Puerperium د . زينب عبد الأمير جعفر 2019-2018

1. Puerperiumد.زينب عبد الأمير جعفر2019-2018

2. Puerperium • Define the puerperium • Understand the normal physical changes occur in puerperium • Define the Puerperal pyrexia • Describe the Causes of Puerperal pyrexia • Describe Management of each Causes of Puerperal pyrexia • Identify Other Abnormalities of Puerperium • Describe the normal lactation and composition of the colostrum,Comparison of the constituents of human and cows 'milk,Advantages of breastfeeding, physiology of lactation and Breastfeeding and breast cancer • Describe The post-natal examination

3. Definition Refer to the 6 weeks period following child birth. When considerable changes occur before return to pre pregnancy state.

4. Physiological changes

5. The uterus:

6. Uterine involution is the process by which the postpartum uterus, weighing about 1kg, returns to its prepregnancy state of less than 100g.

7. Involution occur by process of autolysiswhereby muscle cells diminished in size with no effect on number of muscle cells

8. Immediately after delivery: the uterine fundus lies about 4cm below the umbilicus or more accurately 12cm above the symphysis pubis. The measurement should be taken after emptying the bladder

9. By the end of second week the uterus becomes a pelvic organ. By 6 weeks, the uterus becomes almost normal in size.

11. involution at the rate of 2 cm/day • Involution appear to be accelerated by release of oxytocin in women who are breastfeed.

14. The cervix :

15. **by 2 to 3 weeks, the internal os is closed, but the extnalos can remain open permanently, giving a characteristic appearance to the parous cervix.

16. The vagina:

17. Vagina gradually diminishes in size. • In the 1st few days, the stretched vagina is smooth & edematous • by the 3rd week rugae begin to reappear. • The hymen disappears and is represented by :several small tags of tissue which are known as carunculaemyrtiformes. This is a characteristic sign of parity.

19. Lochia

20. Is the blood stained uterine discharge that is comprised of blood & necrotic decidua.

21. Lochia rubra: For the first 4 days, lochia is red in color. It contains blood as well as decidual debris. • Lochia serosa: From 5th to 9th day, lochia becomes pale in color. It contains still some red cells, but predominantly leucocytes and necrotic decidua. • Lochia Alba: After the 10th day, the lochia changes to yellowish white color. It consists now principally of serous fluid and leucocytes

23. Persistent red lochiasuggest delay involution that is usually associated with • Infection • a retained piece of placental tissue

24. Offensive lochia which may be accompanied by Pyrexia & a tender uterus, suggests infection, should be treated with broad-spectrum antibiotics.

25. Ovarian function:

26.  The onset of the first menstrual period following delivery is variable and depends on lactation • Non lactating women: the mean time of ovulation :is about 6 to 8 weeks and menstruation :returns by 12th week following delivery • lactating women: the mean time of ovulation is 6 months. The physiological basis of anovulation and amenorrhea is due to elevated levels of serum prolactin associated with suckling

27. Cardiovascular & coagulation system:

28. Urinary tract :

29. Normal pregnancy is associated with an increase in extracellular water and puerperal diuresis is a reversal of this process. Diuresis occurs between the second and fifth days.

30. Dilated ureters and renal pelvis return to their prepregnant state within 8 weeks.

31. Puerperal pyrexia: • Defined as a rise of temperature reaching (38°C) or more (measured orally by standard technique) on 2 separate occasions at 24 hours apart (excluding first 24 hours) within first 10 days following delivery

32. Causes of Puerperal pyrexia:

33. Genital tract infection (puerperal sepsis). • Wound infection following Caesarean section. • Urinary tract infection. • Chest complication • Tonsillitis • Thromboembolic causes: • Breast infection including Mastitis or Breast Abscess • Meningitis • Other incidental infections

34. Genital tract infection (puerperal sepsis):

35. Defined as a genital tract infection following delivery.

36. Puerperal sepsis is commonly due to • Uterine Infection (eg.Endometritis) • Perineal wound infection :includes infection of (episiotomy wounds , repaired lacerations & repaired perineal tears )

37. Organisms commonly associated with puerperal genital tract infection: • Aerobes • G+ve (B-haemolytic streptococcus, staphylococcus) • G-ve (E-coli,H.influenzae ) • G-variable (Gardnerella vaginalis ) • Anaerobes(Peptococcus sp.,Peptostreptococcus sp.,Bacteroids) • Miscellaneous(ChlamydiaTrachomatis,Mycoplasma ,ureaplasma urealyticum).

38. Most of the infections in the genital tract are polymicrobial with a mixture of aerobic and anaerobic organisms.

39. Common risk factors for puerperal infection:

40. Antepartum factors • Obesity • Diabetes • Malnutrition and anemia • Human immunodeficiency virus (HIV). • Preterm labour • Chorioamnionitis; • Prolonged rupture of membranes >18 hrs

41. Antepartum factors • Chronic debilitating illness • Immunodeficiency • Antenatal intrauterine infection • Cervical cerclage for cervical incompetence

42. Intrapartum factors • multiple vaginal examinations. • Prolonged labor/prolonged second stageof labour • Instrumental delivery. • caesarean section. • uterine manipulation /manual removal of the placenta.

43. Intrapartum factors • retained products of conception( Retained bits of placental tissue or membranes) • Internal fetal monitoring. • Foreign body • Hemorrhage – antepartum or postpartum

44. Symptoms of puerperal pelvic infection • Malaise, headache, fever, rigor. • Abdominal discomfort, vomiting & diarrhea. • Offensive lochia. • Secondary PPH.

45. Signs of puerperal pelvic infection • Pyrexia • tachycardia. • Uterus- tender& large. (sub involution of the uterus) • Infected wound (perineal wound or C/S) ,may cause break down of wound • Paralytic ileus • Peritonism. • indurated adnexia (parametritis) • Boggines in the pelvis(abcess)

46. Complication of pelvic infection: 1. Wound dehiscence 2. Adnexal infection 3. Pelvic abscess 4. Septic thrombophlebitis 5. Septicemia 6. Subsecquent subfertility.

47. Diagnosis: Evaluation of a febrile postpartum patient should include a careful history & physical examination. • Extra pelvic causes of fever should be excluded.

48. Investigations for puerperal genital infections: • FBC (anemia leukocytosis,thrombocytopenia) • Urea & electrolyte (fluid & electrolyte imbalance) • High vaginal swab (infection screen) • Blood culture • Pelvic u/s (retained product & pelvic abscess)

49. Management Depending on the severity

50. the treatment of endometritis • Gentamicin (2 mg/kg IV loading dose followed by 1.5 mg/kg IV every eight hours) and Ampicillin (1 g IV every 6 hours) or Clindamycin (900 mg IV every 8 hours) should be started