Abnormal puerperium

The most serious complications that may arise during the puerperium are: D V T Infections Secondary post partum hemorrhage Urinary complications Complications of breast feeding Mental disorders

Infections (puerperal pyrexia) 1.Respiratory infection It commonly occur due to the use of general anesthesia but as now epidural anesthesia becom more common the incidence of resp. infection is less. It occur more commonly in patients with chronic bronchitis or who smoke. The patient presented with fever ,cough ,on examination there are rhonchi. If there is sever bronco spasm the possibility of Mendelson’s syndrome The diagnosis of respiratory infection is confirmed by X-ray & seputum culture.

Treatment is by physiotherapy ,broad spectrum antibiotic which may be changed according to the result of culture. In some cases intensive therapy & madical consultation is required. 2. Pelvic infection It can present as an acute life threatening illness or more frequently occur as a low grade infection which causes both immediate & long term morbidity. Pathology At delivery the normal protective barrier against infection are temporarily broken & potential pathogens may pass from the lower genital tract to the normally sterile environment of the uterus & spread to the myometrium, parametrium ,fallopian tubes , peritoneum & to the circulation.

The most virulent organism that cause post partum pelvic infection is β- hemolytic strept. ,staphylococci. ,E coli , Bacterial fragilis ,Clostridia & also Chlamydia could cause chronic pelvic infection. Predisposing factors Prolong rupture of membrane Prolong labor Multiple vaginal examination If there is retained product of conception Surgical interference Clinical presentation During early stage of illness there is Puerperal pyrexia Offensive lochia Lower abdominal discomfort

O/E: with bimanual examination the uterus is tender specially on moving the cervix or there may be collection of pus (abscess formation )lateral to the uterus or in the pouch of Douglas. If the infection spread to the circulation the patient will be presented with features of septicaemia (looks tiered , dyspnoeic , feverish , tachycardia , hypotension & other signs of septic shock ) Diagnosis History Examination Investigation A. different swabs taken from upper vagina, cervical.

canal & from urethra. B. Blood culture if there is features of septicaemia. C. U/S Treatment The 1st line in treatment is the appropriate antibiotic & the best is to combine cephalosporin with metronidazol which cover the most +ve & –ve organism . In acute illness these are given I.V & the treatment continue for 48 hours till response occur then oral rout is used for at least 10 days ,if result of culture & sensitivity is available then the treatment is changed to the most appropriate one. Surgical intervention is indicated when:

2.Urinary tract infection There is a retained product of conception which should be evacuated after 24 hours of antibiotic treatment. Evacuation is don under G.A. If there is failure to response to antibiotic treatment either due to pelvic collection of pus or other diagnosis such as appendicitis. In these conditions laparatomy is indicated either to drain the pus or for management of other conditions . 2.Urinary tract infection These are common during puerperium spatially if there is history of UTI or catheterization to relieve urinary retention Infection may be in the form of cystitis or less commonly pyelonephritis.

Cystitis presented as frequency , urgency & dysurea, the urine is offensive & cloudy or there is heamaturea. Pyelonephritis presented as pyrexia ,shivering tenderness & pain at the renal angle , nausea & vomiting The diagnosis of UTI is confirmed by culturing a sample of midstream urine, U/S The treatment is with broad spectrums antibiotic which then changed according to the result of culture & sensitivity , with increase fluid intake . If the patient had vomiting then parentral antibiotic & I.V fluid are given .The treatment should last for 10 – 14 days

4.Wound infection If the patient had Caesarean section ,the wound may be infected & presented as puerperal pyrexia. The wound become tender , red indurated surrounding area & pus collection The management is by taking swab from the wound for culture & sensitivity & start broad spectrum antibiotic with frequent changing of dressing & after clearance of infection ,secondary suturing may be required if there is a large cavity.

5.Breast abscess 6.Thrombophlebitis It usually develop after 2 weeks from delivery . There is a red ,painful, fluctuant swelling in the breast & the patient is feverish. The milk should be expressed from the affected breast & the abscess should be drained under GA with the use of antibiotic & analgesic drugs 6.Thrombophlebitis Alsoca be presented as puerperal pyrexia therefore the legs should be inspected

Secondary post partum haemorrhage It is the vaginal bleeding that occur after 24 hours following delivery till 6 weeks of puerperium Causes: Retained product of conceptions Infection Clotting defect Chorio carcinoma Presentation either as changing in the colour of lochial discharge to a fresh red blood , or as heavy bleeding with clots. There may be cramping abdominal pain & if the bleeding is heavy the patient is pale & may develop signs of shock.

The uterus may be subinvoluted & on vaginal examination a retained placental tissue may be at the cervical canal. Management The patient should be admitted to hospital. If the bleeding is slight : 0.5 mg ergometrin given IM or IV with gentle massage of the fundus with removal of blood clot or placental tissue from the vagina Then U/S should be don to exclude retained placental tissue ,which if present should be removed surgically. Infection also may cause secondary PPH & if there is evidence of infection then antibiotic should be given If bleeding is heavy: the treatment is IV fluid & preparation of blood

When the patient condition is stabilized examination under GA should be don with surgical evacuation of the uterine cavity Initially the uterine cavity should be explored by fingers then evacuation don by sponge holding forceps but we should be very careful because it is easy to perforate the soft puerperal uterus.

Urinary complications Infections Urinary retention Urinary incontinence This is common after delivery ,spatially if there is bruising or oedema around the bladder base or there is painful episiotomy or after epidural anaesthesia when the sensory stimuli from the bladder is temporarily interrupted. the bladder can hold a litre of urine & as it become more distended , retention with overflow may develop with the passage of 50 -100 cc of urine

Urinary fistula may be caused by The treatment is to leave an indwelling catheter for 48 hours & then the catheter is removed & a close check for the voided urine is don & if retention re -occur then re -catheterization for further 24 hours is don. Incontinence of urine Stress incontinence may be a complication of childe birth but usually it resolve with physiotherapy & improving tone of pelvic floor. If continuous incontinence is present , it must be established if this is urethral or through a fistula. Urinary fistula may be caused by direct injury with obstetric forceps or other instrument ,when the leak of urine will be immediate .

If the fetal head was pressed on the bladder for too long period during obstructed second stage of labour , necrosis of bladder tissue & subsequent sloughing with fistula formation will occur & incontinence will develop at about 8-12 days A ureter may be damaged at a complicated Caesarean section & incontinence will develop after similar interval. The management is by continuous bladder drainage that very small fistula may close spontaneously or if not then surgical repair is required