Abnormal Puerperium

Puerperal Pyrexia

A rise of temperature reaching 100.4 ̊ F or more on

two separate occasions at 24 hours apart (excluding
first 24 hours) within first 10 days following delivery
is called puerperal pyrexia.
Causes
Puerperal Sepsis
UTI, cystitis, pyelonephritis
Mastitis, Breast abscess
Wound infection, CS or episiotomy
Pulmonary infection
Septic pelvic thrombophlebitis
A recrudescence of malaria or Pulmonary
Tuberculosis
Puerperal Sepsis
An infection of the genital tract which occurs as a
complication of deliver is termed as puerperal
sepsis.
Risk Factors
Antepartum Factors:

a. Malnutrition & anemia

b. Preterm labor
c. Premature rupture of the membranes
d. Immunocompromised (HIV)
e. Prolonged rupture of membrane more than 18
hours
f. Diabetes
Risk Factors
 Intrapartum Risk Factors:

1. Repeated vaginal examination

2. Dehydration & ketoacidosis during labor
3. Traumatic vaginal delivery
4. Hemorrhage– Antepartum or post partum
5. Retained bits of placental tissue or
membranes
6. Prolonged labor
7. Obstructed labor
8. Cesarean delivery
 Microorganism Responsible For Puerperal Sepsis
Group A beta-hemolytic streptococcus
Group B beta-hemolytic streptococcus
Staphylococcus pyogens
S.aureus
E.coli
Pseudomonas
Proteus
Chlamydia
Clinical Features

1. Local infection
2. Uterine infection
3. Spreading infection
Clinical Features
1. Slight rise of temperature
2. Generalized malaise or headache
3. Wound become red & swollen
4. Pus in the wound
5. In severe cases fever associated with chills & rigor
6. Rapid pulse, out of proportion of temperature
7. Abdominal pain & dysuria
8. Lochia may be scanty & odorless
9. Uterus may be subinvoluted, tender & softer
Investigation
 CBC
 Blood grouping and Rh typing
 RBS
 Blood Culture
 S. Electrolytes
 Clean catch mid stream urine analysis
 High Vaginal Swab and Endocervical Swab for C/S

 ICT for excluding Malaria

 Pelvic USG
 Blood urea & electrolytes
Treatment
General:
 Isolation of the patient
 Adequate fluid & calorie maintained by i/v
fluid
 Anemia is corrected by Blood transfusion
 An indwelling catheter
 A chart is maintained for recording vital
signs, lochial discharge & fluid intake &
output.
 Antibiotics- Ampicillin, Gentamicin,
Metronidazole
Treatment
 Surgical:

 Perineal wound– The wound is to be cleaned

with sitz bath several times a day is to be
dressed the wound.
 Retained uterine products– After
antibiotic coverage for 24 hours surgical
evacuation should be done for avoiding
septicemia.
 Pelvic abscess– Should be drained by
colpotomy under USG guidance.
Urinary Complication In Puerperium
1. Urinary Tract Infection : Most common cause of puerperal
pyrexia .( 1- 5 % in all deliveries )
Organism : E.coli , Klebsiella, Proteus, Staphylococcus aureus

Clinical Features :
1. Acute aching pains over loins, often radiating to the groin
and costovertebral tenderness
2. Dysuria
3. Haematuria
4. Spiking fever with chills and rigor
5. Anorexia, Nausea, Vomiting, Myalgia
2. Retention of urine : This is a common complication of early
puerperium.
Causes may be Bruising and oedema of bladder neck, reflex
from perineal injuury, unaccustomed position.

3. Incontinence of urine:
The incontinence may be:
1. Overflow incontinence
2. Stress incontinence
3. True incontinence
 Breast Complications
1. Breast Engorgement: it is due to exaggerated normal venous
and lymphatic engorgement of the breasts which precedes
lactation
Onset: It usually manifests after the milk secretion starts
( 3- 4th day of puerperium)
Symptoms: a. pain and feeling of heaviness in both
breasts
b. painful breastfeeding
c. malaise and fever
Prevention: a. initiate breastfeeding early and
unrestricted
b. exclusive breast feeing and correct
positioning
Treatment: a. Support breasts with brassiere
b. Manual expression of any remaining
milk after each feed
c. Analgesics for pain
Breast Complications
2. Cracked and Retracted Nipples:
It may occur due to:
a. unclean hygiene forming crusts over nipple
b. retracted nipple (usually occurs in primigravidae)
c. trauma form baby’s mouth due to incorrect
attachment

Treatment: Correct attachment and smearing

fresh human milk or saliva over nipple have got
healing properties
 Breast Complications
4. Acute mastitis: common organisms are S.aureus, S. epididermis, and S.
viridians and risk factors are poor nursing, maternal fatigue, and cracked
nipple
Symptoms:
1. generalized malaise and headache
2. fever
3. severe pain and tender swelling of breast
Signs: breast becomes swollen, overlying skin is red, hot, and
flushed feels tender and tense
Treatment:
a. Breast support
b. Plenty of oral fluids
c. Breast feeing with good attachment on uninfected side
d. Affected side emptied manually with each feed
e. Antibiotic therapy for 7 days
f. Analgesic for pain
Breast Complications
5. Breast abcess:
Symptoms: 1. Flushed breasts not responding to
antibiotics properly
2. Brawny edema of the overlying skin
3. Marked tenderness with fluctuation
4. Swinging temperature
Treatment: it is an abcess and it may be drained under
general anaesthesia by deep radial incision extending
from near the areolar margin to prevent injury to
lactiferous ducts
Breast Complications
5. Lactation Failure:
Causes: 1. Infrequent suckling
2. Depression or anxiety state in puerperium
3. Reluctance to nurse
4. Ill development of nipples
5. Painful breast lesions
6. Endogenous suppression of prolactin from
retained placenta
7. Prolactin inhibition
Treatment: a. Proper counseling
b. Encourage adequate fluid intake
c. Nursing of the baby regularly
d. Lactation inducing drugs
Thank You