Abnormal Puerperiu and Postnatal Care

Purperium Definition: It is period about 6-8 weeks following delivery during which the changes produced by pregnancy.

Abnormal Puerperium Puerperal infection ----> retention UT complication ----> incontinence ----> stress I true Thrombo embolism 2nd P.P HE Subinvloution of the uterus Foot drop Mental disorder

Genital Tract Infection: AE: 1. Predisposing Factors: 1. General 2. Anternatal Factor Intranatal factor 2. Organism 1. Exogenous 2. Endogenous Streptococci: Streptococci: a. B haemolytic strep group A b. B haemolytic strep group B C. B haemolytic strep group 0 d. Non-haemolytic streptococci e. Anaerobic streptococci

Staph: Staph aureus Anaerobic staph Bacilli: G negative aerobic bacilli E coli, Klebsiella G negative anaerobic bacillus -----> bacteroids Gm positive anaerobic bacilli

ROUTE OF INFECTION: Primary Sites: placental site, wound and laceration, clots and pluc. tissue Secondary Sites: pelvic cellulitis, thrombophlebitis, pelvic peritonitis, generalized peritonitis, septicaemia, and septic shock COMPLICATIONS: Spread of infection Renal failure Death Secondary infertility Sheehan

CLINICAL PICTURE --- depends on site of infection INVESTIGATIONS: History Examination Special investigations

TREATMENT: Prophylaxis: Antenatal, intranatal case, postnatal Active Treatment: 1. General treatment ----> rest ----> diet ----> fluid 2. Medical treatment ----> antipyretic ----> analgesics ----> antibiotics 3. TTT of complication

Puerperal Pyrexia Definition: A rise of temperature above 3SoC occurring in first 3 weeks of puerperium persistent at least 2H hours on recurring within this period.

AE: Puerperal sepsis Breast infection Urinary infection Episiotomy infection Wound infection Other types of infection as respiratory infection, malaria, gluteal abscess, typhoid

INCIDENCE: Infection, haemorrhage, hypertension, disorder remain the most causes of death.

Primary Puerperal Sepsis Definition: Genital tract infection after delivery. It is the commonest cause for puerperal infection. The causative organism 1. Anaerobic streptococci 2. Group A haemolytic streptococci 3. Staphylococci causing suppurative and pus 4. E. coli and non-haemolytic streptococci 5. Specific organism as cl. welchii and tetani

Mode of infection 1. Exogenous infection ----> attendant 2 Mode of infection 1. Exogenous infection ----> attendant 2. Endogenous: organism already present in genital tract 3. Autogenous: organism transmitted to genital tract from other parts of body

SITES OF INFECTION A) Primary Sites: 1. The placental site 2 SITES OF INFECTION A) Primary Sites: 1. The placental site 2. Laceration of cervix, vagina or perineum 3. Dead tissue retained in the uterus as placental remnant or blood clot B) Secondary Sites: -> ext. from primary site 1. Parametritis 2. Salpingo-oophoritis 3. Pelvic thrombophlebitis 4. Pelvic and generalized peritonitis C) Generalized Spread: Septicaemia or pyrexia

PREDISPOSING FACTORS 1. Introduction of bacteria 2. Anaemia 3 PREDISPOSING FACTORS 1. Introduction of bacteria 2. Anaemia 3. Prolonged or instrumental delivery - PRM

PATHOLOGY 1. Uterus ----> Uterus puerperal endometritis localized type septic puerperal endometritis generalized type 2. Infected laceration ----> greenish yellowish 3. The parametrium ----. pelvic cellulitis from: direct lymphatic: cervix, vaginal vault 4. The tubes and ovaries ----> acute salpingo-oophoritis 5. The peritoneum ----> through lymphatic by direct 6. Pelvic veins ----> pelvic thrombophlebitis

CLINICAL PICTURE I. Uterine Infection: a CLINICAL PICTURE I. Uterine Infection: a. In the mild type ---> onset 4 days after delivery b. In the severe type ---> onset 2-3 days or even one day after delivery, increased temperature and pulse, headache and malaria, UT tender, involuted and lochia scanty.

II. Infected Laceration: Mild pyrexia, local discomfort, tenderness, oedema and congestion III. Parametritis: At 10 days after delivery with increased temp and pulse, vague abdominal pain, backache, U/E = tender mass extending from UT to 1st pelvic wall on one or both sides. * SOFTENING ----> parametric abscess

IV. Salpingo-oophoritis: Fever, rigor, vomiting, lower abdominal pain, tenderness at rigidity V. Peritonitis: a. Pelvic peritonitis ---> as complication of salpingitis b. Generalized peritonitis ---> rigor, fever, t pulse

VI. Septicaemia: ----> occurred about the third and fourth day after delivery secondary to UT infection VII. Thrombophlebitis: Secondary to UT infection 7 - 10 days after delivery

Investigation A. History Pre-existing infection before labour TB, UTI Anaemia, toxaemia and diabetes Difficult labour on spontaneous Instrumental used or any complication Catheterization Onset of pyrexia Sore throat, busy mict. B. General Examination: 1. Pulse, temp, BP 2. Anaemia or jaundice 3. Tonsillitis 4. Breast, heart and chest 5. LL ---> thrombophlebitis

c. Abdominal Examination: 1. Tenderness in abdomen, int, loin 2 c. Abdominal Examination: 1. Tenderness in abdomen, int, loin 2. Rigidity 3. Height, fundus and any abdominal mass D. Vaginal Examination: 1. Lochia 2. Laceration 3. Bi-manual examination size and mobility, uterus 4. Speculum examination to see cervix + vagina

E. Laboratory Investigations: 1. Swab from the upper vagina or cervix 2. Catheter specimen of urine for culture 3. Full blood picture Hb, RBCs and leucocytes 4. Widal test, x-ray chest, blood film for malaria

PROPHYLAXIS PUERPERAL SEPSIS A. Antenatal: 1. Diet, vitamin + mineral 2. Treat disease as anaemia, toxaemia or diabetes 3. Treat vaginal discharge B. Intrapartum 1. Proper delivery 2. Strict asepsis -----> patient -----> instrument -----> attendant 3. In prophylactic, antibiotic c. Postnatal: 1. Aseptic precaution 2. Early isolation of suspected cases

TREATMENT OF SEPSIS I. General Treatment: 1. Isolation of patient 2 TREATMENT OF SEPSIS I. General Treatment: 1. Isolation of patient 2. Light diet 3. Correct anaemia 4. Relieved pain by analgesics 5. Give mild laxative II. Antibiotic: 1. Vaginal swab and give correct antibiotic

III. Promotion of Drainage: 1. Sensitivity position 2. Ergometra 3 III. Promotion of Drainage: 1. Sensitivity position 2. Ergometra 3. Removal of suture 4. Drainage of pelvic abscess 5. Gentle of any piece of placenta IV. General Peritonitis: 1. Heavy dose, antibiotic IV _ Ryle tube + IV fluid V. Septic Thrombophlebitis: 1. Antibiotics 2. Anticoagulant 3. Immobilization of limb

Postnatal Care AIMS: 1. Detection of any abnormality that from pregnancy and labour. 2. Follow-up of complication in pregnancy. 3. Advice regarding breast feeding, diet, hygiene 4. Advice regarding contraception.  

The Gynaecological Conditions Which May Be Found Are: 1 The Gynaecological Conditions Which May Be Found Are: 1. Perineal Laceration: Not repaired within 24 hours ----> need operation 3 - 6 months 2. Vesico-Vaginal Fistula: * Fix catheter for 10 - 15 h + antibiotic after 3 - 6 months -----> fistula may heal if small or may need operation

3. Prolapse + 8.1.: * Pelvic floor exercises if condition persist ­-----> operation, 3 - 6 months. 4. RVF of uterus No symptoms ----> no treatment There is symptom ----> correct ut manually ----> insert Hodge pessaries 4-6 weeks 5. Cervical Erosion: * No treatment before 3 months * Persists cauterized 6. Sub-Involution Ergometrium + antibiotic

THE CAUSES OF SUB-INVOLUTION 1. Retained placental segment 2 THE CAUSES OF SUB-INVOLUTION 1. Retained placental segment 2. Infection 3. RVF ---> congestion 4. Over distension of uterus as twins and hydramnios 5. Fibroid 6. Non suckling 7. Bad general condition and anaemia in case of antepartum and postpartum hemorrhage