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Abnormal Puerperium

Puerperal Disorders:

1. Puerperal Pyrexia.
2. 2ry Postpartum Hemorrhage.
3. Thrombo embolism.
4. Perineal Complications.
5. Bladder Dysfunction.
6. Bowel Dysfunction.
Puerperal Pyrexia

Definition:
a temperature of 380C or > , lasts for 2 days
or > in the first 10 days postpartum,
exclusive of the first 24h.

Fever during puerperium must be regarded as

result of genital tract infection

(puerperal sepsis)

until proved otherwise.


Causes:

1. genital tract infection ( puerperal sepsis ).


2. Breast engorgement ,mastitis & breast absces
3. UTI.
4. chest infection.
5. CS delivery - wound infection .
6. meningitis
Genital Tract Infection
( Puerperal Sepsis)

Incidence: 3%
7% of all direct maternal deaths , excluding
deaths after abortion.

Etiology:
Puerperal infection is usually poly microbial
involves contaminants from the bowel
that colonize the perineum and
lower genital tract.
The most frequently identified organisms are :

• Group B Streptococcus, Mycoplasma species.


others: Gram +ve
-beta-hemolytic streptococcus
-staphylococcus aureus.
-staphylococcus faecalis.
Gram –ve
-E coli
Anaerobes
as; Bactroides fragilis.
Miscellaneous
as; Chlamydia trachomatis
Risk Factors

1. instrumental delivery.
2. internal fetal monitoring.
3. multiple vaginal examinations.
4. prolonged ROM and chorioamnonitis.
5. cervical cerclage.

6. Non obstetric :

.. DM.
.. HIV.
Clinical Picture

• vomiting and diarrhoea.


• abdominal discomfort.
• offensive lochia.
• secondary PPH.
• pyrexia and tachycardia.
• uterus is large and tender
• infected wounds as CS or perineal lacerations
• fullness in pelvis due to abscess.
Investigations

1. FBC anaemia, leukocytosis ,


thrombocytopenia
2. Coagulation Profile DIC.
3. RFT & Electrolytes fluid & electrolytes
imbalance.
4. High vaginal swabs infection.
and blood cultures.
5. Pelvic US retained products ,
pelvic abcess
Management

Prevention:
1. awareness of general hygiene principles.

2. good surgical technique with proper hemostasis.

3. prophylactic antibiotics
especially in emergency CS.
a single intra operative dose of cephalosporin+
metronidazole.
Treatment

A. Mild and Moderate infections :


broad spectrum antibiotic as:
cephalosporin + metronidazole.
in the first 48h ,antibiotic should be given IV.

B. Severe infections :
septic/endotoxic shock
appropriate antibiotics should be aggressively
given ,any delay could be fatal.
Complications

1. Pelvic abscess
salpingo- ophoritis and pelvic peritonitis . This
could progress to a generalized peritonitis and
the development of pelvic absess.
Necrotizing Fasciitis

• fatal infection of skin ,fascia and muscle. It occurs


in the perineal tears, episiotomy sites & CS
wounds caused by a variety of bacteria including
anaerobes.
• in addition to signs of infection ,there is extensive
necrosis which is managed by surgical removal of
the necrotic tissue (debridement) under general
anesthesia
This is essential to avoid mortality.
Secondary Postpartum Hemorrhage

• it is fresh bleeding from the genital tract after


the first 24 h. till 6 weeks after delivery ( common
7 – 14 days postpartum).
• the most common cause is retained placental
reminants.
• associated features are cramps abdominal
pain, the uterus is larger than expected and
signs of infection such as tenderness .
Management

Diagnosis :
U/S is mandatory.
Treatment :
• IV blood transfusion.
• Syntocinon infusion.
• Antibiotics -should be given if placental tissues are
found even without evidence of overt infection.
evacuation of the uterus under general anesthesia .
Perineal Complications
1.perineal discomfort
• it is the single major problem for mothers in
the first 3 days .
• discomfort is greatest in the presence of
episiotomy ,spontaneous tears following
instrumental delivery.
treatment • local cooling by crushed ice.
• topical anaesthetics as 5% lignocaine gel.
• analgesics -paracetamol or NSAIDs as;
diclofenac suppositories at delivery
followed by another 12h latter.
2. perineal infection
• uncommon , but if signs of infection occur
these must be taken seriously.
• caused by bacterial contamination during delivery
,thus swabs from infected wounds for culture &
antibiotic sensitivity.
treatment
• antibiotics.
• drainage if there is pus, is collected by removal of
any skin sutures.
• .if there is spontaneous opening of repaired tears or
episiotomy ,in presence of infection,
should be irrigated twice daily
(4) Bladder Dysfunction
• Voiding difficulty and over-distention of the
bladder are not uncommon after delivery ,
especially ,if epidural or spinal anesthesia
has been used.

Causes
• after epidural anesthesia the bladder may
take 8 – 12h to regain normal sensation.
• During this time about 1 liter of urine is
produced and therefore ,urinary retention
occurs.
• caused also by pain or peri urethral edema due to
traumatic delivery as :
instrumental delivery , multiple extended
lacerations ,vulvo vaginal hematomas .

• Distended bladder is diagnosed by being


palpated as a supra pubic cystic mass or it may
displace the uterus upwards or laterally , so
increasing the height of the uterine fundus.
treatment

if regional anesthesia has been used ,urinary


catheter should be left in situ for the first
12 – 24h especially if the residual urine in the
bladder is > 300 ml.
Important
stress incontinence is a rare problem in the
puerperium ,thus any urine incontinence should be
investigated to exclude obstetric fistulae.
Bowel Dysfunction
• Constipation is a common problem in the
puerperium. It is caused either by interruption
in the normal diet and dehydration during
labor or as a result of fear of evacuation of the
rectum due to pain from a sutured perineum.

• Advice on adequate fluid & fiber intake is


necessary.
• In repaired 3rd and 4th degree perineal tears,
avoidance of constipation & straining is very
important as it would disrupt the repaired anal
sphincter and cause anal incontinence.

Long -term anal incontinence following repair


of 3rd and 4th degree perineal tears occurs in
5% and recto-vaginal fistula in 3% in the
postpatum period.