Normal puerperium

Definition;-the change that occur after delivery from 6-8 weeks in genital organ ,vital signs, metabolic…ect

Change in puerperium;-

the term involution means return to normal after delivery

1-In genital organ;-uterus ;-involution within 2 week ,immiditely after delivery →return to umbilicus,after one week →midway
between symphysis pubis and umbilicus,then after another week →under symphsis pubis

Contraction and retraction continous, size return to 80 gram [in pregnancy 1000 gram]

if the Uterus not return to these normal change called subinvolution

2-Cervix;-involution within 1-2 week,return thick and complete close

3-Ovary;-if the female not –lactate the ovulation occur →through 3 week but if the female lactate the ovulation delay maybe
2 years because the prolactin suppress LH ,FSH[responsible for ovulation]

4-Breast;-first 3 days secrete colostrum[different component from the component of normal milk],after 5 days normal milk

4-Menses;-in non lactate return in 6-8 week

5-General change;-

A-Temperature;-first day slight fever called→ reaction,after that If increase occur indicate problem

B-Urinary bladder;- diuresis due to fluid accumulate during pregnancy and swelling

C-Bowel;-constipation due to diuresis→dehydration→constipation

6-Cardiovascular change;-return to normal within 6-8 weeks

Respiratory rate increase,blood pressure decrease,

Cardic output ;- increase in pregnancy 40/ but in puerperium increase 80/ so most cardiac disease appear in period of
pregnancy or pureperium

Prothrompin increase during pregnancy ,in puerperium also stay high even 6 week

Abnormal puerperium

Puerperal fever;-the temperature 38 c or more in 2 occasion in the first 10 days after delivery

Differential diagnosis ;-

1-puerperal sepsis ;-most important due to cause shock→ death,any puerperal fever consider puerperal sepsis until
exclude it

Mastitis;-abscess →signs→general signs of infection[fever,headache,malaise,nausea,vomiting]+breast symptoms

[tender,pain,swelling,redness,difficult feeding]

Mechanism;-crackle in nipple →bacteria found in the mouth of baby →the baby suking the breast→bacteria transmitted
from mouth of baby to breast of mouther, treatment ;-most cause staph,aureus [resist pencillin so treat by
dicloraclin,cephalosporin],evacuation of breast,crackle treat by antibiotic+ointment

3-UTI; most risk factor evacuation of bladder during labour by catheter -general sign of infection
+dysuria,frequency,hematuria

4-respiratory infection;-general signs of infection+symptoms of upper respiratory tract infection

[cough,dyspnea,hemoptysis]
 Puerperal sepsis

Infection of the genital tract during puerperal period

Causes;-bacteria mostly streptococcus

Sources of infection;-

1-exogenous;-instrument and from PV

2-endogenous;-from normal flora

Predisposing factors;-

General;-drug[steroid]-D.M-decrease immune ,infection before pregnancy

Local;-at the time of delivery;-bad hygiene- retained product of conception[most cause]-recurrent PV

Puerperal sepsis divide into

A-primary sites of infection include;-endometritis-wound infection-retained product or membrane in uterus

Endomertritis divide into 2 types

1-localized ;-present of leukocyte barrier so prevent spreading and the immune good,mild pathogen,

Shape of uterus;-suninvlotion,big,contain blood clot and retained product ,offensive vaginal discharge

2-spreading;-leukocyte barrier absent→spread infection cause septicemia ,parametritis and ,low immune
,strong pathogen

B-secondary sites of infection;-transmission from primary site by lymphatic or blood

circulation,include;-parametritis-salpingo-oophoritis,pelvic thrombophlebitis,septicemia,peritonitis

Clinical picture;-

General;-fever,malaise,vomiting,nausea,headache

Vital signs;-hypotension,increase heart rate and respiratory rate,oxygen saturation decrease if organ
failure present

Local ;-depend in the site of infection

1-wound infection[laceration];-tender,redness,offensive discharge from laceration

2-cervix;-tender ,uterus subinvolation[not always ,in septicemia involation],rebound tenderness,gardining

3-parametritis;-general signs of infection+lower abdominal pain ,rigid,rebound tenderness,during

examination;-bilateral mass or unilateral

4-salpingo-oophoritis;-general signs+sever bilateral lower abdomen pain,rigid-rebound tenderness due to

irritation of peritoneum

During examination;-move of cervix cause sever pain ;the female jump so called jumping sign

5-pelvic thrombophlebitis;-very dangeours because the thrombus move direct to inferior vena cava

General signs of infection+pelvic infection ,endometritis ,during examination;-palp the ovary vessles as rope
like structure –very difficult noticed sign
Diagnosis

History;-ask about lacating,breast symptoms,vomiting,diarrhea,cough,discharge[amount ,color,odor],prolong

labour, useantibiotic or not

Examination ;-general,local by PV

Investigation;-swab from discharge culture /sensitive and from cervix

1-Lab-CBC;- hematocrite detect anemia,WBC increase or decrease [both state maybe present in infection
decrease due to some infection affect bone marrow]

CRP,RBS,blood sample,urine test

2-Image;-U.S;-retained product,blood clot,size of uterus ,mass

C.T scan ,MRI;-detect pelvic abscess,pelvic throombophilbitis

Treatment

1-Isolation;-due to the immune of patient low and the most cause of this infection is streptococcus transmitted by
droplet

2-aggressive I.V fluid;-ringer, or normal saline or DNS ,avoid dextrose in shock→ cause cerebral edema

3-Analgesic,antipyretic,fowler,s position[semi-siting]→ to drainage of discharge

4-Antibiotic ;-ampircal even culture /sensitive appear;-ampicillin→ cover gram positive,gentamicin→ cover gram
negative,metrendazole→ cover anerobic

5-Because presence of pelvic thrompo…;- use antcoaglant ;- heparin or felxan[S.E low,not need follow up]

Notes;-

Sepsis;-means source of infection +systemic response to infection[fever, respiratory rate above 20,pulse above
100,WBC above 10,000 or below 4,000]

Sever sepsis;- sepsis+multiorgan failure

Septic shock;-sever sepsis+ hypotension more resist to I.V fluid ,this state enter I.C.U ,mortality rate high

If the primary site delay treatment or immune low →spread cause septicemia ,parametritis,salpingo-oophoritis

Jumping sign ;- present in ectopic pregnancy,parametritis,PID,salpingo-oophoritis

Uterine subinvolution;-from causes uterine fibroid increase in size because→ increase in blood supply

uterine subinvolution treat depend the cause

1-If infection→antibiotic,

2-retained product→evacution ,DNC