Abnormalities of the

Puerperium
• Puerperium is the period following child birth during which the body
tissues especially the pelvic organs revert back to the pre-pregnant
state both anatomically and physiologically

• Begins as soon placenta is expelled and lasts for 6 weeks

Problems of Puerperium
• Secondary post partum hemorrhage
• Puerperal sepsis
• Breast
• Venous complications
• Urinary tract problems
• Genital tract
 Secondary post partum hemorrhage
• 8th to 14th day
Causes:
1. Retained bits of placenta
2. Infection
3. Endometritis & subinvolution
4. Others:
- Infected fibroid - Ca cervix
- Placental polyp - Inversion of uterus
- Chorion epithelioma
Secondary PPH - Diagnosis

• General condition
• Per abdomen - subinvolution
• Bleeding p/v
• Internal examination -subinvolution
• Ultrasound-retained bits of placenta
 Secondary PPH - Management

• Improve the general condition

Conservative measures:
• Methyl Ergometrine 0. 2mg
• Antibiotics
Active treatment
• Exploration of the uterus under anaesthesia
• If following caesarean – laparotomy
PUERPERAL PYREXIA

• A rise of temperature reaching 100.4°F (38°C) or more (measured orally) on 2

separate occasions at 24 hours apart (excluding first 24 hours) within first 10 days
following delivery is called puerperal pyrexia
• CAUSES:
• Puerperal sepsis
• Urinary tract infection (cystitis, pyelonephritis)
• Mastitis
• Infection of cesarean section wound
• Pulmonary infection, atelectasis pneumonia
• Septic pelvic thrombophlebitis
• A recrudescence of malaria or pulmonary tuberculosis —not uncommon in the
tropics
• Unknown origin
PUERPERAL SEPSIS
• infection of the genital tract which occurs as a complication of delivery
• Commonly due to
• Endometritis
• Endomyometritis
• Endoparametritis
• a combination of all these is called pelvic cellulitis
• PREDISPOSING FACTORS OF PUERPERAL SEPSIS:

• The pathogenicity of the vaginal flora may be influenced by certain factors

• The cervicovaginal mucous membrane is damaged even in normal delivery
• The uterine surface too, specially the placental site, is converted into an open
wound by the cleavage of the decidua which takes place during the third stage of
labor
• The blood clots present at the placental site are excellent media for the growth of
the bacteria
• Antepartum factors:
• Malnutrition and anemia
• Preterm labor
• Premature rupture of the membranes
• Chronic debilitating illness
• Prolonged rupture of membrane > 18 hours
• Intrapartum factors:
• Repeated vaginal examinations
• Prolonged rupture of membranes (> 18 hours)
• Dehydration and keto-acidosis during labor
• Traumatic operative delivery
• Hemorrhage—antepartum or postpartum
• Retained bits of placental tissue or membranes
• Placenta praevia—placental site lying close to the vagina
• Cesarean delivery.
• Microorganisms responsible for puerperal sepsis
• Aerobic
• Streptococcus hemolyticus Group A (GAS)—Toxic Shock syndrome, necrotising
fascitis in episiotomy or cesarean section wound
• Streptococcus hemolyticus Group B (GBS)
• Others—Staphylococcus pyogenes, aureus, E. coli, Klebsiella, Pseudomonas,
Proteus, Chlamydia.
• Anaerobic—Streptococcus, Peptococcus, Bacteroides (fragilis, bivius,
fusobacteria, mobiluncus) and clostridia.
• Most of the infections in the genital tract are polymicrobial with a mixture of
aerobic and anaerobic organisms.
• MODE OF INFECTION
• endogenous- organisms are present in the genital tract before delivery eg
Anaerobic streptococcus
• autogenous - organisms present elsewhere (skin, throat) in the body and migrate
to the genital organs by blood stream or by the patient herself
• Streptococcus b hemolyticus, E. coli, Staphylococcus
• Exogenous: infection is contracted from sources outside the patient (from hospital
or attendants)
• Streptococcus b haemolyticus, Staphylococcus and E. coli
• Clinical Features

• LOCAL INFECTION (WOUND INFECTION)

• There is slight rise of temperature, generalized malaise or headache
• The local wound becomes red and swollen
• Pus may form which leads to disruption of the wound
• UTERINE INFECTION

Mild-
• rise in temperature and pulse rate
• Lochial discharge becomes offensive and copious
• The uterus is subinvoluted and tender

• Severe-
• acute onset with high rise of temperature, often with chills and rigor
• Pulse rate is rapid, out of proportion to temperature
• Lochia may be scanty and odorless
• Uterus may be subinvoluted, tender and softer
• EXTRA UTERINE SPREAD-
• evident by presence of
• pelvic tenderness (pelvic peritonitis)
• tenderness on the fornix (parametritis)
• bulging fluctuant mass in the pouch of Douglas (pelvic abscess)

• Parametritis- onset is usually about 7–10th day of Puerperium. Characterized by

• Constant pelvic pain
• Tenderness on either sides on the hypogastrium
• Vaginal examination reveals an unilateral tender indurated mass pushing the uterus to the
contralateral side
• Rectal examination confirms the induration specially extending along the uterosacral ligament
• Pelvic peritonitis
• Pyrexia with increase in pulse rate
• Lower abdominal pain and tenderness
• Muscle guard may be absent
• Vaginal examination reveals tenderness on the fornix and with the movement of
the cervix
• Collection of pus in the pouch of Douglas is evidenced by swinging temperature,
diarrhea and a bulging fluctuant mass felt through the posterior fornix
• General peritonitis
• High fever with a rapid pulse
• Vomiting
• Generalized abdominal pain
• Patient looks very ill and dehydrated
• Abdomen is tender and distended
• Rebound tenderness is often present
• Septicemia
• high rise of temperature usually associated with rigor
• Pulse rate is usually rapid even after the temperature settles down to normal
• Blood culture is positive
• Symptoms and signs of metastatic infection in the lungs, meninges or joints may
appear
• INVESTIGATION OF PUERPERAL PYREXIA
• To locate the site of infection
• To identify the organisms
• To assess the severity of the disease

• A case of puerperal pyrexia is considered to be due to genital sepsis unless proved

otherwise.
• Investigation
• High vaginal and endocervical swabs for culture and sensitivity in aerobic and
anaerobic media
• ‘Clean catch’ mid stream specimen of urine for analysis and culture and
sensitivity
• Blood for total and differential white cell count, hemoglobin estimation
• A low platelet count indicate septicemia or DIC
• Thick blood film for malarial parasites
• Blood culture
• Pelvic ultrasound
• to detect any retained bits of conception within the uterus
• to locate any abscess with the pelvis
• collecting samples (pus or fluid) from the pelvis for culture and sensitivity
• color flow-doppler study to detect venous thrombosis
• CT and MRI
• X-ray chest-in cases with suspected pulmonary Koch’s lesion and also to detect
any lung pathology like collapse and atelectasis
• Blood urea and electrolytes
• TREATMENT
• General care:
• Isolation of the patient is preferred specially when hemolytic streptococcus is
obtained on culture
• Adequate fluid and calorie maintained by intravenous infusion
• correct anemia
• indwelling catheter to relieve any urine retention due to pelvic abscess
• Record pulse, respiration, temperature, lochial discharge and fluid intake and
output.
• Antibiotics
• Gentamicin (2 mg/kg IV loading dose followed by 1.5 mg/kg IV every eight
hours)
• Ampicillin 1 g IV every 6 hours or Clindamycin (900 mg IV every 8 hours)
should be started or
• Intravenous administration of Cefotaxime 1 g, 8 hourly is another alternative
• Metronidazole 0.5 g, IV is given at 8 hours interval to control the anaerobic group
• treatment is continued until the infection is controlled for at least 7–10 days
• Surgical treatment:
• Perineal wound- stitches of the perineal wound removed to facilitate drainage of
pus and relieve pain
• wound is to be cleaned with sitz bath several times a day
• dressed with an antiseptic ointment or powder
• secondary suture may be given at a later date
Retained uterine-
• surgical evacuation after antibiotic coverage for 24 hours should be done to avoid
the risk of septicemia.
• septic pelvic thrombophlebitis -IV heparin for 7–10 days
• Pelvic abscess- drained by colpotomy under ultrasound guidance.

• Wound dehiscence: scrub the wound twice daily

• debridement of all necrotic tissue and then closing the wound with secondary
suture
• Appropriate antimicrobials are used following culture and sensitivity
• Laparotomy –indicated in unresponsive peritonitis
• Hysterectomy - indicated in cases with rupture or perforation, having multiple
abscesses, gangrenous uterus or gas gangrene infection
• Necrotizing fasciitis is rare but fatal complication
• involves muscle and fascia
• Infection is caused by Gr. A hemolytic streptococcus and often it is polymicrobial
• Tissue necrosis is the significant pathology.
• Treatment -wound scrubbing, debridement of all necrotic tissues, and use of
effective antimicrobial agents.
SUBINVOLUTION
• When the involution of uterus is impaired or retarded it is called subinvolution
• CAUSES:
• Predisposing factors are
• Grand multiparity
• Over-distension of uterus as in twins and hydramnios
• Maternal ill health
• Cesarean section
• Prolapse of the uterus
• Retroversion after the uterus becomes pelvic organ
• Uterine fibroid
• Aggravating factors are:
• Retained products of conception
• Uterine sepsis (endometritis)
• SYMPTOMS:
• may be asymptomatic
• The predominant symptoms are:
• 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.
• 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 sub involution may be evident

• MANAGEMENT:
• therapy instituted only when sub involution is found to be associated with local pathology:
• Antibiotics in endometritis
• Exploration of the uterus in retained products
• Pessary in prolapse or retroversion.
URINARY COMPLICATIONS IN
PUERPERIUM
• URINARY TRACT INFECTION
• Incidence-1–5% of all deliveries
• The infection may be the consequence of any of the following:
• Recurrence of previous cystitis or pyelitis
• Asymptomatic bacteriuria may become overt
• Infection contracted for the first time during Puerperium is due to
• effect of frequent catheterization either during labor or in early Puerperium to
relieve retention of urine
• stasis of urine during early Puerperium due to lack of bladder tone and less desire
to pass urine
• Organisms-E.coli, Klebsiella, Proteus and Staphylococcus aureus

• RETENTION OF URINE:
• causes are
• Bruising and edema of the bladder neck
• Reflex from the perineal injury
• Unaccustomed position
• Treatment:
• an indwelling catheter is to be kept in situ for about 48 hours
• Following removal of catheter, the amount of residual urine is to be measured. If
it is found to be
• more than 100 mL, continuous drainage is resumed
• Appropriate urinary antiseptics administered for about 5–7 days
• INCONTINENCE OF URINE:
• Causes-
• Overflow incontinence
• Stress incontinence
• True incontinence-due to genitourinary fistula
 Breast complications

• Breast engorgement

• Cracked nipple

• Mastitis &
breast abscess

• Lactational failure
• Breast Engorgement
• due to exaggerated normal venous and lymphatic engorgement of the breasts
which precedes lactation.
• prevents escape of milk from the lacteal system
• Onset: manifest on 3rd or 4th day postpartum
• Symptoms
• Considerable pain and feeling of tenseness or heaviness in both the breasts
• Generalized malaise or even transient rise of temperature
• Painful breast feeding
• Treatment:
• binder or brassiere
• Manual expression
• Analgesic
• Breast feeding regularly at frequent intervals
• breast pump
CRACKED AND RETRACTED NIPPLE
• Cracked nipple
• cause
• unclean hygiene
• retracted nipple
• trauma from baby’s mouth due to incorrect attachment
• Symptom
• Pain while sucking
• Treatment:
• Correct attachment of baby's mouth while feeding
• Application of milk and Purified lanolin
• breast pump and Nipple shields

• Retracted nipple
• Manual expression
• Syringe pumping
 Acute mastitis

• Incidence:
• Lactating: 2 to 5% - Non-lactating: 1%
• Organism:
• Staph.Aureus
• S.Epidermidis
• Streptococci
• Mode of infection:
• Congestive mastitis
• Infective mastitis
• Clinical features:
• Fever
• Severe tenderness & swelling
• Complications:
• Breast abscess

• Treatment:
• Nursing care:
• Unaffected side to establish let down
• Affected side - emptied manually with
each feed
• Antibiotics
• Analgesics
Breast abscess

• Clinical features:
• Tender swollen breast
• Swinging temperature
• Fluctuant mass

• Treatment:
• Drained under general anaesthesia
• Deep radial incision
• Cavity is packed with gauze
 Lactation failure
Causes:
• Infrequent suckling
• Depression or anxiety
• Reluctance or apprehension to nursing
• ill development of nipples
• Exogenous drugs: pyridoxine, diuretics, ergot preparations
 Managing Lactational Failure

• Reassurance
• Adequate fluid intake
• Breast feeding on demand
• Galact & Lactare granules
• Metaclopramide
PUERPERAL VENOUS THROMBOSIS AND PULMONARY
EMBOLISM

• Risk factors
• Vascular stasis
• Hyper coagulability of blood
• Vascular endothelial trauma
• acquired risk factor for thrombosis are
• Advanced age and parity
• Operative delivery (10 times more)
• Obesity
• Anemia
• Heart disease
• Infection-pelvic cellulitis
• Trauma to the venous wall
• Immobility, Smoking, and Prior DVT or PE
• Venous thrombo-embolic diseases include:
• Deep vein thrombosis (ileofemoral)
• Thrombophlebitis (superficial and deep veins)
• Pulmonary embolus
• DEEP VEIN THROMBOSIS
Symptoms-
pain in the calf muscles, edema legs and rise in skin temperature
On examination-
asymmetric leg edema (difference in circumference between the affected and the
normal leg more than 2 cm)
A positive Homan’s sign-pain in the calf on dorsiflexion of the foot may be present.
• Investigations-

• Doppler ultrasound
• Venous ultrasonography (VUS)
• MRI
Pelvic Thrombophebitis
• Puerperal infection may extend along venous routes and cause thrombosis
• Lymphangitis often coexists.
• The ovarian veins may then become involved because they drain the upper
uterus, which most often includes veins draining the placental site.
• In a fourth of women, the clot extends into the inferior vena cava, and
occasionally extends to the renal vein.
Pelvic Thrombophebitis
• It should be suspected when pyrexia continues for more than a week in spite of
antibiotic therapy

• It usually develops on the second week of puerperium.

• The affected leg is swollen, painful, white and cold.

• Blood count shows polymorphonuclear leucocytosis.

• The diagnosis may be made by venous ultrasound, computed tomography (CT) scan or
by magnetic resonance imaging (MRI).
Prophylaxis
• Prevention of trauma, sepsis, anemia, dehydration
• Use of elastic compression stocking & pneumatic compression devices
• Leg exercises, early ambulation,
• Anticoagulation
 Pulmonary Embolism

Pulmonary embolism is the leading cause of maternal deaths .

While deep venous thrombosis in the leg or in the pelvis is most likely the cause of
pulmonary embolism, but in about 80–90 percent, it occurs without any previous
clinical manifestations of deep vein thrombosis.

The classical symptoms of massive pulmonary embolism are sudden collapse with
acute chest pain and air hunger. Death usually occurs within short time
Symptoms:

Dyspnoea/ pleuritic chest pain /cough-haemoptysis

Signs:
Tachypnoea/ tachycardia/Hypoxia

IF PE suspected, start treatment dose LMWH and admit to hospital

Postnatal prophylaxis
• MCQ
• 1)secondary post partum hemorrhage occurs after how many days of delivery
• a)immediately following delivery
• b) within 24 hours of delivery
• c) within 8-14 days of delivery
• d)after 2 weeks of delivery

• 2)puerperal pyrexia is called when the temperature rises above

• a)99.5°F
• b) 100.2◦F
• c) 100.4◦F
• d)100.6◦F
• 3)Organism responsible for urinary tract infection in Puerperium are
• a)E.coli
• b)proteus
• c)Klebsiella
• d)all of the above

• 4)Drug given in case of lactational failure is

• a)domperidone
• b)metoclopramide
• c) bromocriptine
• d)none of the above
• SAQ

• Define puerperal pyrexia. Enumerate causes of puerperal pyrexia?

• Investigations done in puerperal pyrexia?