NORMAL & ABNORMAL PUERPERIUMUndergraduate Teaching Programme

Dr G Holding ST3

02/09/2015

Introduction• Puerperium is defined as the period from delivery of

placenta through to six weeks after delivery

• The various changes that occurred during pregnancy revert to the non-pregnant state

Postnatal care• Uterus/genital tract• Vaginal loss (lochia)• Perineum• Wound• Bladder• Bowels• Breasts • Pain• Fatigue• Emotions

Normal Puerperium• Cardiovascular system – extra load on heart disappears

by second week• Uterus - pregnant term uterus weighs about 1000g; at

6/52 weighs about 100g• Vaginal loss (lochia) – volume and duration of vaginal

discharge is variable and changes, average 3-6 weeks• Perineum – vagina & perineum initially increase in

oedema; most muscle tone regained by 6/52

Normal Puerperium• Bladder - passing urine can initially be painful, stress

incontinence• Bowels - constipation common, haemorrhoids• Breasts - engorged and tender 2-3 days post delivery,

usually resolves, milk replaces colostrum

Normal Puerperium• Pain – ‘after pains’ as uterus contracts, postoperative

pain, back ache• Fatigue – disturbed sleep, recovering from birth• Emotions – baby blues, anxiety

Abnormal Puerperium• Bleeding• Sepsis• Thromboembolism• Pre-eclampsia/hypertension• Psychiatric disorders

Post Partum Haemorrhage (PPH)

• Primary PPH is blood loss of 500ml or more occurs within the first 24 hours after delivery

• Secondary PPH is ‘excessive’ loss occuring between 24 hours and 6 weeks postpartum

PPH

• Causes –Early PPH: uterine atony, retained placenta, lower

genital tract trauma, uterine rupture, inversion, coagulopathy, haematoma

• Incidence–Vaginal delivery: 4% incidence –Caesarean delivery: 10% incidence –Delayed ‘secondary’ PPH occurs in 1-2% of patients,

usually due to infection, retained products, or both

• Management –History – how much bleeding? Risk factors–Examination – Inspection lower genital tract, bimanual

examination– Investigations – FBC/clotting/X-match–Treatment – resuscitation/uterine massage/

pharmacological therapy/surgery

Sepsis• Number 1 cause of maternal death in the UK

• Endometritis• Group A streptococci• E. coli• Chlamydia

• Incidence: • Vaginal delivery 1-3%• Elective LSCS 5-15%

• Urinary tract infections - bacteruria 33%, symptomatic infection 2%

• Wound infection - perineal infection 0.5 – 10%, LSCS wound 3-15% reduced to 2% with abx

• Mastitis – staph aureus, abscess complicates 5-11% cases

Thromboembolism • VTE is number three ‘direct’ cause of maternal death in

the UK• Statutory VTE assessment on everyone admitted to UK

hospitals • High index of suspicion, not just in obvious presentations

such as chest or calf pain

Pre-eclampsia/hypertension • Pre-eclampsia - usually settles in the first 24 hours after

delivery but can be unpredictable• 50% cases of eclamptic fit, the first fit is post partum• Treatment:

– BP control (nifedipine; labetolol infusion)– Magnesium sulphate for prevention of further fits

• Common to have a residual hypertension lasting some weeks– Aim to keep BP at less than 140/90

Psychiatric disorders• Four disorders• Postpartum blues

– transient disorder– lasts hours to weeks– characterized by bouts of crying and sadness

• PND– more prolonged affective disorder– weeks to months, and even years– Not well defined in terms of diagnostic criteria, but signs and

symptoms same as depression in other settings

• Postpartum psychosis– first postpartum year, usually begins abruptly at 5-15 days– refers to a group of severe and varied disorders that elicit psychotic

symptoms

• Incidence– 50-70% develop symptoms of postpartum blues– PND occurs in 10-15%– PTSD affects 1% of mothers but most will not report it

• Often, may only materialise years later, for instance when the woman experiences emotional or physical symptoms surrounding planning of a future pregnancy

– Puerperal psychosis in 0.2%

• Morbidity and mortality– Can have hugely deleterious effects on the mother, the relationship with

the partner, the family, and on social, cognitive, and emotional development of the newborn

– Suicide is one of the top causes of maternal death within a year of childbirth

Treatment

•Postpartum blues - little effect on a patient's ability to function, often resolves by day 10

– No pharmacotherapy is indicated – Providing support and education has been shown to have a

positive effect

•PND generally lasts for 3-6 months– 25% of patients still affected at 1 year– Affects ADLs– Supportive care/reassurance is first-line but low threshold for drug

therapy

•Postpartum psychosis– Supervised by a psychiatrist and may involve hospitalisation– Generally lasts only 2-3 months

Other issues• Breast feeding• Sexual intercourse• Contraception• Resuming normal activities

Any Questions ?