Purperium
Definition:It is period about 6-8 weeks following delivery during which the changes produced by pregnancy.
Abnormal Puerperium
1. Puerperal infection ----> retention 2. UT complication ----> incontinence ----> stress I
true 3. Thrombo embolism4. 2nd P.P HE5. Subinvloution of the uterus6. Foot drop 7. Mental disorder
Genital Tract Infection:AE: 1. Predisposing Factors:
1. General2. Anternatal Factor
Intranatal factor
2. Organism 1. Exogenous 2. Endogenous Streptococci:
Streptococci:a. B haemolytic strep group A b. B haemolytic strep group B C. B haemolytic strep group 0 d. Non-haemolytic streptococci e. Anaerobic streptococci
Staph: Staph aureus Anaerobic staph
Bacilli: G negative aerobic bacilli E coli, Klebsiella
G negative anaerobic bacillus -----> bacteroids
Gm positive anaerobic bacilli
ROUTE OF INFECTION: Primary Sites: placental site, wound and laceration, clots and pluc.
tissue
Secondary Sites: pelvic cellulitis, thrombophlebitis, pelvic peritonitis, generalized peritonitis, septicaemia, and septic shock
COMPLICATIONS: Spread of infection Renal failure Death Secondary infertility Sheehan
CLINICAL PICTURE --- depends on site of infection
INVESTIGATIONS: History Examination Special investigations
TREATMENT: Prophylaxis: Antenatal, intranatal case, postnatal
Active Treatment: 1. General treatment ----> rest
----> diet ----> fluid
2. Medical treatment ----> antipyretic ----> analgesics ----> antibiotics
3. TTT of complication
Puerperal Pyrexia
Definition:
A rise of temperature above 3SoC
occurring in first 3 weeks of puerperium
persistent at least 2H hours on
recurring within this period.
AE:
Puerperal sepsis
Breast infection
Urinary infection
Episiotomy infection
Wound infection
Other types of infection as respiratory infection,
malaria, gluteal abscess, typhoid
Primary Puerperal SepsisDefinition:Genital tract infection after delivery. It is the
commonest cause for puerperal infection.
The causative organism1. Anaerobic streptococci 2. Group A haemolytic streptococci 3. Staphylococci causing suppurative and pus 4. E. coli and non-haemolytic streptococci 5. Specific organism as cl. welchii and tetani
Mode of infection
1. Exogenous infection ----> attendant
2. Endogenous: organism already present in genital tract
3. Autogenous: organism transmitted to genital tract from other parts of body
SITES OF INFECTION A) Primary Sites:
1. The placental site 2. Laceration of cervix, vagina or perineum 3. Dead tissue retained in the uterus as placental remnant or blood clot
B) Secondary Sites: -> ext. from primary site 1. Parametritis 2. Salpingo-oophoritis 3. Pelvic thrombophlebitis 4. Pelvic and generalized peritonitis
C) Generalized Spread: Septicaemia or pyrexia
PREDISPOSING FACTORS 1. Introduction of bacteria 2. Anaemia 3. Prolonged or instrumental delivery - PRM
PATHOLOGY
1. Uterus ----> Uterus puerperal endometritis localized type septic puerperal endometritis generalized type
2. Infected laceration ----> greenish yellowish 3. The parametrium ----. pelvic cellulitis from: direct
lymphatic: cervix, vaginal vault 4. The tubes and ovaries ----> acute salpingo-oophoritis 5. The peritoneum ----> through lymphatic by direct 6. Pelvic veins ----> pelvic thrombophlebitis
CLINICAL PICTURE I. Uterine Infection:
a. In the mild type ---> onset 4 days after delivery
b. In the severe type ---> onset 2-3 days or even one day after delivery, increased temperature and pulse, headache and malaria, UT tender, involuted and lochia scanty.
II. Infected Laceration: Mild pyrexia, local discomfort, tenderness, oedema
and congestion
III. Parametritis: At 10 days after delivery with increased temp and
pulse, vague abdominal pain, backache, U/E = tender mass extending from UT to 1st pelvic wall on one or both sides.
* SOFTENING ----> parametric abscess
IV. Salpingo-oophoritis: Fever, rigor, vomiting, lower abdominal pain,
tenderness at rigidity
V. Peritonitis: a. Pelvic peritonitis ---> as complication of
salpingitis b. Generalized peritonitis ---> rigor, fever, t pulse
VI. Septicaemia: ----> occurred about the third and fourth
day after delivery secondary to UT infection
VII. Thrombophlebitis: Secondary to UT infection 7 - 10 days after
delivery
InvestigationA. HistoryPre-existing infection before labour TB, UTI Anaemia, toxaemia and diabetes Difficult labour on spontaneous Instrumental used or any complication Catheterization Onset of pyrexia Sore throat, busy mict.
B. General Examination: 1. Pulse, temp, BP 2. Anaemia or jaundice 3. Tonsillitis 4. Breast, heart and chest 5. LL ---> thrombophlebitis
c. Abdominal Examination: 1. Tenderness in abdomen, int, loin 2. Rigidity 3. Height, fundus and any abdominal mass
D. Vaginal Examination: 1. Lochia 2. Laceration 3. Bi-manual examination size and mobility, uterus 4. Speculum examination to see cervix + vagina
E. Laboratory Investigations: 1. Swab from the upper vagina or cervix 2. Catheter specimen of urine for culture 3. Full blood picture Hb, RBCs and leucocytes 4. Widal test, x-ray chest, blood film for malaria
PROPHYLAXIS PUERPERAL SEPSIS A. Antenatal:
1. Diet, vitamin + mineral 2. Treat disease as anaemia, toxaemia or diabetes 3. Treat vaginal discharge
B. Intrapartum 1. Proper delivery 2. Strict asepsis -----> patient -----> instrument
-----> attendant 3. In prophylactic, antibiotic
c. Postnatal: 1. Aseptic precaution 2. Early isolation of suspected cases
TREATMENT OF SEPSIS
I. General Treatment: 1. Isolation of patient 2. Light diet 3. Correct anaemia 4. Relieved pain by analgesics 5. Give mild laxative
II. Antibiotic: 1. Vaginal swab and give correct antibiotic
III. Promotion of Drainage: 1. Sensitivity position 2. Ergometra 3. Removal of suture 4. Drainage of pelvic abscess 5. Gentle of any piece of placenta
IV. General Peritonitis: 1. Heavy dose, antibiotic IV _ Ryle tube + IV fluid
V. Septic Thrombophlebitis: 1. Antibiotics 2. Anticoagulant 3. Immobilization of limb
Postnatal Care
AIMS:1. Detection of any abnormality that from
pregnancy and labour. 2. Follow-up of complication in pregnancy. 3. Advice regarding breast feeding, diet, hygiene4. Advice regarding contraception.
The Gynaecological Conditions Which May Be Found Are:
1. Perineal Laceration:
Not repaired within 24 hours ----> need operation 3 - 6
months
2. Vesico-Vaginal Fistula:
* Fix catheter for 10 - 15 h + antibiotic after 3 - 6
months -----> fistula may heal if small or may need
operation
3. Prolapse + 8.1.: * Pelvic floor exercises if condition persist -----> operation, 3 - 6 months.
4. RVF of uterusNo symptoms ----> no treatment There is symptom ----> correct ut manually ----> insert Hodge
pessaries 4-6 weeks
5. Cervical Erosion: * No treatment before 3 months * Persists cauterized
6. Sub-InvolutionErgometrium + antibiotic