abnormal pueperium

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ABNORMAL PUERPERIUM

• By Dr M.Chiduo
• OBGY Dept
• HKMU
• 2023

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OBJECTIVES

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

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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.

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Puerperal Sepsis

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

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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).

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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

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I. GENITAL TRACT INFECTIONS

• Involved structures-
• Perineum
• Vagina
• Cervix
• Uterus
• Adnexa
• Parametrium

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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

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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

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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.

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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.

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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

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Favorable Conditions for Sepsis

• Manipulation
• Surgical trauma
• Foreign body
• Devitalized tissues
• Blood and serum collection

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Route of Infection

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

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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.

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Investigations

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

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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.

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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

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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

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Other Antibiotic Options

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

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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.

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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

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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.
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Endometritis Management

• Hospitalization
• Analgesics and Antipyretics
• IV fluids
• IV Antibiotics for 48-72 hours
• Uterine cavity revision and evacuation of
  remaining products of conception

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Complications

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

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PERITONITIS

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

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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

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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.

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PARAMETRIAL PHLEGMON

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

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PELVIC ABSCESS

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

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Endometritis Sequelae
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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

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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.

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BREAST DISORDERS

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

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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

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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

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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

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Breast Engorgment
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Breast Engorgement.

• Considerable pain and feeling of tenseness or
  heaviness in both breasts
• Generalized malaise or even transient raise in
  temperature
• Painful breastfeeding

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Breast Engorgement.

• Management
• Breast Support by a binder or brassiere
• Manual expression/breast pump after each feeding
• Regular and frequent feeds
• Analgesics for pain

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ACUTE MASTITIS

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

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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.

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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

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Mastitis
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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!

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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

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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

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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

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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

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Reduced milk supply.

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

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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

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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

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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)

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PUERPERAL VENOUS THROMBOSIS

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

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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

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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

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DVT

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

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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

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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.

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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

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PULMONARY EMBOLISM

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

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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

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PULMONARY EMBOLISM

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

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PULMONARY EMBOLISM

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

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THANK YOU FOR YOUR ATTENTION!!!!

• THE END