TOPIC – ABNORMALITIES OF THE PUERPERIUM

CASE STUDY
1.A women with 24 years old presented to local emergency department after two days of vaginal
delivery. On observation, she was presented with febrile, chills, tachycardia and hypotension. After
sometimes her conditions get severed so she shifted to tertiary care centre. She is provided with
vasopressor and ventilator support for sepsis and shock. She is also managed with surgical management
like supracervical hysterectomy. So what is she diagnosed with?

a. Puerperal sepsis

b. Puerperal pyrexia

c. Puerperal venous thrombosis

2.A nurse calls you about a patient who had an uncomplicated vaginal delivery 12 hours ago. She is
concerned that the patient has the following findings. Which of the would of most concern to you?

a. Abdominal rigidity

b. Leucocytosis of 1600

c. Proteinuria

d. A single temperature spike of 100.4°F

3.A patient had a normal vaginal delivery with episiotomy repair. She is complaining of inability to void
urine, which is managed by the nurse with Foley catheterization. Which of the following can be a serious
etiology of inability to void in the immediate postpartum period?

a. Epidural analgesia

b. Pain at the episiotomy site

c. Genital tract hematoma

d. Over distension of the bladder

4.A 22 year old primigravida delivered a 4kg baby vaginally. She had poor weight gain and anemia during
her pregnancy. She had a difficult and prolonged labor with forceps delivery and a third-degree vaginal
laceration. Which of the following is the greatest predisposing factor for puerperal infection in this
patient?

a. Iron deficiency

b. Poor nutrition

c. Tissue trauma

d. Young age
5.A 22 year old primigravida delivered a 4kg baby vaginally. She had poor weight gain and anemia during
her pregnancy. She had a difficult and prolonged labor with forceps delivery and a third-degree vaginal
laceration. She develops a persistent fever of 101°F on the 3 rd postpartum day. What is the most likely
cause of her fever?

a. Mastitis

b. Endometritis

c. Pneumonia

d. Thrombophlebitis

6.A 22 year old primigravida delivered a 4kg baby vaginally. She had poor weight gain and anemia during
her pregnancy. She had a difficult and prolonged labor with forceps delivery and a third-degree vaginal
laceration. She develops a persistent fever of 101°F on the 3 rd postpartum day. On clinical examination
the uterine fundus is just below the umbilicus, the uterus is firm and slightly tender. On pelvic
examination, there is foul smelling lochia and the fornices are non tender. Her local wound shows
redness and mild induration, the stiches are intact. Blood reports shows Hb 10gm/dl and a TLC count of
22,000.what is the most likely site of infection?

a. Perineal laceration

b. Placental site

c. Cervical tissue

d. Parametrial tissue

7.A 23 year old primigravida delivered a 3kg baby vaginally. She had poor weight gain and anemia during
her pregnancy. She had a difficult and prolonged labor with forceps delivery and a third-degree vaginal
laceration.She is also diagnosed with the puerperal genital infection. But which is the most common
organism responsible for puerperal genital infection?

a. Beta streptococcus

b. Clostridium

c. E. Coli

d. Pepto streptococcus

8.A mother complains that her baby is not breast feeding properly. Baby is not getting enough milk out
of the breast.The milk get collected in the lobules.On examination, the breasts are swollen and tender.
This makes baby to suck difficult. Also causes the pain in women if she continues. What is the likely
cause?

a. Breast engorgement

b. Mastitis

c. Sore nipple
d. Breast abscess

9.A woman presents with high grade fever 1 week after delivery. She complaints of her right breast
being engorged, hot and painful. What is the most likely organism responsible for her breast infection?

a. E. Coli

b. Aerobic streptococcus

c. Anaerobic streptococcus

d. Staph aureus

10.A 20-year-old woman (gravida 1) has just delivered. After expulsion of the placenta, a red, raw
surface is seen at the vaginal introitus. Simultaneously, the nurse states that the patient is pale and her
BP is 70/40 mm Hg. External bleeding has been of normal amount. Which of the following would be the
most likely diagnosis?

a. Ovarian cyst

b. Ruptured uterus

c. Vaginal rupture

d. Uterine inversion

11.An 18-year-old patient finally delivered a 4,000-g infant vaginally. Her prenatal course was
complicated by anemia, poor weight gain, and maternal obesity. Her labor was protracted, including a 3-
hour second stage, a mid-forceps delivery with a sulcus laceration, and a third-degree episiotomy. He
develops a persistent fever of 101°F on the third day postpartum. What is the most likely etiology?

a.Cholecystitis

b. Endometritis

c. Mastitis

d. Thrombophlebitis

12.An 18-year-old patient finally delivered a 4,000-g infant vaginally. Her prenatal course was
complicated by anemia, poor weight gain, and maternal obesity. Her labor was protracted, including a 3-
hour second stage, a mid-forceps delivery with a sulcus laceration, and a third-degree episiotomy.
Puerperal infection may be spread by several routes. Which of the following is the most common route
that results in serious complication of a septic thrombophlebitis?

a. Arterial

b. Direct extension

c. Venous

d. Lymphatic
13.A 24-year primigravida woman, who is intent on breast feeding, decides on a home delivery.
Immediately after birth of a 4.1kg (9-lb) infant, the patient bleeds massively form extensive vaginal and
cervical lacerations. She is brought to the nearest hospital in shock. Over 2hours, 9 units of blood are
transfused and the patient's blood pressure returns to a reasonable level. A hemoglobin value the next
day is 7.5g/dl, and 3 units of packed red blood cells are given. The most likely late sequela to consider in
this woman is which of the following?

a. Hemochromatosis

b. Stein-Leventhal syndrome

c. Sheehan syndrome

d. Simmonds syndrome

e. Cushing syndrome

14.A 38-year-old G3P3 begins to breast feed her 5-day old infant. The baby latches on appropriately
begins to suckle. In the mother, which of the following is a response to suckling?

a. Decrease of oxytocin

b. Increase of prolactin-inhibiting factor

c. Increase of hypothalamic dopamine

d. Increase of hypothalamic prolactin

15.A 34-year old G1P1 who delivered her first baby 5 weeks ago call your office and asks to speak with
you. She tells you that she is feeling very overwhelmed and anxious. She feels that she cannot do
anything right and feels sad throughout the day. She tells you that she finds herself crying all the time
and is unable to sleep at night. Which of the following is the most likely diagnosis?

a. Postpartum depression

b. Maternity blues

c. Bipolar disease

d. Postpartum blues

ANSWERS:

1.Puerperal sepsis is the diganosis because of rising fever and increasing uterine tenderness on
postpartum day 2.

2.Abdominal rigidity which is due to infection like peritonitis , intra peritoneal bleeding. Others are
normal findings but temperature spike may be comes in case it persists but in this case it doesn't
persists over long period so it can't comes under this case.
3.Genital tract hematoma which is due to collection of blood that results in vulval hematoma or vaginal
hematoma which leads to hypovolemia so that it needs immediate treatment.

4.Tissue trauma is the greatest predisposing factor and others also can be included in predisposing
factors but greatest is tissue trauma.

5.Endometritis (i.e genital infection)is the most common cause of the high fever but others can also be
included but this will be persists for long duration in puerperium.

6.Placental site is the most likely site of infection because route of delivery is the most important thing
for puerperal infection or genital infection.

7.Pepto streptococcus is most common cause of puerperal genital infection because it is a anaerobic
streptoccoci.

8.Brest engorgement is the most likely cause for swollen and tenderness of breast.

9.Staph aureus is the most likely organism responsible for her breast infection. Here we may see she is
presents with high grade fever so we may say that she is also presents with mastitis so above mentioned
organism is the most probable cause for her breast infection.

10.Uterine inversion is the most likely diganosis. Here we may see red surface at vaginal introitus.

11.Endometritis is the most likely etiology it may occurs due to infection in the lining of the uterus.

12.Venous route is the most common route that results in serious complication of a septic
thrombophlebitis.This is one of the leading cause of maternal mortality.

13.Sheehan syndrome seems a likely possibility in this woman. This syndrome of anterior pituitary
necrosis related to obstetric hemorrhage can be diagnosed by 1 week postpartum as lactation fails to
commence normally. Although many modern women choose hormonal therapy to prevent lactation the
women mentioned in the question was intent on breast feeding and so would have received
suppressant.

14.Increase of hypothalamic prolactin occurs due to decrease of PIF production.

15.Postpartum depression is the most likely diagnosis.It develops in about 80℅ to 15% of women.