Abnormal Puerperium

Moderator- Dr. Garima Kapoor

Presenter- Dr. Soni Kumari
Dr. Nalini
Dr. Soni Kumari
Dr. Roohat
Dr. Bhawna
 Contents
• Puerperal Pyrexia
• Puerperal Sepsis
• Subinvolution
• UTI
• DVT
• PE
• Breast complication
• Psychiatric disorder
 PUERPERAL PYREXIA

• A rise of temperature reaching 100.4°F (38°C) or

more
• (measured orally) on two separate occasions at 24
hours apart
• excluding first 24 hours
• within first 10 days following delivery is called
puerperal pyrexia.
 PUERPERAL SEPSIS
• Puerperal sepsis is defined as infection of genital tract
occurring at any time between the onset of rupture of
membrane or labour, till 42nd day postpartum in
which two or more of following is present:
• Pelvic pain
• Fever(oral temp) ≥ 38*C
• Abnormal vaginal discharge
• Foul smelling discharge PV
• Delay in rate of involution of uterus(<2cm/day first 8
day)
 Causes of Puerperal Pyrexia
• Genital tract- endometritis, endomyometritis, parametritis
• Breast- mastitis, breast engorgement, breast abscess
• UTI- gram-negative bacterial infection of urinary tract, acute
pyelonephritis
• Respiratory-Pnuemonia, ARDS, Atelectasis
• Skin and soft tissue infection- iv cannulae or injection site
infection, caesarean or episiotomy wound, necrotizing
fasciitis
• Gastroenteritis- Salmonella and Campylobacter, C. difficile
• Pharyngitis- most – viral; 10%- d/t GAS
• Related to anaesthesia- spinal abscess d/t- S. aureus,
streptococcus
 RISK FACTOR
ANTEPARTUM INTRAPARTUM
• Poor general condition and • CS- 5-15% risk in elective LSCS,
malnutrition 30-35% in Emergency LSCS
• Anemia • Vaginal delivery- 1-3% risk
• Lower socia economic status • Multiple pv exam (WHO-
• Premature labour recommends pv @ 4hrly in
• PPROM active phase of labour)
• Prolonged LPV > 18 hrs
• APH
• Operative and instrumental
• Immunocompromised status
deliveries
• Medical condition in mother like
• Home delivery by Dai
DM, GDM, H/O PID
• Obstructed labour
• GAS infection in close contacts/
• Twin delivery
family member
Organisms causing Puerperal sepsis
• Group A streptococcus
(streptococcus pyogenes)
• Escherichia coli
• Staphylococcus aureus
• Streptococcus pneumoniae
• MRSA, Clostridium
septicum, Morganella
morganii
• MSSA, Klebsiella ( in our
hospital)

(MC org. causing P.

sepsis) (RCOG green-top-guidelines no.
64b)
SPREAD OF INFECTION
• Exogeneous- Direct inoculation of
organisms into genital tract or
lacerated wound. E.g.- staph.
aureus
• Endogeneous- organism from
vagina and cervix spread to cause
other pelvic structure infection.
E.g. anaerobes, streptococcus
• Autogeneous- infection spread to
genital tract from other body parts
like in sore
throat.e.g.streptococcus, E.coli,
Staph. aureus (dental hygiene is
important in pregnancy)
MODE OF INFECTION
• Multiplication of organism in
devitalized tissue like open
placental site or perineal
laceration, uterine wound and
blood clots which acts as good
culture media
• Introduction of microorganism
from outside during delivery due
to multiple pv and unsterile
delivery conditions
• Lowered general/ host
resistance as in
immunocompromised state
 PATHOGENESIS
Favorable sites for bacterial growth and multiplication
• Endometrium (placental implantation site),
• cervical lacerated wound,
• vaginal wound or
• perineal lacerated wound

• The devitalized tissue, blood clots, foreign body (retained

cotton swabs), and surgical trauma favor polymicrobial
growth, proliferation and spread of infection.

• This ultimately leads to Endometritis, parametritis and/or

cellulitis.
 CLINICAL FEATURES
Local infection (Surgical
site infection):
(1)rise of temperature,
generalized malaise or
headache,
(2) wound becomes red and
swollen,
(3) Pus formation leads to
disruption of the wound.

• severe (acute), there is high

grade fever with chills and rigor.
UTERINE INFECTION

• Endometritis- Infection
of decidua
• Endomyometritis-
Infection involving
decidua+ myometrium
• Parametritis – Infection
involving decidua+
myometrium+
parametrial tissue
Septic pelvic thrombophlebitis

• Rare postpartum complication

• Pelvic infection spreads and leads to infection of vein wall and
intimal damage leading to thrombogenesis.
• May involve the ovarian veins( R>L) , uterine veins, pelvic
veins and rarely, the inferior vena cava.
Pathogenesis-
• Inflammatory process lead to formation of clot, blocking the
vein involved.
• This leads to injury to organ and activation of intrinsic
coagulation cascade by tissue factor activation.
• Virchow's triad of thrombogenesis is completed by
hypercoagulable state, blood stasis along with endothelial
damage from adjacent infection.
• This clot can dislodge and lead to thromboembolic episodes.
• Clinical Features- prolonged spiking fever despite antibiotic therapy,
tachycardia
– Per Abdomen- lower abdomen tenderness, subinvoluted, tender uterus
– Per Speculum- Foul smelling lochia
– Per Vaginum- tender fornices to the side involved, sausage shaped mass may be
palpable.
– Sometimes may present with PE, SOB
• Risk factor- Bacterial vaginosis, chorioamnionitis, prolonged labour,
Multiple pv, Multiple gestation, PID
• Diagnosis- by clinical suspicion, raised CRP, increased WBC, CT scan/
MRI imaging.
• CT-
• 1) enlargement of the vein involved
• 2) low density lumen within the vessel wall
• 3)sharp enhancement of the vessel wall.
• MRI – the thrombosed vessel appear bright whereas normal blood
flow looks dark.
• Management-
• Antibiotics-
Inj. Clindamycin 600 mg i.v. 8 hourly + Inj.
Gentamicin 80 mg i.v. 12 hourly + Inj. Ampicillin
500 mg i.v 6 hourly for 7 days
• In case of deep vein involvement, use of
anticoagulants like heparin will help prevent
clot from growing. Inj. Enoxaparin 1 mg/kg for
2 weeks
• Use of support stockings to prevent recurrence
and thromboembolism.
• Fever usually resolves within 96 hrs.
Parametritis

• Definition- Inflammation of parametrium,

the connective tissue of the pelvic floor,
extending from the subserous coat of the
uterus laterally between the layers of the
broad ligament
• Onset  7–10th day of puerperium.
• Clinical Features – high grade fever with chills
and rigor, lower abdominal pain and
tenderness with muscle guarding
• Per Vaginum -Vaginal examination reveals a
unilateral tender indurated mass pushing the
uterus to the contralateral side, tender
fornices, foul smelling lochia
• Per Rectal -Rectal examination confirms the
induration especially extending along the
uterosacral ligament. It takes a few weeks to
resolute completely.
 Parametrial Phlegmon
• Definition-A condition of intense
parametrial cellulitis which forms an
area of induration called – phlegmon
• Usually unilateral and limited to
parametrium at base of broad ligament
• Clinical Features- persistent fever > 72
hrs despite iv antibiotics therapy
• If inflammation is severe, may extend
posterior to involve rectovaginal
septum.
• Treatment : broad spectrum antibiotics
regimen for 10-14 days
 Toxic Shock Syndrome
• Definition-Acute febrile illness with severe multisystem
derangement caused by staph aureas exotoxin TSST-1 which is
superantigen
• Clinical features- fever, headache, mental confusion, diffuse
macular erythematous rash, subcutaneous edema, nausea,
vomiting, watery diarrhoea
• Severe- renal failure, hepatic failure, DIC, shock
• TSST-1 provoke profound endothelial injury and activate T-cell to
create cytokine storm
• Treatment- usually supportive, Antibioctics
If wound- debridement
• Case fatality rate-10-15 %
 Generalised peritonitis

• Definition- Inflammation of peritoneum occurring due to

spreading pelvic infection
• Clinical Features- High grade fever, tachycardia, Patient
looks very ill and dehydrated/sick look, vomiting,
diarrhoea, generalized abdominal pain and tenderness
• Per Abdomen- generalized tenderness, generalized
muscle guarding and rigidity, abdomen distended.
Rebound tenderness is present.
Septicemia

Definition- septicemia is a life threatening condition

defined as organ dysfunction resulting from infection.
• Clinical Features-High grade fever associated with rigor.
• Tachycardia, tachypnoea
• Per Abdomen-lower abdominal pain/ tenderness,
subinvoluted uterus, uterus is tender
• Per Speculum- foul smelling lochia
• Blood culture is positive
• Symptoms and signs of metastatic infection in the lungs,
meninges may be present.
 Septic shock
• Definition- septic shock(distributive shock) is a
potentially fatal medical condition occurring in
sepsis which lead to organ damage and
circulatory failure
• The Third International Consensus Definitions for
Sepsis and Septic Shock (Sepsis-3) defines septic
shock as a subset of sepsis in which particularly
profound circulatory, cellular, and metabolic
abnormalities are associated with a greater risk of
mortality than with sepsis alone.
Early Management Comprises 6 elements to be Completed
within 1 hour, Reduces mortality by upto 50%
1. Administer oxygen to maintain SpO2 at >94% and monitoring
urine output
2. Take blood cultures
3. Administer intravenous antibiotics
4. Check serial lactates.
5. Fluid resuscitation
6. Early administration of vasopressors to maintain MAP of > 65
mm Hg.
Early recognition and prompt initiation of resuscitation
HISTORY -H/o fever, rigors, diarrhea, vomiting's, abdominal / pelvic pain, offensive
vaginal discharge, productive cough, urinary symptoms.
GENERAL PHYSICAL EXAMINATION- Look for vitals and assess for level of
consciousness
Spo2- {tachycardia, tachypnea, labored breathing, cyanosis, airway obstruction}
Urine output, Shock index
B/L Breast examination – ( for engorgement, redness, tenderness, abscess)
PER ABDOMEN –look for guarding, tenderness, rigidity, fundal height & tone of
uterus, look for uterine tenderness, signs of wound infection, hematoma,
dehiscence
PER SPECULUM- any foul smelling discharge or lochia, foreign body, retained
products.
PERINEAL EXAMINATION- look for episiotomy site infection, or hematoma
STABILIZE THE PATIENT ( POSITION : left lateral decubitus position is preferred)
 INVESTIGATIONS
Principles in investigations are:
(1) To locate the site of infection,
(2) To identify the organisms,
(3) To assess the severity of the disease.
• Lactate levels and blood cultures levels should be obtained
within 1 hours of suspected sepsis presentation.
• Blood should be taken for culture before the first dose of
antibiotics given.
• Serum lactate:
– Is a marker for anaerobic metabolism subsequent to tissue
hypoperfusion, raised when microcirculatory failure,
reduced oxygen extraction, increased glycolytic flux due to
catecholamine surge during sepsis, & hepato-renal
dysfunction
– Baseline lactate helps in monitoring resuscitation by
targeting its clearance.
– If >2 mmol/L - remeasured within 2–4 hrs.
– Values >4 mmol/L a/w increased mortality.
 Parameters for monitoring resuscitation

• MAP ( ≥ 65mm of Hg)

• Urine output ( ≥0.5 mL/kg/ hr )
• CVP between (8-12 mm of Hg)
• Lactate level improves
• Heart rate
• Respiratory rate
• Skin color (CRT improves)
• Temperature
• Oxygen saturation
• Mental status improves
 TREATMENT
• General care:
(i) Isolation of the patient is preferred especially when hemolytic
Streptococcus is obtained on culture (to limit the risk of
transmission of infection)

(ii) Adequate IV fluid

adequate calorie supplement

(iii) Anemia correction if needed

 (iv) An indwelling catheter for monitoring hourly urine
output

(v) monitoring of pulse, respiratory rate, temperature, and

fluid intake and output. Regular and frequent monitoring of
all vital chart must be recorded on a modified early
obstetric warning sign(MEOWS) chart.
(RCOG-Green top guidelines 64b)

(vi) Antibiotics: administration of intravenous broad

spectrum antibiotics within 1 hour of suspicious of severe
sepsis with/ without septic shock, is recommended
(RCOG- green top guidelines 64b)
Accg. to SSC ‘2016 guidelines
IV antibiotics should be administered within 1 hour after
recognition of both sepsis/septic shock.

“Golden hour of sepsis” stresses relationship between timely

initiation of antibiotic treatment and outcome.
Each hour delay - reduces sepsis survival by 7.6%*
Antimicrobial therapy
• should be initiated and not delayed (if delay in obtaining
cultures)
• Empirical broad spectrum antibiotics should be started,
combination therapy is preferred
• Definitive therapy should be started after identifying the
causative organism
National Treatment Guidelines for Antimicrobial Use in Infectious Diseases,
GOI 2016 recommends antimicrobial therapy as follows:
• Sepsis in Pregnancy
Piperacillin-Tazobactam 4.5 g IV QID or
Cefoperazone + Sulbactam 3 g IV BD and
MRSA cover with Vancomycin/ Teicoplanin may be required.
• Chorioamnionitis
Clindamycin/ vancomycin/ teicoplanin and cefoperazone- sulbactum
if patient not in sepsis then IV Ampicillin
• Endomyometritis-
Empirical therapy with Ampicillin 500 mg QID + Metronidazole 500 mg IV TDS
Or ceftriaxone 2 gm iv od
Peritonitis, Intra-abdominal abscess-
Empirical therapy - Piptaz 4.5 gm IV TDS or Cefoperazone
+Sulbactam 3 gm IV BD
In sick patients fluconazole iv 800 mg loading dose day 1,
followed by 400 mg OD.
Alternate regimen- Imipenem 1g IV TDS or Meropenem 1gm
IV TDS or Doripenem 500 mg TDS or Ertapenem 1 gm IV OD.
• Antimicrobial therapy duration - 7 to 10 days in most cases
• SSC recommends daily assessment for de-escalation of
antimicrobial therapy in patients with sepsis and septic shock
• Procalcitonin levels can be used to guide duration of antibiotics
• SSC recommends source control intervention should be
implemented as soon as medically and logistically practical
after the diagnosis is made
SURGICAL INTERVENTION required
• Pyoperitoneum
• Retained products of conception
• Tubo-ovarian abscess
• Necrotising soft tissue infection
Necrotizing fasciitis
• rare but fatal complication of wound infection (abdominal,
perineal, vaginal),
• Involves muscle and fascia.
• Risk factors are diabetes, obesity and hypertension.
• Infection is caused by Group A beta-hemolytic Streptococcus
and often it is polymicrobial.
• Tissue necrosis is the significant pathology.
Treatment includes:
• Rehydration,
• wound scrubbing,
• debridement of all necrotic tissues, and
• use of high dose broad-spectrum antibiotics.
• Necrotizing fascitis-
Empirical therapy - Piperacillin-Tazobactam 4.5 gm IV QID or
Cefoperazone-Sulbactam 3 gm IV 12 BD + Clindamycin 600-900
mg IV TDS
Alternatively- Imipenem 1g IV TDS or Meropenem 1gm IV TDS +
Clindamycin 600-900 mg IV TDS/ linezolid 600 mg IV
BD/daptomycin 6mg/kg/day.
 Neonatal implications of sepsis

• The baby is especially at risk of streptococcal and

staphylococcal infection during breast feeding.
• If either the mother or baby is infected with invasive GAS
in the postpartum period, both should be treated with
antibiotics.
• GAS pose highest risk of sepsis in the neonates.
• Hence antimicrobial prophylaxis should be given
routinely to neonates of mothers with GAS infection.
(RCOG-green top guidelines 64b)
WHEN TO SUSPECT? TO SUMMARIZE:
S.No Entity Clinical manifestation
1 Endometritis low grade fever, lower pain abdomen,
uterine tenderness

2 Endomyometritis high grade fever, rigor, malaise,

tachycardia, foul-smelling lochia,
subinvoluted uterus, tender uterus
3 Parametritis high grade fever with rigor and chills,
abdominal and pelvic pain, increased
parametrial tenderness, uterosacral
ligament- indurated and nodular on
vaginal and rectal examination

4 Pelvic peritonitis high grade fever with tachycardia, lower

abdominal and pelvic pain and tenderness
with muscle guarding, fornices are tender
and indurated

5 Pelvic Abscess high grade fever, loose motion, bulging

mass in posterior fornix due to collection
in POD
S. no Entity Clinical manifestation
6 General Peritonitis High grade fever with tachycardia,
dehydration, nausea and vomiting,
generalized abdominal pain and
tenderness, rebound tenderness.
 PREVENTION
• Antenatal period- Diagnosis and treatment of UTI, anaemia,
malnutrition, treatment of sexually transmitted disease and
other vaginal infection, diagnosis and management of
prolonged rupture of membrane >12 hrs
• Intrapartum prophylaxis- Strict adherence to established
antiseptic and sterilization procedures in vaginal delivery as
well as CS.
Restricting vaginal examinations.
Encourage voiding urine during labour thereby avoiding
unnecessary catheterization.
 SUBINVOLUTION
• DEFINITION:
When the involution of uterus is impaired or retarded, it is
called subinvolution.
The uterus is the most common organ affected in subinvolution.

• CAUSES:
Predisposing factors (1) Grand multiparity,
(2) Overdistension of uterus
(3) Maternal ill-health,
(4) Caesarean section,
(5) Prolapse of the uterus,
(6) Retroversion after the uterus
(7) Uterine fibroid.
Aggravating factors are:
(1) Retained products of conception,
(2) Uterine sepsis (endometritis).

SYMPTOMS:
i. Abnormal lochia discharge
ii. Irregular or at times excessive uterine bleeding,
iii. Irregular cramp-like pain in cases of retained
products.
iv. Rise of temperature in sepsis.
SIGNS:
i. The uterine height is greater than the normal for
the particular day of puerperium.
ii. Normal puerperal uterus may be displaced by a full
bladder or a loaded rectum. It feels boggy and
softer.
iii. Presence of features responsible for subinvolution
may be evident.
MANAGEMENT
• Appropriate therapy is to be instituted for particular
local pathology:

(1) Antibiotics in endometritis,

(2) Exploration of the uterus in retained products,
(3) Pessary in prolapse or retroversion.
 Urinary tract infection
Most frequent bacterial infection .

● Incidence :(William 25th edition)

Asymptomatic bacterial infection(2-7%)
Acute cystitis (1-4%)
Acute pyelonephritis(0.5-2%)
● Definition:
a) Asymptomatic bacteriuria:Isolation of specified quantitative count of bacteria in
appropriately collected urine specimen from a person without signs and symptoms of
UTI.

b) Acute cystitis: Symptomatic bladder infection characterized by

frequency,urgency,dysuria or suprapubic pain in person with normal genitourinary
tract .
c) Acute pyelonephritis:Ascending bacterial infection of renal pelvis and renal
parenchyma presenting with fever ,loin pain and bacteriuria.

UTI is more common in female due to short urethra and proximity to anus.
In pregnancy ,there is relative sparing of left ureter because of protection from
sigmoid colon and upper rectum
Etiology of UTI in pregnancy and puerperium:

1.Urinary stasis due to gravid uterus compressing ureter

2.High progesterone → ureteric smooth muscle relaxation → dilatation (hydronephrosis)
3.Increase in PH of urine due to increase glucose ,amino acids
4.Increase in vesicoureteric reflux
5.Multiparity, anemia (specially sickle cell),DM ,low socioeconomic status
6.Prolonged catheterisation
7.Ureteral obstruction(stone,stricture)
8.labor trauma /epidural analgesia due to bladder sensitivity
Organisms associated with UTI:
1.E.coli (80-85%)
2.Staphylococcus saprophyticus(5-10%)
3.Ohers:Klebsiella,proteus,pseudomonas,enterobacter
Asymptomatic bacteriuria:

● Incidence - Highest (african-american)

lowest (white women)

● Diagnostic criteria:
>105 CFU /ml in 2 consecutive midstream clean catch urine specimen
OR
>102 CFU/ml in urine collected from urinary bladder catheter.

Recommended screening for bacteriuria at 1st prenatal visit /12 weeks whichever is earlier.
(ACOG or GRADE A RCOG)

● Investigation:

Urine routine microscopy

Leucocyte esterase /nitrite dipstick(cost effective)
Urine culture and sensitivity (gold standard)
Complications: More common in 1st trimester.(RCOG green top guidelines 37b)
 Acute pyelonephritis

● Most serious medical complication of pregnancy

● leading cause of septic shock during pregnancy
● Mostly unilateral and right sided
● 90% cases ( 2nd and 3rd trimester)

Clinical features:
● Fever
● Rigors
● Nausea
● Vomiting
● Renal angle tenderness
● Fetal tachycardia
Complications :

● Anemia(25%) ref:UTI in preg. Practise essentials.2021

● Pyonephrosis
● Septicemia and septic shock
● Acute respiratory distress(2%) due to endotoxin induced
alveolar injury
● Preterm labor pain
 Acute cystitis

Clinical features:

● Frequency(m/c),
● Dysuria,
● Urgency,
● Pyuria,
● Microscopic hematuria,
occasionally gross hematuria from hemorrhagic cystitis.
40% of pregnant female with acute pyelonephritis have symptoms of
lower tract infection.
 Asymptomatic Acute Pyelonephritis
bacteriuria cystitis
Urine +ve +ve +ve
culture &
sensitivity
Urinary -ve +ve +ve
symptoms
Fever -ve -ve +ve
Renal angle -ve -ve +ve
tenderness
D/D of UTI:

1.Gonococcal and non gonococcal urethritis

2.Chemical cystitis
3.Vaginitis,cervicitis
4.Appendicitis,pancreatitis,cholecystitis
5.Preterm labor pains,Chorioamnionitis,abruption,adnexal torsion

General management to reduce the incidence of UTI in puerperium:

1.Washing the genitals after sexual intercourse
2.Plenty of fluids
3.Simple analgesics to reduce suprapubic pain
Oral antimicrobial agents used for treatment for asymptomatic bacteriuria and acute cystitis
in puerperium(Williams 25th edition)
Single dose treatment :3 g Amoxicillin
2 g Ampicillin
2 g Cephalosporin
200mg Nitrofurantoin
320/1600 mg Trimethoprim sulfamethoxazole
3 day course : Amoxicillin 500mg TDS
Ampicillin 250 mg QID
Ciprofloxacin 250 mg BD
Levofloxacin 250 or 500 mg OD
Nitrofurantoin 50-100 mg QID or 100 mg BD
Trimethoprim-sulfamethoxazole 160/800 mg
Others: Nitrofurantoin 100 mg QID × 10 days
Nitrofurantoin 100 mg BD ×5-7 days
Nitrofurantoin 100 mg HS × 10 days
Treatment failure: Nitrofurantoin 100 mg QID × 21 days
 Management of acute pyelonephritis:(Williams 25th edition)

INITIALLY DURING HOSPITAL

STAY

● Hospitalize patient ● Repeat samples after ● Repeat urine culture 1 to 2 weeks after
● Ix -CBC, 48 hrs antimicrobial therapy completed.
KFT,
Serum electrolytes,
Urine routine microscopy,
Urine or blood culture
sensitivity

Treatment: ● Chest X ray if dyspnea ● Change to oral antimicrobials when

● Foley catheterisation or tachypnea afebrile.
● Intravenous crystalloid ● Discharge when afebrile 24
solution
● Vital charting including hours,consider antimicrobials therapy for
urinary output >50 ml/hr 7-10 days.
every 2-4 hrly
● I.V. antimicrobial therapy*
Antibiotics:*
1.Inj ceftriaxone 1 gm I.V. OD till patient becomes afebrile then shift to
cephalexin 500mg QID for 14 days
2.Inj vancomycin 1gm I.V. BD plus gentamycin 1.5 mg/kg TDS till patient
patient becomes afebrile.
Non antibiotic treatment for acute cystitis:
1.Vitamin C: Antimicrobial
Non enzymatic antioxidant decreases the free radicals
Strengthen the immune system
Ref:Fazly Bazzaz,B.S.et al. Deep insights into urinary tract infections and effective
natural remedies.Afr J Urol (2021) 27:6

2.Cranberry juice: Potent uro protective agent

Antibacterials
Contents:>80% water,,10% carbohydrates (glucose+fructose),
Organic acids & and some phytoconstituents
Ref:Das,S.Natural therapeutics for urinary tract infections- a review Future Journal
of Pharmaceutical Sciences(2020)6:64.
 RETENTION OF URINE

This is a common complication in early puerperium.

CAUSES:
● Primiparity
● Caesarean section
● Perineal laceration
● Oxytocin induced labor
● Operative VD
● Foley during labor
● Labor >10 hrs
Diagnosis and treatment: (Williams 25th edition)

If not voided <4 hrs after delivery

Diagnosis Directly examine Suprapubic bulge

Indirectly by palpating uterus(fundus above umbilicus)
Automated bladder scanner sonography

Pervaginal & perectal examination for any hematoma

Simple measure (Adequate hydration,running tape,sprinkle of lukewarm water over lower abdomen
& perineum)

If simple measures fails to initiate micturition, indwelling catheter inserted ✖ 24 hrs

 Following removal of catheter, Measure the residual urine

If > 200 mL, If < 200 ml,catheter can be removed

Continue foley for
next 24 hrs.

● Appropriate urinary antiseptics should given for 5–7 days

.
VTE IN PUERPERIUM:
 INCIDENCE:
• Although the absolute VTE rates are low, pregnancy-
associated VTE is an important cause of maternal morbidity
and mortality
• Venous thromboembolism (VTE), complicates 0.5–2.2 per
1000 deliveries.
• During pregnancy, the risk of VTE is increased five to tenfold
• Risk is same in all trimesters
• In the postpartum period, the risk of VTE is increased 15-
to 35-fold .
• Risk of thrombosis is greatest during the first 3–6 weeks
postpartum. ACOG 2018, RCOG 2015
 PATHOGENESIS

Pregnancy is risk factor for VTE -

Due to activation of the Virchow’s triad.

Activation of Virchow’s triad

a. Venous stasis- decreased venous tone- (venous pooling and
valve incompetence) and compression of gravid uterus
b. Hypercoagubality- Increased coagulation factors- progressive
increases in several coagulation factors, including factors I, II,
VII, VIII, IX, and X, along with a decrease in protein S (30 %).
c. Endothelial injury- maximum after delivery (esp. traumatic
delivery)
 VENOUS THROMBOSIS

• DEEP VEIN THROMBOSIS(80%)

• PULMONARY EMBOLISM(20%)
 DEEP VEIN THROMBOSIS
• PROXIMAL DVT
Popliteal, femoral, iliac veins

• DISTAL DVT
Below the knee and is
confined to calf veins
(peroneal, posterior,
anterior tibial and muscular
veins)
Pelvic vein thrombosis: rare
outside pregnancy
 CLINICAL PRESENTATION
• The 2 most common symptom are pain and swelling
of extremity.
• erythema, warmth and tenderness of the lower
extremity +
• Diagnosis can be difficult due to physiological
changes of pregnancy.
• More common in left lower limb (80%) (MAY
THURNER SYNDROME )
• More common in proximal veins
 PRETEST PROBABILTY:

• Common predictive scoring systems eg: Wells score

• LEFt clinical prediction rule
• D-dimer levels
However, these tools have not been validated in large
prospective trials and, in general, they are less useful in
pregnant women than in the general population.
 WELLS SCORE
Score

Wells scoring
Active cancer (treatment ongoing or within previous 6 months 1
or palliative) system for
DVT:
Paralysis, paresis or recent plaster immobilization of the lower 1 -2 to 0: low
extremities probability(3%)
1 to 2 points:
Recently bedridden > 3 d or major surgery within 4 weeks 1
Moderate
Localized tenderness along the distribution of the deep probability(17%
1
venous system )
3 to 8 points:
Entire leg swollen 1
high
Calf swelling 3 cm > asymptomatic side (measured 10 cm probability(50-
1
below tibial tuberosity) 75%)

Pitting edema confined to the symptomatic leg 1

Collateral superficial veins (non-varicose) 1

Alternative diagnosis as likely or greater than that of DVT −2

 LEFt CLINICAL PREDICTION RULE

Left side(L)

Mid-calf circumference >2cm(E=edema)

First trimester presentation(Ft)

None, one, or two to three of these variables, DVT was diagnosed in
zero, 16, and 58 percent.
 SERUM D-DIMER
• Break down product of fibrin

• Increases during pregnancy and slow decline in post

partum

• High negative predictive value for DVT when clinical

suspicion is low and CUS is negative

• Levels < 500 ng/ml is associated with low predictive

value for DVT
 INVESTIGATIONS
• Baseline investigations- CBC, coagulation
profile, LFT, RFT
• Compression ultrasonography (CUS)
• Doppler imaging
• D-dimer
• MRI venography
• Ascending contrast Venography
 Compression Duplex ultrasound
• Primary diagnostic test for DVT
• High definition B mode USG (grey scale and Doppler)
• Proximal and distal venous network bilaterally
• Scanned in left lateral postion
• DVT is diagnosed with lack of compressibility of a
thigh vein
• Less specific for pelvic vein and calf vein
 Compression Duplex ultrasound
• Doppler analysis of flow variation with
Respiration(Absence of this variation is suggestive of
iliac /pelvic vein thrombosis)
• Iliac vein – Absence of Doppler flow/ Turbulence in
flow or direct visualisation of a thrombus
• Serial CUS for leg vein for diagnosis/extension of
thrombus
• The sensitivity of serial compression USG with
Doppler is 94.1%, RCOG 2015

• The negative predictive value is 99.5%

Magnetic resonance
imaging –
• Appears as a filling defect.

Ascending contrast
venography
• Performed by injecting iodinated
contrast into a dorsal foot vein to
outline the entire deep venous
system of the lower extremity.
• An intraluminal defect that is
present in more than one view is
diagnostic of DVT.
• Invasive, expensive, technically
difficult to perform and interpret
and associated with complications
including contrast-induced allergic
reactions and renal insufficiency
PULMONARY EMBOLISM
• Symptoms - dyspnoea,
abrupt onset chest pain
and cough.
• Signs - tachycardia,
tachypnoea and
crackles
 INVESTIGATIONS:
Arterial blood gases :
• A respiratory alkalosis is a very common feature of both pregnancy and PE.
• Presence of hypoxemia with a normal chest radiograph should raise clinical
suspicion for PE in pregnancy and prompt further evaluation.
Brain natriuretic peptide (BNP)
• Limited diagnostic value. However, elevated BNP or its precursor, N-terminal (NT)-
proBNP may be useful prognostically for risk stratification of patients diagnosed
with acute PE.
Troponin
• Serum troponin I and T levels are useful prognostically but not diagnostically.
• As markers of right ventricular dysfunction, troponin levels are elevated in 30 to
50 percent of patients who have a moderate to large PE and are associated with
clinical deterioration and death after PE.
D-DIMER:
• Low sensitivity (high false negative rate) and specificity (high false positive rate)
• A high D-dimer is not diagnostic of PE and a low D-dimer (even <500 ng/mL) only
modestly lowers the suspicion but does not effectively eliminate PE from the
differential .
Electrocardiography
• Nonspecific.
• The most common findings are tachycardia and nonspecific ST-segment
and T-wave changes (70 percent).
• Abnormalities historically considered to be suggestive of PE (S1Q3T3
pattern, right ventricular strain, new incomplete right bundle branch block)
are uncommon (less than 10 percent)

Echocardiography
• Not routinely performed .
• Can be performed to exclude pregnancy-related cardiomyopathy or to
evaluate the size of the right ventricle (RV) in a patient with confirmed PE.
• Chest radiograph: less specific A peripheral infarct
might be suggested by a shallow wedge-shaped
opacity in the periphery of the lung with its base
against the pleural surface (Hampton's hump).
 V/Q SCAN:
V/Q scan results in pregnancy are
stratified into the risk categories :
●Normal/very low probability
●Low probability
●Moderate probability
●High probability
In general, only normal or very low
probability scans and high probability
scans are considered diagnostic.
Normal or very low probability scans
are associated with a 0 to 6 percent
chance of having a PE.
High probability scans are associated
with a 56 to 96 percent chance of
having a PE.
All other scans are indeterminate.
 CT pulmonary angiography —

• Computed tomographic pulmonary

angiography (CTPA) remains a highly
sensitive and specific test for the
diagnosis of PE.
• The demonstration of a filling defect
in any branch of the pulmonary
artery (main, lobar, segmental,
subsegmental) by contrast
enhancement is considered
diagnostic of PE during pregnancy.
 TREATMENT OF VTE

Anti coagulation - LMWH, UFH

IVC Filters

Thrombolysis/thrombectomy
 UNFRACTIONATED HEPARIN
• IV UFH bolus of 80 units/kg, followed by a continuous infusion of 18 units/kg per hour
• The infusion is titrated every six hours to achieve target PTT (60-80 sec) aPTT - 1.5 to 2.5
times normal.
• Once the target aPTT level is achieved, it should be rechecked once or twice daily
• IV UFH can be transitioned to SC UFH or SC LMWH if long-term or outpatient anticoagulant
therapy is planned
• The transition is traditionally done after the patient has received IV UFH for 5 to 10 days
• The first aPTT checked six hours after the first SC UFH dose and then six hours after each
dose
• Once a stable dose of SC UFH is achieved, the aPTT may be initially checked once or twice
daily for three to four days and then every few weeks.
• IV UFH(DOC)- Surgical intervention/Labour, Massive PE, Severe renal
failure(creatinine clearance <30ml/min)
 LMWH
• LMWHs are the agents of choice for antenatal and postnatal thrombo-
prophylaxis. They are safe, effective, reliable pharmacokinetics, practical,
lower rates of adverse effects like bleeding, allergic reactions, symptomatic
osteoporosis, thrombocytopenia etc
• Safe in breast feeding period
• Routine monitoring of platelet count is not required
• It is only necessary to monitor the platelet count if the woman has had prior
exposure to unfractionated heparin (UFH).
• Monitoring of anti-Xa levels is not required when LMWH is used for
thromboprophylaxis.
• Routine measurement of peak anti-Xa activity for patients on LMWH for
treatment of acute VTE in pregnancy or postpartum is not recommended
except in women at extremes of body weight (less than 50 kg and 90 kg or
more) or with other complicating factors (for example, with renal impairment
or recurrent VTE).
RCOG 2015
ACOG 2018
 MAINTENANCE THERAPY
• Prophylactic dose- Depends on risk factors
2- 10 days
3 or more – 6 weeks

• Therapeutic dose- first episode of VTE – 3-6

months from diagnosis

• APLA, high risk thrombophilia, Phlegmasia

cerulea dolens- 12 months
Oral Direct
Thrombin Oral direct thrombin inhibitors (dabigatran) and
anti-Xa inhibitors (rivaroxaban, apixaban,
Inhibitors edoxaban, betrixaban) should be avoided in
pregnancy and lactation because there are
and insufficient data to evaluate safety for the
woman, fetus and breastfeeding neonate.
Anti-Xa
Inhibitors

ACOG 2018
 IVC FILTER

Indications:
• Patients with iliac vein VTE to reduce the risk of PE
• Recurrent VTE on full dose medical therapy
• Have contraindication to systemic anticoagulation
• Massive PE – pulmonary bed is severely compromised

Placed by the jugular or femoral route.

Temporary retrievable filters.

• Filter complications – migration, tilt, fracture, and retrieval

particularly in relation to venous dilation in labour, contractions
and changes in IVC diameter
 THROMBOLYSIS / THROMBECTOMY
• Reserved for life threatening or limb
threatening VTE
• Catheter directed thrombolysis is a non
surgical, percutaneous targeted lytic delivery
directly into the compromised vessel.
• Systemic thrombolysis consists of
administration of intravenous lytic such as
alteplase etc to hydrolyse fibrin molecules
(increased risk of bleeding like intracranial
haemorrhage.)
• Advanced therapies like percutaneous
thrombolectomy ( thrombus aspiration,
fragmentation of thrombus by catheter or
rheolytic thrombectomy) can warrant good
results but is dependent on local expertise
MASSIVE PE WITH HEMODYNAMIC INSTABILITY
• Multidisciplinary team
• Maternal resuscitation - ABC.
• IV UFH is drug of choice in massive PE
• An urgent portable echocardiogram or CTPA
within 1 hour of presentation should be
arranged. If massive PE is confirmed, or in
extreme circumstances prior to confirmation,
immediate thrombolysis should be considered.
 BREAST RELATED
COMPLICATIONS IN
PUERPERIUM
 BREAST RELATED COMPLICATIONS IN PUERPERIUM

LOW MILK SUPPLY BREAST COMPLICATIONS

1. Perceived lactational failure 1. Retracted/Inverted nipple

2. Actual lactational failure 2. Cracked nipple

3. Breast engorgement

4. Mastitis

5. Breast abscess
 LOW MILK SUPPLY (Breastfeeding challenges,
ACOG 2021)

• Most common reason: False perception of low milk supply.

Perceived low milk supply:

Milk supply is adequate if-
 Average feeding frequency: 8–12 times per day (some infants need more
frequent feedings)
 Steady weight is gained by day four or day five
 6–8 wet diapers occur on average per day.
 CONDITIONS ASSOCIATED WITH INCREASED RISK OF LOW OR INADEQUATE MILK
SUPPLY (Breastfeeding challenges, ACOG 2021)

Maternal medical history • Difficulty breastfeeding or slow weight gain with previous children
• Endocrine disorders such as thyroid disorders, Diabetes mellitus or
insulin resistance, PCOS, hypopituitarism
• Obesity
• Eating disorders
• Autoimmune disease
• Connective tissue disorders
• Psychiatric illness
• Renal failure
• Stress
• Tobacco use
• Extremes of maternal age
• Infertility
• Social concerns (lack of breastfeeding support, early return to work)

Maternal anatomy • Primary mammary glandular insufficiency (tubular breasts)

• History of breast surgery enlargement or reduction
• Nipple variations such as inverted and very large nipples
• Breasts that didn’t increase in size during pregnancy
 CONDITIONS ASSOCIATED WITH INCREASED RISK OF LOW OR INADEQUATE MILK
SUPPLY
Antepartum, intrapartum or
postpartum conditions
Fetal or neonatal conditions
(ACOG 2021)
• Preeclampsia
• Pregestational and gestational DM
• Theca lutein cyst
• Prolonged labor
• Medications during labor that can cause drowsiness in the
newborn, ex- opioids and benzodiazepines
• Preterm delivery
• PPH
• Retained placenta
• Infections
• Allergy
• Ankyloglossia
• Biliary atresia
• Multiple gestation
• Prematurity
• SGA
• Genetic conditions such as Down’s syndrome, cystic fibrosis
• Neurological diseases
 CONDITIONS ASSOCIATED WITH INCREASED RISK OF LOW OR INADEQUATE MILK
SUPPLY (ACOG 2021)

Fetal or neonatal conditions  Congenital anomalies-

• CNS abnormalities
• Congenital heart defects
• GI anomalies
• Micrognathia
• Cleft lip or palate
 Inborn errors of metabolism
 Malabsorption
 Sepsis or infections of the newborn
 Thyroid disorder
 Medical problems(eg: hypoglycemia, infection, jaundice,
respiratory distress, birth trauma, birth asphyxia)

Maternal signs and symptoms  Perceived inadequate milk supply

 Sore nipples or evidence of nipple compression with feedings
 Failure of secretory activation or lactogenesis stage II. (Milk didn’t
noticeably ‘’come in’’ by 72 hours postpartum.)
 Mother unable to hand express colostrum.
 Need for breastfeeding aids (eg: nipple shields, breast pumps,
supplemental nursing systems) at the time of hospital discharge
 Use of breast milk substitutes during hospital stay
CONDITIONS ASSOCIATED WITH INCREASED RISK OF LOW OR INADEQUATE
MILK SUPPLY (ACOG 2021)

Infant signs and symptoms  Persistently sleepy infant

 Difficulty in latching on to one or both breasts.
 Ineffective or unsustained suckling
 Excessive infant weight loss( greater than 7-10% of birth weight in
the 1st 48 hours or greater than 75th percentile for age and mode
of delivery on the Newborn Weight Tool).
 Supplementation with breast milk substitues
 Early pacifier use
 Signs of infant dehydration:
• Lack of bowel movements-early sign
• Dry mucous membranes-early sign
• Urate crystals in diaper
• Loss of skin turgor
• Sunken eyes
• Depressed anterior fontanelle
• Thready radial pulse-late sign
• Cold extremities-late sign
 Jaundice
MANAGEMENT of low milk supply:
A. Antenatal:
• To counsel the mother regarding the advantages of nursing her baby with
breast milk.
• To take care of any breast abnormality especially a retracted nipple and to
maintain adequate breast hygiene especially in the last 2 months of
pregnancy.
B. Puerperium:
• Mother should be given assurance and should be relieved of all anxiety.
• To encourage adequate fluid intake.
• To nurse the baby regularly.
• Painful local lesion is to be treated to prevent development of nursing
phobia.
• Manual expression of the residual milk after each feed may be helpful.
• Pharmacotherapy: Use of galactagogues.
GALACTAGOGUES:
(Breastfeeding challenges, ACOG 2021)
Definition:
Medications and other substances believed to assist initiation,
maintenance, or augmentation of rate of maternal milk synthesis.
Types:
A. Herbal galactagogues like galact or lactonic granules contain:
• Fenugreek
• Fennel
• Garlic
• Milk thistle
Dose: can be used with milk 2-3 times per day.
 Herbal galactagogues and their adverse effects:
(Ref: McGuire TM. Drugs affecting milk supply during lactation. Aust Prescr. 2018 Feb;41(1):7-
9.)

Herb Adverse effects

Alfalfa Medicago sativa Dose-related bleeding

Blessed thistle Cnicus benedictus Gastric irritation and potential allergies, as it is part of the ragweed
family

Chaste tree Vitex agnus-castus Nausea, vomiting, irritation, pruritus, rash, headache, increased
menstruation

Dill Anethum graveolens Alterations in sodium balance

Fennel Foeniculum vulgare Allergic reactions, dermatitis (photo and contact)

Fenugreek seed Trigonella foenum-graecum Hypoglycaemia, hypertension, diarrhoea and maple syrup body odour in
mother
Allergy potential as part of the peanut family

Goat’s rue Galega officinalis Hypoglycaemia, hypotension, coughing, dose-related toxicity

Milk thistle (silymarin) Silybum marianum Allergic reactions, diarrhoea

Malunggay Moringa oleifera Hypoglycaemia, sedation

Raspberry leaf Rubus idaeus Hypersensitivity reactions, changes in blood glucose

Shatavari Asparagus racemosus Possible teratogenicity – avoid in pregnancy

Damiana Turnera diffusa Hepatotoxicity, confusion and hallucinations with high-dose Turnera
 B. PHARMACEUTICAL GALACTAGOGUES:

1. DOMPERIDONE:
• Agent of choice as a galactagogue because of its superior side effect profile,
efficacy, and minimal passage in to breastmilk.
• Mechanism of action: Dopamine D2 receptor antagonist; thus increases prolactin
levels.
• Other actions: Prokinetic and anti-emetic role.
• Maximum and standard Dose: 10 mg TDS
Side effects:
• Headache
• Dizziness
• Dry mouth
• Abdominal cramps
• Depressed mood
• Rarely extrapyramidal side effects like dystonias, parkinsonism, akathisia and
tardive dyskinaesia.
• Avoided in conditions where mother or baby:
 has any evidence of cardiac abnormalities and specifically arrhythmia.
 is receiving other medications known to prolong QT interval or potent
CYP3A4 inhibitors (e.g. ketoconazole, macrolide antibiotics, SSRI
antidepressants, tricyclic antidepressants, salbutamol)
 has severe hepatic impairment.
 has high or low levels of potassium, or low levels of magnesium.

2. METOCLOPRAMIDE:
• Mechanism of action: Dopamine D2 receptor antagonist; thus increases
prolactin levels.
• Other actions: Prokinetic and anti-emetic role.
• Dose: 10 mg TDS
Side effects:
• Extrapyramidal side effects
• Oculogyric crisis
• Prolactinemia
 SIDE EFFECTS(CONTD)

• Diarrhea
• Sedation
• Panic disorder
• Major depression
Contraindications:
• Gastrointestinal bleeding
• Obstruction
• Perforation
• Pheochromocytoma
• Seizures
• Depression
• Parkinson disease
• History of tardive dyskinesia
• Chlorpromazine and Sulpiride have galactagogue properties but
undesirable side effects limit their effectiveness for this application.
• Recommendation : Galactogogues should not be considered a first-line
therapy because current research on the effectiveness of
pharmaceutical and herbal galactagogues is relatively inconclusive and
all substances have potential adverse effects.
(Breastfeeding challenges, ACOG 2021)
 BREAST COMPLICATIONS

1.RETRACTED NIPPLE
Definition: Nipple is not protracted out but is retracted in
the breast, making breastfeeding difficult.
Treatment:
2. Mother is asked to roll out nipples with her fingers many
times a day.
3. Inverted syringe technique: Using a 10 mL syringe with its
end cut and piston, nipple can be lifted up into the
syringe. It should be tried everyday to make the nipple
more protracted.
 2. CRACKED NIPPLE
 Definition: Loss of surface epithelium with the formation of a raw area
on the nipple or due to a fissure situated either at the tip or the base
of the nipple.
 Most common in 1st 30 days postpartum.
Causes :
 Unhygienic practices resulting in formation of a crust over the nipple
 Nipple abnormalities like retracted nipple, semi-protruding and/or
malformed nipples, depigmented nipples
 Trauma from baby’s mouth due to poor breastfeeding
technique/position/latch-on.
 Use of a feeding bottle
 Breast engorgement
 Primiparity
 Use of breast pumps
 Infection with Candida albicans and S. aureus is often present.
When infected, the infection may spread to the deeper tissue producing mastitis.

PROPHYLAXIS
• Includes local cleanliness during pregnancy and during puerperium before and after
each breastfeeding to prevent crust formation over the nipple.

TREATMENT:
• Correct attachment (latch on).
• Fresh human milk and saliva- healing properties.
• Moisturizers such as white soft paraffin or purified lanolin.
• When severe; use a breast pump and infant is fed with the expressed milk.
• Miconazole lotion is applied over the nipple as well as in the baby’s mouth if there is
oral thrush.
• Nipple shields (thin latex) can be used.
• The persistence of a nipple ulcer, in spite of therapy mentioned, needs biopsy to
exclude malignancy.
3. BREAST ENGORGEMENT:
• Definition: It is physiological bilateral breast fullness that is caused due to
exaggerated normal venous and lymphatic engorgement of the breasts
which precedes lactation.
• It is typically a reassuring sign that mature milk is being ejected.
• Most common in women who don’t breastfeed.
• Onset: Typically between 3rd and 5th day postpartum.
(Williams 26th edition)
• Factors associated with severely symptomatic breast engorgement :
(Breastfeeding challenges, ACOG 2021)
 Primigravida
 History of large amounts of fluids given during labour
 History of premenstrual breast tenderness
 History of breast surgery
 Breast engorgement:
SYMPTOMS :
a) Considerable pain and feeling of tenseness or heaviness in both the breasts
b) Generalized malaise
c) Painful breastfeeding
d) Sometimes fever which seldom persists for longer than 4 to 16 hours.

Breast engorgement and infection are responsible for puerperal pyrexia.

PREVENTION:
(i) To avoid prelacteal feeds
(ii) To initiate breastfeeding early and unrestricted
(iii) Exclusive breastfeeding on demand
(iv) Feeding in correct position and posture
TREATMENT:
(1) To support the breasts
(2) Frequent suckling
(3) Manual expression of any remaining milk after each feed
(4) Cool packs and oral analgesics for pain
(5) In a severe case, gentle use of breast pump

Recommendation: Patients experiencing breast engorgement should

minimally express breast milk for relief of breast engorgement as excess
emptying of breast may induce oversupply with associated risks of mastitis
and plugged ducts.
(Breastfeeding challenges, ACOG 2021)
4. ACUTE MASTITIS

• Definition: Infection of the glandular system of the breasts.

• Postpartum incidence of mastitis: 3% (Williams, 26th edition)
• The common organisms involved are
1. Most common: S. aureus esp. MRSA (Williams, 26th edition)
2. Coagulase negative staphylococci
3. Streptococci viridans.
RISK FACTORS
Poor nursing, maternal fatigue, cracked nipple and oral antibiotic therapy.

MODE OF INFECTION:
 Two types of mastitis depending upon the site of infection.
• Infection that involves the breast parenchymal tissues leading to cellulitis.
The lacteal system remains unaffected. It manifests during 1 st week of
puerperium.
• Infection gains access through the lactiferous duct leading to
development of primary mammary adenitis. Usually manifests near the
end of 2nd week.


The source of organisms is the infant’s nose and throat .
 Infecting organism can be cultured from milk.
ONSET:
 Almost U/L
 Marked engorgement usually precedes inflammation.
 In superficial cellulitis, the onset is acute during first 2–4 weeks postpartum.
 However, acute mastitis may occur even several weeks after the delivery.

Symptoms:
a)Generalized malaise and headache, nausea, vomiting.
b)Fever (39°C or more) with chills or rigors
c)Severe pain and tender swelling in the affected breast.

Signs:
d)Presence of toxic features
e)Induration over affected area.
f) The overlying skin is red, hot and flushed and feels tense and tender.
DIAGNOSIS:
• USG is usually diagnostic.
• Microscopic examination of breast milk
 leucocytes more than 10,00,000/mL and
 bacterial count more than 1000/mL.

COMPLICATIONS:
• In 10% cases, it can lead to formation of a breast abscess due to variable
destruction of breast tissues.
• Toxic shock syndrome-Rare

PROPHYLAXIS :
 Thorough hand washing before each feed,
 cleaning the nipples before and after each feed, and
 keeping them dry
reduce the nosocomial infection rates.
MANAGEMENT:
(a)Breast support.
(b)Plenty of oral fluids.
(c)Continued breastfeeding by putting baby first on the uninfected side to
establish let down.
(d)The infected side is emptied manually with each feed.
(e)Analgesics (ibuprofen with paracetamol) for pain.
(f)Antibiotic therapy:
• Drug of choice-Dicloxacillin ( penicillinase resistant penicillin)
• Dose: 500 mg QID is started orally till the sensitivity report available.
• Alternate drug: Erythromycin in patients who are allergic to penicillin.
• Duration of antibiotic: for at least 7 days.

 The infection usually resolves within 48 hours if appropriate therapy for

mastitis is started before suppuration begins.
(Williams 26th edition)
 5. BREAST ABSCESS
Definition: An abscess should be suspected when defervescence does not follow within
48-72 hours of treatment or when a breast mass is palpable.

Clinical features:
(1) Flushed breasts not responding to antibiotics promptly,
(2) Brawny edema of the overlying skin,
(3) Marked tenderness with fluctuation
(4) Swinging temperature.
Diagnosis: USG

TREATMENT: (Indian J Surg. 2013)

A. General measures:
• Analgesics
• Breast support
• Role of cold cabbage leaves
• Breast emptying and continuation of breastfeeding
• Antistaphylococcal antibiotics: For at least 10 days
B. Specific measures:
• Aspiration of pus
• USG guided
Needle aspiration
Catheter drainage
• Incision and drainage

Incision and drainage:

• Under general anaesthesia
• Incision: Submammary/Periareolar/Radial incision.
• Incision perpendicular to the lactiferous ducts increases the risk of fistula formation and ductal
occlusion.
• Finger exploration done to break up the walls of the loculi.
• The cavity is loosely packed with gauze which should be replaced after 24
hours by a smaller pack.
• The procedure is continued till it heals up.
• Breastfeeding is continued in the uninvolved side.
• The infected breast is mechanically pumped every 2 hours and with every let down.
• Once cellulitis has resolved, breastfeeding from the involved side may be resumed.
• Antibiotics to be continued depending upon the culture report of pus.

Note:

Women who have negative early breastfeeding experiences are at increased risk for postpartum
depression. Therefore these women should be screened for psychiatric illnesses.
(Breastfeeding
challenges, ACOG 2021)
 SIGNS OF A GOOD LATCH
• Infant’s chest rests against the mother’s body and chin touches the breast.
• Infant’s tongue is down and lips flanged outwards.
• Little or no areola is visualized.
• Rhythmic sucking present.
• Audible swallowing present.
• The latch is not uncomfortable or painful.
• The nipple is not injured or misshapen after breastfeeding.
PSYCHIATRIC DISORDERS IN
PUERPERIUM
 PSYCHIATRIC DISORDERS
A psychiatric disorder is a mental illness diagnosed by a mental health
professional that greatly disturbs your thinking, moods, and/or behavior
and seriously increases your risk of disability, pain, death, or loss of
freedom.
• During the postpartum period,
– 85% of women suffer from some type of mood disturbances.
– In most women, symptoms are transient and relatively mild (i.e.
postpartum blues).
– 10-15% of women experience a more disabling and persistent form
of mood disturbance (eg : postpartum depression, postpartum
psychosis).
 RISK FACTORS FOR MILD DISEASE

History of
• Premenstrual mood changes
• Oral contraceptive use that is associated with mood
changes
• Depressive syndromes predating pregnancy
• Antepartum depressive symptoms
• Caesarian section
• Not breastfeeding
• Stress around child care
• Psychosocial impairment
• Family history of depression
 RISK FACTORS FOR SEVERE DISEASE
• Poor perinatal physical health (eg, obesity at the time of conception,
pregestational or gestational diabetes, antenatal or postnatal hypertension, or
infection following delivery)
• Body image dissatisfaction (preconception, antenatal, and/or postpartum)
• Personality traits, such as neuroticism (which is marked by an enduring tendency
to worry and to feel anxious, angry, sad, and guilty).
• Perinatal sleep disturbance .
• Adverse pregnancy and neonatal outcomes (eg, including stillbirth, preterm birth,
very low birth weight, and neonatal death)
• Postpartum blues (subsyndromal depressive symptoms)
• Breastfeeding difficulty(shorter duration/cessation )
• Childcare stress such as inconsolable infant crying, difficult infant temperament,
or infant sleep disturbance
TYPES:
• Post partum blues
• Post partum depression
• Post partum psychosis
 POSTPARTUM BLUES
Mild depressive symptoms that are generally self-limiting, or may
manifest as more severe syndromes of major depression.
Symptoms typically develop within two to three days of delivery, peak
over the next few days, and resolve within two weeks of onset.
CLINICAL FEATURES:
Postpartum blues (maternity blues or baby blues occur within the first 2 weeks after delivery) refer to a transient self limiting condition characterized by :
 sadness
 crying
 irritability
 anxiety
 insomnia
 exhaustion
 decreased concentration
 mood lability that may include elation
 Only supportive treatment is given. Further evaluation is needed if symptoms persist for >2weeks
 POST PARTUM DEPRESSION

The DSM-5 specifier “with peripartum onset” is used when

onset of major depression occurs either during pregnancy or
in the four weeks following delivery, or within 6 weeks of
delivery (WHO)
The somatic symptoms of major depression – changes in sleep,
energy level, and appetite – overlap with changes observed in
postpartum women who are not depressed.
 ASSESSMENT

When to suspect post partum depression —

●Anxiety about the health of the infant
●Concern about one’s ability to care for the infant
●Negative perception of infant temperament and behavior
●Despondency for at least two weeks
●Lack of interest in the infant’s activities
●Lack of response to support and reassurance
●Using alcohol, illicit drugs, or tobacco
●Nonadherence to postnatal care
●Frequent nonroutine visits or telephone calls to the obstetrician or
pediatrician.
 TREATMENT
• Exclude medical causes for mood disturbance (eg,
thyroid dysfunction, anemia).
• Mild to moderate postpartum unipolar major
depression- psychotherapy (Cognitive behavioral
therapy)
• Mild to moderate unipolar major depression who are
breastfeeding-antidepressants. Most SSRIs pass into
breast milk at a dose that is less than 10 percent of the
maternal level and are generally considered compatible
with breastfeeding of healthy, full-term infant
Characteristic Post partum blues Post partum depression

Duration Within 14 days More than 2 weeks

Onset Within 2 to 3 days During pregnancy or

within 4 weeks

Prevalence more less

Severity Mild dysfunction, self Moderate to severe

limiting dysfunction

Suicidal tendency no May be

PLLR Guidelines
 ANTI DEPERESSANTS

TYPICAL ATYPICAL
Increase HT Other mechanisms

MAO inhibitors Reuptake inhibitors Bupropion, Mitrazapine

SELECTIVE
NON SELECTIVE
Inhibit reuptake of 5HT
Moclebemide (RIMA) Inhibit reuptake of 5HT
and NA Eg: fluoxetuine,
escitalopram
 POSTPARTUM PSYCHOSIS
Incidence: 1 in every 1000 deliveries.
The clinical picture of postpartum psychosis includes rapid onset of psychotic symptoms
including
• hallucinations and delusions,
• bizarre behavior,
• confusion,
• disorganization that may appear to be delirium.
Postpartum psychosis is a medical emergency which requires hospitalization, and a
comprehensive medical evaluation and psychiatric management.
Treatment: antipsychotics + mood stabilizer (Li/valproate/carbamazepine)
Valproate is preferred in breast feeding mothers.
Concerns associated with postpartum psychosis
• Ensure safety to infant and mother as in the first year after
childbirth, suicide increases 70-fold, usually violently.
• One third of women hospitalized for postpartum psychosis
express delusions about their infants.
• 9 percent have thoughts of harming their infants.
• Approximately 4 percent of women with postpartum psychosis
have been found to commit infanticide.
• Disorganization and confusion in the mother add to the
potential risks for the infant, who should not be left alone in the
care of a mother with postpartum psychosis .
• Mother may not be able to breast feed and care for her child..
 TREATMENT OPTIONS
• Psychotherapy
• Pharmacotherapy
• Psychotherapy And Pharmacotherapy
• Electroconvulsive Therapy in resistant cases
 TYPES OF PSYCHOTHERAPY

• Cognitive-behavioral therapy (CBT) combines cognitive therapy with behavioral

therapy. Cognitive therapy is intended to modify dysfunctional thoughts and illness
beliefs; behavioral therapy is intended to change problematic behaviors .
• Interpersonal psychotherapy focuses upon improving problematic interpersonal
relationships or circumstances that are directly related to the current depressive episode; eg,
marital conflicts), role transitions (eg, becoming a mother).
• Behavioral activation: promoting activities and behaviors that are rewarding, decreasing
avoidance behaviors and rumination, and by helping patients to improve their problem
solving skills.
• Nondirective counseling (also called listening visits) aims to help patients gain insight into
and acceptance of their feelings.
 PHARMACOTHERAPY
Principle of t/t-
1.Monotherapy is preferred.
2.Minimal effective and least teratogenic dose is given.
3. Avoid sub therapeutic dose.
4. In patient hospitalization in major depression
5. Minimum effective duration of treatment – 2 weeks to say
whether the patient is responding to treatment or not.
Medication effects upon the fetus vary according to gestational age
the fetus is most vulnerable to major morphologic teratogenesis
during organogenesis between the third and eighth week of gestation
.Neonatal toxicity and withdrawal are the result of third trimester
exposure
Treatment concerns
• Any of the concerns must be weighed against the risks of stopping
medication during pregnancy.
• Discontinuation of medication, will likely lead to illness relapse.
• Rate of relapse of illness in patients who have withdrawn from
antipsychotics is around 50%, while for people who have continued
medication is about 15%.
• The risk of relapse is greater with abrupt discontinuation compared
with a gradual withdrawal.
Thank you