Abnormal Puerperium

Dr. Jully Chaudhary

Assist. Professor
CMC-TH
 Peurperium

– The period following delivery during which pregnancy-induced

maternal anatomical and physiological changes return to the non-
pregnant state.
– Its duration is between delivery of placenta to 4 or 6 weeks
PUERPERAL COMPLICATIONS

– IMMEDIATE ( first 24 hrs)

– EARLY (upto 7 days)
– Delayed (upto 6 weeks)
 PUERPERAL COMPLICATIONS
(a) Immediate—
– Primary Postpartum haemorrhage ,
– Uterine Inversion
– Postpartum eclampsia,
– Pulmonary embolism—liquor amnii or air
PUERPERAL COMPLICATIONS
(b) Early (within one week)—Puerperal Infection
– Puerperal fever/sepsis,
– Perineal infections and perineal trauma infection
– Abdominal incisional infections
– Acute retention of urine,
– Urinary tract infection,
– Subinvolution
– Breast engorgement
– Mastitis and breast abscess,
– Pulmonary infection (atelectasis),
– Adnexal abscesses and peritonitis
PUERPERAL COMPLICATIONS
(c) Delayed—
– Secondary postpartum hemorrhage,
– Thromboembolic manifestation—pulmonary embolism,
thrombophlebitis,
– Parametrial phlegmon
– Septic pelvic thrombophlebitis
– Toxic shock syndrome
– Disturbed Mental health
– Separated symphysis pubis
– Obstetrics paralysis
 PUERPERAL PYREXIA

A rise in temperature reaching 100.40F (380C) or

more (measured orally) on 2 separate occasions
at 24 hours apart (excluding first 24 hours)
during the period from the end of 1st to the end
of 10th day of delivery.
Causes of puerperal pyrexia

(1) Puerperal sepsis

(2) Urinary tract infection (cystitis, pyelonephritis)
(3) Breast complications
(4) Infection of Episiotomy or cesarean section wound
(5) Pulmonary infection, atelectasis, pneumonia
(6) Septic pelvic thrombophlebitis
(7) A recrudescence of malaria or pulmonary tuberculosis
(8) Others: Pharyngitis, gastroenteritis
 Puerperal Sepsis

Definition:
• An infection of the genital tract which occurs as a
complication of delivery is termed puerperal sepsis.
• Also known as post partum uterine infection

Puerperal pyrexia is considered to be due to genital tract

infection unless proved otherwise.
Causative organisms: Vaginal flora:

In late pregnancy and at the onset of labor:

• Doderlein’s bacillus (60–70%)
• Candida albicans (25%)]
• Staphylococcus aureus
• Streptococcus—anaerobic common; beta hemolyticus rare
• E. coli and Bacteroides group
• Cl. Welchii on occasion.
Predisposing factors of Puerperal Sepsis

The pathogenicity of the vaginal

flora may be influenced by
certain factors:
(1)Damage of cervicovaginal
mucous membrane
(2) The uterine surface is
converted into an open wound by
the cleavage of the decidua
(3)Blood clots present at the
placental site are excellent media
for the growth of the bacteria.
Predisposing factors of Peurperal Sepsis

Antepartum factors:
1. Malnutrition and anemia
2. Preterm labor
3. Premature rupture of the membranes
4. Chronic debilitating illness
5. Prolonged rupture of membrane > 18 hours.
Predisposing factors of Peurperal Sepsis

Intrapartum factors:
1.Repeated vaginal examinations
2. Prolonged rupture of membranes (> 18 hours)
3. Dehydration and keto-acidosis during labor
4. Traumatic operative delivery
5. Hemorrhage—antepartum or postpartum
6. Retained bits of placental tissue or membranes
7. Cesarean delivery.
Bacteria Commonly Responsible for Female Genital Infections

Aerobes
• Gram-positive cocci—group A, B, and D streptococci,
enterococcus, Staphylococcus aureus, Staphylococcus
epidermidis
• Gram-negative bacteria—Escherichia coli, Klebsiella,
Proteus species
• Gram-variable—Gardnerella vaginalis
Others
• Mycoplasma and Chlamydia species, Neisseria gonorrhoeae
Anaerobes
• Cocci—Peptostreptococcus and Peptococcus species
• Others—Clostridium, Bacteroides, and Fusobacterium
species, Mobiluncus species
MODE OF INFECTION

Sources of infection may be:

– Endogenous where organisms are present in the genital
tract before delivery.
– Exogenous: sources outside the patient (from hospital or
attendants).
 Pathogenesis
Normal vaginal flora
• Loss of normal protective mechanisms
• Internal examination/ monitoring
• PROM/ prolonged labor
• Chorioamnionitis
• Manual removal of placenta
• Uterine incision
Inoculation into uterus
• Blood clots
• Retained bits of placenta and membranes
• Anemia, malnutrition, DM
Growth of bacteria

Clinical Infection
• Uterine infection
• Parametrial cellulitis
• Abdominal wound infection
 History and examination

• History:
• Antenatal, intranatal and postnatal history of any high risk factor for
infection like anemia, prolonged rupture of membranes or prolonged
labor are to be taken.
• Clinical examination includes
 Thorough general, physical and systemic examinations.
 Abdominal and pelvic examinations are done to note the involuation
of genital organs and locate the specific site of infection.
 Legs should be examined for thrombophlebitis or thrombosis.
 CLINICAL FEATURES

Can be classified as:

• Local infection
• Uterine infection
• Spreading infection
CLINICAL FEATUES

LOCAL INFECTION (WOUND INFECTION):

(1) There is slight rise of temperature, generalized malaise or

headache,
(2) The local wound becomes red and swollen,
(3) Pus may form which leads to disruption of the wound.
When severe (acute), there is high rise of temperature with
chills and rigor.
 CLINICAL FEATUES
– UTERINE INFECTION
– Mild—
– (1) There is rise in temperature and pulse rate,
– (2) Lochial discharge becomes offensive and copious.
– (3) The uterus is subinvoluted and tender.
– Severe—
– (1) The onset is acute with high rise of temperature, often with chills and rigor,
– (2) Pulse rate is rapid, out of proportion to temperature,
– (3) Lochia may be scanty and odorless,
– (4) Uterus may be subinvoluted, tender and softer. There may be associated wound
infection (perineum, vagina or the cervix).
 CLINICAL FEATUES

– SPREADING INFECTION (EXTRA UTERINE SPREAD)

– pelvic tenderness (pelvic peritonitis),
– tenderness on the fornix (parametritis),
– bulging fluctuant mass in the pouch of Douglas (pelvic abscess).
 CLINICAL FEATUES

– Pelvic peritonitis—
– (1) Pyrexia with increase in pulse rate,
– (2) Lower abdominal pain and tenderness. Muscle guard maybe
absent,
– (3) Vaginal examination reveals tenderness on the fornix and
with the movement of the cervix,
– (4) Collection of pus in the pouch of Douglas is evidenced by
swinging temperature, diarrhea and a bulging fluctuant mass
felt through the posterior fornix.
 CLINICAL FEATUES
– Parametritis—
The onset is usually about 7–10th day of puerperium.
– (1) Constant pelvic pain,
– (2) Tenderness on either sides on the hypogastrium,
– (3) Vaginal examination reveals an unilateral tender
indurated mass pushing the uterus to the contralateral
side,
– (4) Rectal examination confirms the induration specially
extending along the uterosacral ligament.
 CLINICAL FEATUES

– IF suppuration occurs, the features are:

– (a) Steady rise of spiky temperature with chills and rigor,
– (b) Intense pain,
– (c) Gradual deterioration of the general condition,
– (d) A fluctuant point may be palpated according to the spread
along the cellular plane but usually above the medial aspect of
Poupart’s ligament ( Inguinal Ligament)
– (e) Leucocytosis.
 CLINICAL FEATUES

– General peritonitis—
– (1) High fever with a rapid pulse,
– (2) Vomiting,
– (3) Generalised abdominal pain,
– (4) Patient looks very ill and dehydrated,
– (5) Abdomen is tender and distended. Rebound
tenderness is often present.
 CLINICAL FEATURES

– Thrombophlebitis—
– (1) The clinical features of pelvic thrombophlebitis are similar
to those of uterine infection or parametritis,
– (2) There may be swinging temperature continued for a longer
period with chills and rigor,
– (3) The features of pyemia are present according to the organs
involved.(rare with the advent of wider range of antibiotics).
 CLINICAL FEATUES

– Septicemia—
– (1) There is high rise of temperature usually associated with rigor. Pulse rate is
usually rapid even after the temperature settles down to normal
– (2) Blood culture is positive
– (3) Symptoms and signs of metastatic infection in the lungs, meninges or joints
may appear.
– Bacteremia, endotoxic or septic shock is due to release of bacterial endotoxin
(lipopolysaccharide) causing circulatory inadequacy and tissue hypoperfusion.
– It is manifested by hypotension, oliguria and adult respiratory distress syndrome
 Investigations
– Blood for Haemoglobin, Total count, differential count,
platelet.

– High vaginal and endocervical swabs for culture and

sensitivity

– Clean catch mid stream specimen of urine for routine

analysis and culture and sensitivity test.

–
 Investigation

• Pelvic ultrasound is helpful

a. To detect any retained bits of conception within the uterus,
b. To locate any abscess within the pelvis
• Renal function test
• X-ray chest -suspected pulmonary Koch’s lesion and also to
detect any lung pathology like collapse and atelectasis (following
inhalation anesthesia)
 Prophylaxis

• Antenatal prophylaxis
a) Improvement of nutritional status (to raise hemoglobin level)
b) Eradication of any septic focus (skin, throat, tonsils) in the body.

• Intranatal prophylaxis includes—

a) Full surgical asepsis during delivery.
b) Screening for group B streptococcus in a high risk patient.
c) Prophylactic use of antibiotic at the time of cesarean section
Postpartum prophylaxis includes

• Aseptic precautions for at least one week following

delivery.
• Too many visitors are restricted.
• Sterilized sanitary pads are to be used.
• Infected babies and mothers should be in isolated room.
 Treatment

– Adequate fluid and calorie is maintained by intravenous

infusion.
– Anemia is corrected by oral iron or if needed by blood
transfusion.
– A chart is maintained by recording pulse, respiration,
temperature, lochial discharge and fluid intake and output.
 Antibiotics

Ideal antibiotic regime should depend on the culture and

sensitivity report. Pending the report

• 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.
Complication of uterine and pelvic infection

• In more than 90 percent of women, metritis responds to treatment within

48 to 72 hours.
• In some of the remainder, any of several complications may arise. These
include:
 Wound infections
 Wound dehiscence
 Complex pelvic infections such as:
 phlegmons
 abscesses
 septic pelvic thrombophlebitis
Parametrial Phlegmon
Septic Pelvic Thrombophlebitis
 Uterine Infection

Postpartum uterine infection or puerperal sepsis has been called variously:

• Endometritis
• Endomyometritis
• Endoparametritis

As infection involves not only the decidua but also the myometrium and
parametrial tissues, we prefer the inclusive term metritis with pelvic
cellulitis,
 Perineal and genital tract infection

– Episiotomy infections are not common -performed much less frequently now
than in the past
– Infection of a fourth-degree laceration can be more serious
– Although life-threatening septic shock is rare, it may still occur as a result of
an infected episiotomy
– Occasionally also, necrotizing fasciitis develops
Perineal and genital tract infection

• Episiotomy dehiscence is most commonly associated with infection.

• Other factors include
 coagulation disorders,
 smoking, and
 human papillomavirus infection
• Symptoms
 Local pain and dysuria, with or without urinary retention,
 In extreme cases, the entire vulva may become edematous, ulcerated, and
covered with exudate.
Perineal and genital tract infection

– Vaginal lacerations may become infected directly or by extension from the

perineum.
– The mucosa becomes red and swollen and may then become necrotic and
slough.
– Parametrial extension may result in lymphangitis.
– Cervical lacerations are common but seldom are noticeably infected, which may
manifest as metritis.
– Deep lacerations which extend directly into the tissue at the base of the broad
ligament may become infected and cause lymphangitis, parametritis, and
bacteremia
 Abdominal Incisional Infections
Wound infection is a common cause of persistent fever in women treated for metritis.
Risk factors include
 Obesity
 Diabetes
 Corticosteroid therapy
 Immunosuppression
 Anemia
 Hypertension
 Inadequate hemostasis with hematoma formation.
 Incidence: 2- 10% depending on risk factor

LOCAL INFECTION (WOUND

INFECTION):
(1) There is slight rise of temperature,
generalized malaise or headache
(2) The local wound becomes red and
swollen
(3) Pus may form which leads to
disruption of the wound
– Treatment includes antimicrobials and debridement of
devitalized tissue
– At 4 to 6 days, healthy granulation tissue is typically present
– Secondary closure of the open layers.
– Sutures may be removed on post procedural day 10.
 Wound dehiscence:

– Wound disruption or dehiscence refers to separation of the

fascial layer. This is a serious complication and requires
secondary closure of the incision in the operating room.
– Dehiscence of abdominal wound following cesarean
section is managed by scrubbing the wound twice daily,
– debridement of all necrotic tissue and
– then closing the wound with secondary suture.
– Appropriate antimicrobials are used following culture and
sensitivity
Adnexal abscesses and peritonitis

– An ovarian abscess rarely develops in the puerperium.

– Presumably caused by bacterial invasion through a rent
in the ovarian capsule.
– Usually unilateral
– Rupture is common, and peritonitis may be severe.
Peritonitis

• Peritonitis is infrequent following cesarean delivery.

• It is almost invariably preceded by metritis.
• It most often is caused by :
• Uterine incisional necrosis and dehiscence
• Ruptured adnexal abscess
• An inadvertent bowel injury at cesarean delivery.

• Rare after vaginal delivery due to virulent strains of group A

β-hemocyte streptococcci.
 Treatment

– In an intact uterus and extends into the peritoneum,

antimicrobial treatment alone is usually sufficient.
– Conversely, peritonitis caused by uterine incisional necrosis or
from bowel perforation, needs surgical intervention.
– Pelvis abscess should be drained by colpotomy under ultrasound
guidance.
 Toxic Shock Syndrome

It is the acute febrile illness with multisystem derangement.

Fatality rate of 10-15%

Etiology
Staphylococcus aureus
• A staphylococcal exotoxin, termed toxic shock syndrome
toxin-1 (TSST-1) by provoking profound endothelial injury.
• Principal therapy is supportive, while allowing reversal of
capillary endothelial injury.
• Antimicrobial therapy that includes staphylococcal and
streptococcal coverage is given.
SUBINVOLUTION:

When involution is impaired or retracted, Causes:

– Overdistension of uterus as in twins, hydramnios, big baby
– Puerperal sepsis, retained placental tissue
– Delivery by LSCS
– Presence of uterine fibroid
– Non lactating mothers
– Only size of uterus is not important
– If subinvolution is associated with excessive lochia, heavy and irregular
bleeding p/v, foul smelling discharge p/v then it is important.
Urinary Complication In Puerperium:

1. Urinary tract infection

Common cause of puerperal pyrexia
May be due to:
– Presence of previous infection
– Asymptomatic bacteriuria becomes symptomatic
– Effect of catheterisation
– Stasis of urine due to lack of bladder tone and decrease desire to
pass urine
– Reflux of urine from bladder to renal pelvis
Organism: E. Coli, Klebsiella, Proteus, Streptococcus

Presentation: fever , malaise, suprapubic tenderness, flank pain & renal

angle tenderness if kidneys are involved

Investigation: TLC,DLC, urine routine and culture,

USG for kidney status

Treatment: sensitive antibiotics

2. URINARY RETENTION:
Bladder sensation & its capacity to empty spontaneously
Is decreased in puerperium
Moreover because of pain less desire to pass urine

Treatment: simple measure

Indwelling cather for 24- 48 hours
Rule out infection
Appropriate antibiotics
 BREAST COMPLICATION:

1. Breast Engorgement,
2. Cracked Nipples,
3. Retracted Nipples and Flat nipple
4. Mastitis and
5. Breast Abscess
1. Breast Engorgement:

Due to exaggerated normal Venous and lymphatic engorgement of breast

which precedes lactation. This prevents escape of milk from lacteal system
Onset: 3-4 days of puerperium
Presentation: feeling of heaviness and tenseness in breasts, transient rise of
temperature, malaise
Treatment:
– Regular breast feeding,
– expression of milk.
– Tight breast support
– Analgesics for pain
 2. Cracked nipples:
Painful nipple due to
– Loss of surface epithelium with formation of raw area
– Fissure situated either at tip or the base of nipple
Causes:
– Crusting over the nipple
– Retracted nipples
– Vigorous sucking by infant
Presentation : pain during feeding
If infection , spreads to deeper tissue producing mastitis
Treatment: emollient ( antibiotic cream)
Breast feeding with nipple shield
Severe cases: stop feeding for 24- 48 hours
Maintain hygiene
3.Retracted and Flat nipple

Retracted nipples:
seen in primigravida
Causes difficulty in breast feeding
Usually be teased out by gentle pulling with finger and
thumb
Use of nipple shield
4. Acute mastitis:

– Infection of breast parenchyma

– Infection follows cracked nipples
– Organisms gain access through lactiferous duct
– Following contact with carrier of S. Aureus (nose & mouth of
infant)
– Common organism: staphylococcus aureus
– Occurs 3- 4 weeks after delivery
Presentation:
Marked engorgement of breast followed by inflammation
Fever with chills and rigors, tachycardia, generalized malaise and
headache
Breast becomes hard, reddened, tense and tender
Overlying skin tense, tender and hot flushed
If not treated: abscess formation
Treatment: cloxacillin 500mg po 6 hourly 7- 10 days
Analgesics: ibuprofen
Continue breast feeding
If very tender: pumping of milk
Infection resolves within 48 hours
5. Breast abscess:

All features of mastitis and infection

Fails to resolve within 48 – 72 hours
Development of mass with presence of fluctuation
If doubt: USG can be done

Treatment:
– Surgical drainage under GA
– Pus for culture & sensitivity
– Appropriate antibiotic
Pulmonary Atelectasis:

Usually occurs in LSCS patients done under general

anesthesia due to aspiration
Presentation :
– Fever within 48 hours
– Crackles, decrease breath sound
– Dullness on percussion
– Diagnosis of pulmonary infection by
chest x- ray
Treatment: Broad spectrum antibiotics
Chest physiotherapy
 Deep vein thrombosis

Deep vein thrombosis: occurs due to stasis of blood in Lower limbs and
pelvic veins
Causes: prolonged rest, alterations in blood constituents, Infections, trauma to
venous wall
Presentations: onset within 1 week
Pain in calf, rise in temperature, overlying skin becomes red, rise in pulse rate ,
swelling of limbs: difference of circumference of Calf or thigh of 2cm or more
at identical site
Investigation: Doppler ultrasound
Preventation: trauma, sepsis and anemia prevented Dehydration corrected, leg
exercises and ambulation
Management: heparin therapy
Pulmonary embolism: leading cause of maternal death in 80 -90% of
cases , embolus is the thrombus arising from leg or pelvic veins
following deep vein thrombosis
Presentation: sudden onset of chest pain, dyspnea, cough, hemoptysis,
syncope, cyanosis
Diagnosis: chest x- ray: oligemic film, decrease vascular marking
Lung scanning: ventilation/perfusion scintigraphy
Pulmonary angiography
Treatment: heparin
Obstetric Palsies:

Obstetric palsies:
Most common seen in puerperium is foot drop
Cause: pressure on branches of the lumbo-sacral plexus during labor
Unilateral foot drop: peroneal nerve palsy due to bruising of peroneal nerve
against fibula when placing patient in lithotomy position
Presentation: intense neuralgic pain or cramp like pain
Extending down on one or both legs as soon as head descends down the
pelvis
Weakness of lower limbs and difficulty in walking
Treatment : analgesics for pain, physiotherapy avoidance of pressure sores
Psychological Problems In Puerperium:

Psychological problems in puerperium:

– Maternity blues: mild, transient depression usually on day 3-5
– Postnatal depression:
– Postnatal psychosis
Any Questions???