Disorders of the Puerperium

Nick Harvey
 The Puerperium
• 6 weeks following delivery
– Reproductive tract returns to normal state
• Uterus
– Umbilicus after delivery
– Below SP at 2 weeks
– Normal at 6 weeks
 Puerperal Problems
• Anaemia
– 25-30%
• Bowels
– Constipation (20%)
– Haemorrhoids (20%)
• Breast (2/3)
– Nipple pain, cracks, bleeding
– Engorgement
– Mastitis
• Thrombophlebitis
– 1%
• Secondary PPH (24 hours – 6 weeks)
 Puerperal Problems
• Episiotomy breakdown
• Incontinence
• Psychiatric problems
– Postnatal blues
– Postnatal depression
– Puerperal psychosis
• Puerperal pyrexia (>38°C in first 14/7)
– Endometritis
– UTI
– Pneumonia
– Mastitis
– DVT/PE
– Necrotising fasciitis
 Incontinence
• 3-5% UTIs in 1st year
• 20% stress incontinence at 3/12
(neuropraxia)
• 5% faecal/flatus incontinence
• 35% primips have sphincter damage on
USS
 Breast Problems
• Engorgement
– 2-4 days postpartum if not breastfeeding
– Anytime whilst breastfeeding
– Conservative management
• Tight bra, ice packs, analgesia, ?cabbage leaves?!
• Bromocriptine?
• Mastitis
– Regional staph aureus infection
– Fever, focal erythema, oedema & tenderness
– 3rd - 4th week
– Uncommon
– >50% of cases are in primips
– Management
• Feed or pump (overcome obstruction)
• Oral Abx
• Analgesia
• Aspiration/I&D for abscess (10%)
Spot diagnosis
Spot diagnosis
Spot diagnosis
 Endometritis
• Microbial infection of endometrium
– Often invades myometrium
• <5% after VD
• 5-10 times more after Caesarean
• Other risk factors:
– Prolonged rupture of membranes
– Multiple VEs
– Manual removal of placenta
– Internal foetal monitoring
 Endometritis
• Clinical diagnosis:
– 5-10 days post delivery
– Fever
– Uterine tenderness
– Foul purulent PV discharge or increased bleeding
• Treatment
– Broad spectrum abx (until clinically well and afebrile for 24-48 hours)
– ?D&C
• Complications
– Abscess
– Septic pelvic thrombophlebitis
 Secondary PPH
• Infection
• Retained products
• Vulval haematoma
• Caesarean scar dehiscence
• Trophoblastic disease
 Postnatal Blues
• 50%
• Begins 2-4/7; peaks 4-6/7; lasts 2-7/7
• Tearful, sad, sleep disturbed, restless,
headaches, poor concentration
• Reassure, support
 Postnatal Depression
• 10-25% in 1st year
• Peak 3-4 weeks
• 2/3 self limiting; 1/3 sustained/severe
• Irritable, tired, decreased libido, guilt,
unable to cope, undue anxieties
• Psychotherapy, counselling,
antidepressants
 Puerperal Psychosis
• 1/500-800
• Begins 3-7/7; peak 2/52
• 5% commit suicide
• 4% kill baby
• Symptoms
– Suspicious – denies pregnancy and baby
– Delusions
– Hallucinations
– Confusion
– Cognitive impairment
• Risk factors
– Previous psychosis, unmarried, Caesarean, infection, perinatal
death
• 20% have it again next pregnancy
• 50% psychotic again later in life