Normal and Abnormal

Puerperium
FRANK ANKOBEA
UST/SMS
puerperium
Puerperium : Is period during which
the reproductive organs and all the
system of the body returns to their
normal condition following the
delivery of the placenta and
Ends approximately 6 weeks later.
puerperium
When the endocrine influences of
the placenta removed the
physiological changes of
pregnancy is reversed
Puerperium
Maternal physiology is well prepared for
hemorrhage:
increase in blood volume .

hypercoagulable state.

the tourniquet effect of uterine contractions.

MECHANISM OF HAEMOSTASIS
AFTER DELEVERY
Uterine contraction & retraction
Platelet aggregation clot formation
The Principal Changes
1) Uterine Involution :
The principal changes
Uterine involution :

1. Uterine involution :
After the delivery of baby the uterus (myomaterial
muscle )is well contracted & retracted and become at
the level of the umbilicus , and after 10 14 days the
uterus well become as pelvic organ.
Uterine involution :

Breast feeding leading to release of

oxytocin from the hypothalamus &
posterior pituitary aiding the process
of involution & more contraction &
retraction of the myomaterial muscle
of the uterus and decrease the
incidence of post partum hemorrhage
Uterine involution

At the time of the delivery

uterine weight about ( 1 Kg)
then after few weeks become
50 -60 gm and shrinks at the
process of autolysis .
2)cervix
Cervix is very flaccid and curtain like
after delivery but within a few days is
returning to the original form and
consistency .
The cervical canal become closed to a
finger during the second week of
Puerperium .
3)Vagina
shrinks to a nonpregnant state
resolution of the increased vascularity
and edema occurs by 3 weeks
the vaginal epithelium appears atrophic
on smear. This is restored by weeks 6-10.
4)Perineum
swelling and engorgement are completely
gone within 1-2 weeks
the muscle tone may or may not return to
normal, depending on the extent of injury.
5)Ovaries
ovulate as early as 27 days after delivery
(not breastfeed ); 12 weeks (most); 7-9
weeks (mean).
the suppression of ovulation due to the
elevation in prolactin
6)Lochia
a large amount of red blood initially flows
from the uterus as the contraction phase
rapidly occurs. (5 weeks)
lochia rubra; lochia serosa (brownish red,
with a more watery consistency); lochia
alba (yellow)
7)Breasts
Lactation can occur by 16 weeks' gestation.
Lactogenesis is initially triggered by the
delivery of the placenta (EPand prolactin).
the prolactin levels decrease and return to
normal within 2-3 weeks (not breastfeeding)
The colostrum(the first 2-4 days)
The milk continues to change throughout the
period of breastfeeding to meet the changing
demands of the baby.
 8)Other systems
During the first few days the bladder and urethra may
show evidence minor trauma sustained at delivery but
don't usually remains in evidence for long .
The physiological hydroureter & hydronephrosis
will disappears within 6 weeks .
there is usually a diuresis during first day of the
puerperium and there is fall in plasma volume.
Abnormal puerperium
 Serious , and sometimes fatal
complication arise during
puerprium , the most serious
complications are :
 PUERPERAL PYREXIA
Temperature38C(100.4F)or higher on any
2 of the first 10days postpartum, exclusive
of the first 24hrs, to be taken by mouth by
a standard technique at least four times
daily.
COMMON CAUSES
Genital tract infection(genital sepsis)
Malaria
RTI
UTI
Mastitis
Wound infection
Meningitis
DVT
PUERPERAL SEPSIS
Childbed fever, milk fever
Important cause of maternal mortality
1-8% Normal deliveries, more in c-section
COMMON RISK FACTORS FOR
PUERPERAL SEPSIS
Antenatal uterine infections
C-section

PROM

Prolonged labour

Multiple PV

Instrumental delivery

Manual removal of placenta

RPOC

Malnutrition

Anaemia, HIV etc.

AETIOLOGY
COMMENSALS- Aerobic and anaerobic
polymycrobial
Miscellaneous eg. c-trachomatis, mycoplasma
hominis
Puerperal Infection
Common pathogens
1. Aerobes
Group A, B, and D streptococci
Gram-negative bacteria: Escherichia coli,
Klebsiella
Staphylococcus aureus
Puerperal Infection
2. Anaerobes
. Petococcus species
Peptostreptococcus species
Bacteroides fragilis group
Clostridium species
3. Other
Chlamydia trachomatis
Mycoplasma species
SYMPTONS AND SIGNS
General malaise, headache, fever, rigors
Abdominal pain, vomiting, diarrhoea
Offensive lochia
2PPH
Temperature, pulse
Tender and boggy uterus
Peritonism
Paralytic ileus
Indurated tender adnexae
INVESTIGATION
FBC
Urine RE c/s
Urea and electrolytes
HVS
Blood culture
Pelvic ultrasound
TREATMENT
A. Antibiotics:
Cephalosporing + metronidazole
C-amosiklav + metronidazole
B. Parenteral dose in severe infections
C. Fluid and electrolyte balance
COMPLICATIONS
Pelvic abscess
Septicaemia - endotoxic shock
Pelvic thrombophlebitis
Necrotising fasciitis
Infertility
Death
SECONDARY PPH
Fresh bleeding from the genital tract
between 24hrs and 6weeks after delivery.
1% (7-14)days
Causes

retained placental tissue

Infection eg. endometritis
Injury
Inversion
Trophoblastic disease
Bleeding disorder
SECONDARY PPH

Features

Cramping abdominal pain

Passage of placental tissue
Uterus larger than appropriate
signs of infection
SECONDARY PPH
Management

gping /x-matching
Iv fluids
Oxytocin
USG
Antibiotics
Transfusion
EOU
SUB INVOLUTION
Delay in involution of the uterus after delivery
Causes

Uterine infection

RPOC

Uterine fibroids

Broad ligament haematoma

Full bladder and loaded rectum

Idiopathic

Treatment depends on the cause

PSYCHIATRIC DISORDERS

Minor disorders common

Severe disorders very rare
These illnesses often resolve
spontaneously
Risk factors include
Minor disorders in pregnancy esp. 3rd trimester
Previous episodes in pueperium
Previous psychiatric illness
Still birth, perinatal death etc
3 psychiatric disorders may arise
in the post partum period
A. Post partum blues
A transient disorder that lasts hours to
weeks
30-50%
Characterized by irritability, tiredness, anxiety,
crying spells.
Reassurance, bed rest, family support.
Often resolves by post partum, day 10
B. Post partum depression
a more prolonged affective disorder.

Lasts for weeks to months (3-6months).

Symptoms of depression eg. Headache mood change,

poor feeding, neglect.

25% of patients may still be affected at 1 year.

Greatly affects the patients ability to complete

activities associated with daily living.

Treatment

selective sorotonin reuptake inhibitors(SSRI)

eletroconvulsive therapy
C. Post partum Psychosis
Occurs in the first post partum year
Confusion, delusion, hallucination, mania,
suicidal, homicidal tendencies.
Psychiatrists Management
Better prognosis than non-puerperal psychosis
MISCELLANEOUS

NEUROLOGICAL
LUMBOSACRAL PLEXUS,LUMBOSACRAL DISC
FOOT DROP- LAT POPLITEAL

CARDIOMYOPATHY
1IN 5000
CCF,ARRYTHMIA,CARDIOMEGALY
VIRAL,IMMUNOGENIC,TOXIC,GENETIC
BEDREST,DIG,DIURETICS,OXYGEN
60% -NORMALISE
IF NOT DIAGNOSED AND TREATED-DEATH
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