigations-
- Chest X-ray Diffuse lung infiltrations
- Coagulation profile low platelets fibrinogen
levels - Blood grouping and X-match
64PULMONARY EMBOLISM
- Management..
- Rest in cardiac position
- Oxygen ( intubation)
- IV line
- Urinary catheter
- Monitor vital signs
- Diuretics IV Furosemide
- Morphine and Heparin
65THANK YOU FOR YOUR ATTENTION!!!!