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Title: abnormal pueperium


1
ABNORMAL PUERPERIUM
  • By Dr M.Chiduo
  • OBGY Dept
  • HKMU
  • 2023

2
OBJECTIVES
  • Definitions Puerperal Pyrexia. Puerperal Sepsis
  • Causative microorganisms
  • Types of Infection Vulvovaginitis. Endometritis.
    Salphingoophoritis Pelvic Abscess.
    Thromboflebitis.
  • Pulmonary Embolism.
  • Breast disorders.
  • Psychiatric problems

3
PUERPERAL 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.

4
Puerperal Sepsis
  • Infection of genital tract and other organs
    related to pregnancy and delivery occurring
    during the first 42 days postpartum

5
Puerperal 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).

6
Puerperal 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

7
I. GENITAL TRACT INFECTIONS
  • Involved structures-
  • Perineum
  • Vagina
  • Cervix
  • Uterus
  • Adnexa
  • Parametrium

8
II. 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

9
Predisposing 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

10
Causative 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.

11
Causative 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.

12
Microorganisms
  • Anaerobes
  • Aerobes
  • 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

13
Favorable Conditions for Sepsis
  • Manipulation
  • Surgical trauma
  • Foreign body
  • Devitalized tissues
  • Blood and serum collection

14
Route of Infection
  • Muco-cutaneal
  • Connective tissue
  • Vascular(blood)
  • Clinical Features
  • Depend on the type and localization of infection.

15
Investigations
  • 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.

16
Investigations
  • Blood Grouping Cross matching
  • Check LFT, RFT, Electrolytes
  • Blood culture in case of suspected septicaemia
  • Abdominal pelvic ultrasound
  • Chest X-ray
  • Echocardiography

17
General 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.

18
Management
  • 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

19
Management
  • 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

20
Other Antibiotic Options
  • Ampicillin Gentamycin
  • Cephalosporins (Cefotaxime, Cefoxitin etc)
  • Amoxicillin-Clavuronic acid Metronidazole
  • Metronidazole Gentamycin Ampicillin
  • Metronidazole Kanamycin Ampicillin
  • If no Improvement consider complications.

21
VULVOVAGINITIS
  • 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.

22
ENDOMETRITIS
  • 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

23
Pathology 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.
24
Endometritis Management
  • Hospitalization
  • Analgesics and Antipyretics
  • IV fluids
  • IV Antibiotics for 48-72 hours
  • Uterine cavity revision and evacuation of
    remaining products of conception

25
Complications
  • Parametrial Phlegmon
  • Pelvic Cellulitis
  • Pelvic Peritonitis
  • Pelvic Abscess
  • Generalized Peritonitis
  • Septic Pelvic Thrombophlebitis
  • Infected Haematoma

26
PERITONITIS
  • Infection extended to pelvic peritoneum
  • Occurs post-Caesarean section complicated with
    Endometritis with incisional necrosis and
    dehiscence
  • Post Endometritis-Salphingoophoritis

27
PERITONITIS
  • Clinical Features
  • High fever 39C, tachycardia
  • Ill looking
  • Lower/generalized abdominal pain
  • Lochia persistent red or pussy with offensive
    smell
  • Subinvolutioned uterus
  • Muscle guarding

28
Peritonitis..
  • 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.

29
PARAMETRIAL PHLEGMON
  • Parametrial induration
  • To be considered in case of poor/no improvement
    /persistent fever
  • PV palpable firm mass, unilateral base of Broad
    ligament

30
PELVIC ABSCESS
  • Supurated Parametrial phlegmon
  • Fluctuating parametrial mass (on Broad ligament)
  • Bulging and tender posterior fornix (fluid
    collection)
  • Antibiotics and Colpotomy/Laparotomy

31
Endometritis Sequelae
32
SEPTIC 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

33
Thrombophlebitis.
  • 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.

34
BREAST DISORDERS
  1. Retracted and Cracked Nipples
  2. Breast Engorgement
  3. Mastitis
  4. Breast Abscess
  5. Lactation Failure

35
Retracted 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

36
CRACKED 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

37
BREAST 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

38
Breast 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

41
ACUTE MASTITIS
  • The most common micro organisms
  • Staphylococcus aureas
  • Staphylococcus epidermidis
  • Streptococci viridians
  • The source of micro organisms is the infants nose
    and throat.

42
ACUTE 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.

43
Acute 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

44
Mastitis
45
Acute 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!

46
BREAST ABSCESS
  • Clinical Features
  • Flushed breast not responding promptly to
    antibiotics
  • Browny oedema of the underlying skin
  • Marked pain and tenderness with fluctuation.
  • Swinging temperatures

47
Breast 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

48
Lactation 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

49
Reduced 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

50
Reduced milk supply.
  • Ill development of the breasts
  • Painful breast lesion
  • Endogenous suppression of prolactin
  • Prolactin inhibition e.g., Egort preparation,
    diuretics, pyridoxine.

51
Cont
  • 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

52
URINARY 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

53
2. 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)

54
PUERPERAL VENOUS THROMBOSIS
  • DEEP VEIN THROMBOSIS (ileofemoral)
  • THROMBOPHLEBITIS (superficial and deep veins)
  • SEPTIC PELVIC THROMBOPHLEBITIS
  • PULMONARY EMBOLISM

55
ETIOPATHOGENESIS
  • 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

56
DEEP 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

57
DVT
  • Management
  • Bed rest with foot raised above the heart level
  • Antibiotics
  • Analgesics
  • Anticoagulants eg IV Heparin/ oral Warfarin
  • Mobilization after 7days of treatment

58
PELVIC 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

59
PULMONARY 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.

60
PULMONARY 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

61
PULMONARY EMBOLISM
  • - Prolonged labour
  • - Precipitate labour -unusually rapid labour
    less than 3hrs. (spontaneous or induced)
  • - Meconium stained liquor
  • - IUFD

62
PULMONARY 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

63
PULMONARY EMBOLISM
  • Investigations-
  • Chest X-ray Diffuse lung infiltrations
  • Coagulation profile low platelets fibrinogen
    levels
  • Blood grouping and X-match

64
PULMONARY EMBOLISM
  • Management..
  • Rest in cardiac position
  • Oxygen ( intubation)
  • IV line
  • Urinary catheter
  • Monitor vital signs
  • Diuretics IV Furosemide
  • Morphine and Heparin

65
THANK YOU FOR YOUR ATTENTION!!!!
  • THE END
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