DR FOUZIAGUL

IT IS A PERIOD OF 6 WEEKS (42 DAYS) FOLLOWING THE BIRTH OF A CHILD DURING WHICH ALL THE PHYSIOLOGICAL AND ANATOMICAL CHANGES, WHICH HAVE OCCURRED DURING PREGNANCY RETURN BACK TO THEIR NORMAL LEVEL

To monitor the physiological changes of puerperium i.e.To diagnose and treat any post natal complicationTo establish infant feedingTo give the mother the emotional supportTo advise about contraception

Placenta-the main hormonal supply, responsible for all pregnancy changesPELVIC ORGAN CHANGESWEIGHTBLOOD OTHER SYSTEMSOTHER CHANGES

UTREUS: Immediately after deliveryAbout 18 cm long ,palpable at level of umbilicus and weighs 1000 gmAt the end of first week, it is 12 cm &500 gmsAt the end of second week it disappears in pelvis & weighs about 300 gmsThe rate of involution is relatively slow after C/section than after normal delivery

The decidua is shed and zona basalis remains intact ,from which new endometrium regrowsMaximum involution is achieved at around 6 weeks but never regains its nulliparous size being 20 % larger than before pregnancyThe speed of involution is unaffected by breast feedingThe reduction in size is due to contraction of myometrial fibers not b/c of autolysis

CERVIXReceives some kind of permanent damage but regains its shape and consistency rapidlyAt end of second week, the internal os hardly admits one finger & is closed at 6 weeks, the external os is not unusual to stay open permanentaly

VAGINA AND SUPPORTING STRUCTURESSoon after delivery, vagina is capacious and smooth walled passage. It regains its size with rugae appearance in 3-4 weeksReturn of supporting structures of uterus and pelvic joints may take 6 weeks and is often incomplete

Normal perpeural vaginal dischargeShreds of decidua , remains of trophoblastic tissues, blood , leucocytes and organismsIt begins as frank blood , then lochia Rubra b/c of cotribution from clotts, lochia serosa when it is brownish pink and eventually yellow white lochia alba which appears on 10th postnatal day

Pica disappear abruptly after deliveryThe esophageal reflux is corrected in 24 hrs & reduction of bowel motility is corrected in 3-4 daysWith the initial rise in weight of 450 grams in multi parous women only, the weight continues to fall till 10 weeks after delivery

The hyperinsulinemia of pregnancy is corrected in 2-3 daysThe plasma glucose level falls below the late pregnancy level during the first five postpartum days, so glucose and insulin levls are low in immediate post partum periodGTT

The plasma volume reduces by 20% & red cell mass returns to prepregnancy level with in first 24 hoursThe Hb levels falls immediately due to blood loss at delivery & is lowest on 4th postnatal dayThe diuresis begins at 2-4 days &continues for 3-4 days and Hb raises to pre-parturition level at the end of first week.ESR rises in the first week & falls back to prepregnancy level in the 4th week

There is transient fall in the coagulation factors (fibrinogen,platelets)in the blood at the time of placental separation b/c of their consumption at placental site.These factors recovers to high pre-delivery levels with in 24 hours & remains high up to two weeks postpartum.fibrinolytic activity returns to normal within few hours of parturition leading to rise in FDPPlasminogen remains at pre-delivery level for 2-3 weeks

The HR & Heart sounds returns to normalThe cardiac output returns to normal in 2 weeksBoth systolic and diastolic BP returns to normal at the end of first weekThe lung volumes & capacity reverts to normal at 2 weeks and tidal volume takes 6 weeksThe respiratory rate increases by 1/minute during puerperiumi.e and returns to normal in several weeks

The size of the kidneys begins to reverse within 48 hrs and is completed with in 6 weeksThe dilatation of the upper urinary tract reverts in 2 weeksThe bladder hypotonia is maintained in the first postpartum week & returns to normal in subsequent few weeksGlycosuria of pregnancy is corrected in few daysTSH returns in first week while thyroid binding globulin cortisol may take 2-4 weeks

The divarication of recti and striae gravidarum are permanent, though the colour of later may fade.Chloasma gravidarum and varicose veins recover slowly The backache improves with improvement in posture

DR FOUZIA GUL

PUERPERAL PYREXIASECONDARY PPHTHROMBOEMBOLISMURINARY PROBLEMSTHE PUERPERAL MENTAL DISORDERS

DEFINITION: It is defined as temprature of 38 c or higherOn any two consecutive days within first 10 days postpartum but after first 24 hoursIn first 24 hours, the rise in temprature is reflection of tissue response to traumaSubsequent inter current small rises in the temprature are related to physiological changes occurring in the uterus and are not necessarily related to uterus

This definition applies to booked hospital patientsIn manipulated patients ,the infective organisms have already been introduced and the patient may have pyrexia due to infection within first 24 hours

EndometritisUTIRTIWound infectionDVTMASTITIS

PREDISPOSING FACTORSC/SectionProlonged rupture of membranesProlonged labor with multiple vaginal examinationsRPOCSInstrumental deliveryMannual placental removalManagement of labour outside the hospitalCausative organasims:beta hemolytic streptococci(GP A & B),E coli,bacteroides flagalis,clostridia,chlamydia

The protective barrier in the lower genital tract are temporarily broken downThe placental site is raw area containing NECROTIC TISSUE AND BLOOD CLOTTS which is growth media for various organism RPOCs, blood clotts ,ORGANISMS MULTIPLY and penetrate from endometrium into the myometrium, parametrium ,fallopian tubes further into peritonium and even peripheral circulation causing septicemia and ENDOTOXIC SHOCK AND ABSCESS FORMATION

CLINICAL FEATURES:A LOCALIZED INFECTION: fever,feeling of being unwell,foul smellind vaginal discharge,secondary PPHO/E: soft tender uterus with large size on abdominal examination & pussy,profuse pelvic discharge with open cervixB ADENEXAL MASS: csytic swelling lateral to uterus/abcesss in POD will be felt projecting into post fornixC SYSTEMIC INVOVEMENT:septicemia ,endotoxic shock

PRE-DISPOSING FACTORS:Short urethera with close approximation to vaginaAsymptomatic bacteriuriaCatheterizationPrevious history of UTICYSTITIS: urgency, frequency, dysuriaPYELONEPHRITIS: Pyrexia,s shivering ,loin pain & tenderness at costovertebral area

More commonly seen in patients after GA for C/sectionMost common in patients who are smokers, obese and suffer from chronic bronchitisThe clinical features includes productive cough with ronchi, fever and poor inspiratiry efforts

It includes episiotomy, perineal tears and c-section scarTHE RISK FACTORS FOR WOUND INFECTIONS c/section fop prolonged labourWound hematomaplacement of open drainsObesityDiabetesDelayed and poor suturing technique

It ususally presents as fever and red swollen tender breast in 3rd or 4th weekCracked nipple is the predisposing factorPELVIC TLROMBOSIS :most common after C/Section than NVDIt often present as tender pelvic mass with spiking feverIt is difficult to differentiate from pelvic infectionRapid response to heparin therapy is diagnostic

THE HALLMARK OF MANAGEMENT OF PUERPERAL PYREXIA

IS TO LOCATE INFECTION SITE

HISTORY: Antenatal record, labour detail , delivery notes, placental removalHistory of urinary, respiratory and genital tract infectionHistory of risk factors /predisposing factorsEXAMINATION: GPE: temprature, pulse , BP,R/R, pallor, jaundice, lymphadenopathy, dehydration levelThroat examination, Neck stiffness in case of epidural and spinal anesthesia

BREASTEXAMINATION:Engorgement,Inflammation,abscess formationHeart and Lung auscultationDVT and Thrombophlebitis in lower limbs

VISCEROMEGALY: Liver and spleen UTERINE SIZE: size, consistency, tenderness , mobility RENAL ANGLE TENDERNESS:BOWEL SOUNDSWOUND EXAMINATION:PELVIC EXAMINATION:Inspection of external genitaliaColour, amount ,odour of lochiaSpeculum/digital pelvic examination

BLOOD COMPLETE: Hb,TLC/DLC,Platelet countPELVIC SCAN:COLOUR FLOW DOPPLER for DVT CULTURES: urine R/E and C/S HVS, Wound swab, sputum for culture, blood cultureX-RAY CHESTBLOOD UREA AND ELECTROLYTES

RPOCS, Tubo-ovarian mass, pelvic abscessColour flow Doppler in DVTX-Ray chest: lung infection, lung collapseBlood urea and electrolytes: dehydrated patients and those with renal failure

GENERAL MEASURES:Hydration:Anemia:Analgesia:Bladder/bowel care:Urinary retention----- indwelling catheterDistended bowel------- improves with the correction of fluid and electrolyte balance

SPECIFIC TREATMENTANTIBIOTICS: commenced soon after taking the specimen for C/SSURGICAL TREATMENT: RPOCS----- Evacuation and curetage after 12-24 hours of commencement of antibiotics to achieve adequate blood levels to deal with organism which may get access to general circulation leading to septicemia and septic shock

TUBOOVARIAN ABSCESS:It needs drainage if no response to antibiotics in 48 hoursINFECTED WOUND: drainage and daily dressing and debridementBREAST ABSCESS: antibiotics, pain relief, incision drainagePHYSIOTHERAPY: especially in chest infectionTHROMBOPHLEBITIS: Heparin and antibiotics

PUERPERAL INFECTION CAN BE PREVENTED BYAsepsis:Identification of risk factorsProphylactic antibioticsSurgical technique: avoid manual removal of retained placenta at c/section, peritoneal lavage in high risk cases, proper hemostasis and dead space occlusion, proper suturing technique with appropriate suture materialPERSONAL HYGIENE:

URINARY RETENTION:PAINFUL PERINEAL WOUND, CONTINUED BLADDER HYPOTONIAFailure to pass urine 6 hours after delivery warrants abd exam to palpate bladderTREATMENT: INDWELLING CATHETER FOR 48 HOURSMay resolve spontaneously

URINARY INCONTINENCE:Stress incontinence: seen in 10-25 % of patients and is physiological in most casesReassurance and pelvic floor exercise is treatment of choiceFistula formation: which requires specialist treatment

They are divided into three groupsPOSTPARTUM BLUESPOSTPARTUM DEPRESSIONPOSTPARTUM PSYCHOSIS

POSTPARTUM BLUES:Experienced by 50-70% of the women world wideInsomnia, weepiness, depression, anxiety,Headache, poor concentration , fatigueEtiology : withdrawl of pregnancy hormonesThe symptoms reach peak by day 5 postpartum to recover quickly thereafterTREATMENT: self limiting , no medication needed, needs only reassurance , education, emotional support

POSTPARUM DEPRESSION: is defined as the occurrence of at least five of the following symptomsDepressed mood, insomnia or hyper-somniaSignificant changes in weight or appetitePsychomotor agitation or retardationFatigueGuiltFeeling of worthlessnessPoor concentrationIndecisivenessRecurrent suicidal thoughts

HOSPITALISATION:DRUG THERAPY: SSRI,TRICYCLIC ANTIDEPRESSANT,LITHIUMBreast feeding may be continued with tricyclic and SSRIBreast feeding is contraindicated with lithium, doxepin and flouxetinThe antidepressant should be continued for at least 6 months

Psychotherapy:ECT: required in some casesThyroid dysfunction must be excluded in all patients with postpartum depression

Occurs in 2/1000 deliveriesInsomnia, weepiness, depresion, anxiety,Headache, poor concentration, fatigue which are associated mania and less often depressionThe typical symptoms are thought disorders such as delusion and hallucinations, patient feels that baby is defective or dead or have desire to kill the babyD/D sepsis, metabolic disturbances,Intoxication , electrolyte imbalance must be ruled out

Hospital admissionBaby isolation Neuroleptic drugs: chlopromazine,haloperidol Antidepressant, lithium and bezodaizipne may also be usedIt takes 2-3 months to be improved20-50 % risk of recurrence

2% of the women may have ovulation by 28th day postpartum and may have an unplanned pregnancy if contraception is not discussed before going homeNONLACTATING MOTHERS:IUCD may be insertedOCP may be commenced at any day after 21 daysLACTATING MOTERS:OCP is not used -----milk suppression

POP can be prescribed with high failure rates but fertility is also reducedBarrier methods can also be practised by both partenersSterilization (BTL,Vasectomy) can be carried out when family is complete, but it is done few weeks after puerperium to enhance its success rate