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Puerperal complications (Abn. peuperal conditions) (Puerperal infection…
Puerperal complications (Abn. peuperal conditions)
:star: Urinary
retention
*M/C complication in early puerperium
Def:
Absence
of Spontaneous micturition
within 6 hr
after
Vx delivery
Cause: mayb fr Injury to pudendal n. during birth process
Risk factors: Nulliparous, Instrument assisted delivery, Prolonged first and second stage and Epidural analgesia
Mx
Initial treatment
Non invasive:
Helping pt to bathroom
instead of bedpan, privacy, taking a warm bath
Catherterization
Self-limited disorder that can expect resolve
within 1 wk
Uterine
subinvolution
Learning
Normal
involution
1 wk PP → :arrow_down: 50% in size
2 wk PP → Not be palpated from abdomen
4-6 wk PP → Return to Nonpregnant size
Def: Abnormal (arrest or retardation) healing of placental site and endometrium
Causes
Retained placental tissue (piece of placenta or membranes)
Infection (endometritis, metritis)
:leaves:
S&S
Irregular/Excessive uterine bleeding
Delayed PPH
Abnormal lochia and foul smell
Fever, chills
Tenderness of uterus and adnexa
Inappropriate size of Ut and PP date
:bulb:
Dx
PE
PV exam
U/S (to detect placental tissue)
:evergreen_tree:
Rx
depends on the cause
Puerperal
infection
Def: bacterial infection of the genital tract
after
delivery
More def:
Puerperal fever
: BT > 38℃ occurs
within 10 days
but not in first 24 hr of delivery and temperature
must be
take by
mouth
and
≥ 4 times/day
:bird:
DDx
(must ddx with other infection)
Breast engorgement, Mastitis
Respiratory complications
Atelectasis
Aspiration pneumonia
Bacterial pneumonia
Acute pyelonephritis
Thrombophlebitis, DVT
Predisposing factors :grapes:
PROM, PPROM
Prolonged labor
Frequent Vg examinations during labor
C/S
Operative Vaginal delivery
Cervical/Vaginal laceration
Manual removal of placenta
Retention of placenta
Bacterial colonization
Low socioeconomic status
Malnutrition
Causative organisms
colonized bac in genital tract ; most are low virulence ; 2/3 of cases are caused by Mixed organism
:star: Common
anaerobic
organism
Peptostreptococcus
Peptococcus
Streptococcus
Bacteroides fragilis
Common
aerobic
organisms
Group A, B and D streptococci
Gram neg bacilli - E. coli
Enterococci
Incidence
Aero + Anaero 63%
Anae alone 30%
Aerobe alone 7%
'Peptostreptococcus and Peptococcus' 45%
Bacteroides 9%
:leaves:
S&S
High grade fever + Chills + Tachycardia
Abdominal/Uterine/Parametrial
tenderness
Foul-smelling, profuse
Lochia
Bloody/Pus-like
D/C
Uterine
subinvolution
Some are asymptomatic
:deciduous_tree:
Mx
**Should exclude Extrapelvic causes of fever
C/S
should obtained fr Blood, Endocervix, Uterine cavity, Catheterized urine specimen
Broad-spectrum ATBs
for 7 - 14 d
Eg: Ampi, Cephalo, Genta, Metro, Clinda, Imipenam
Oral / IV(if severe) form
Doses
:yellow_heart:
Gold standard
: Clindamycin 900 mg + Gentamicin 1.5 mg/kg q 8 hr IV
90 - 97% efficacy, once-daily gentamicin dosing acceptable
May added
Ampicillin
if Sepsis syndrome or Suspected enterococcal infection
Pain and fever relief
Paracetamol, NSAIDs
Noted that: S&S should improve in 48 - 72 hrs; BF is not prohibited; If suspects thrombophlebitis (
ขาบวมหนึ่งข้างไรงี้
), give
heparin
Complications
Wound infection
Wound dehiscence
Ovarian abscess (
Uni
lateral > bilateral)
Peritonitis
Parametrial
phlegmon
Can't Sx
gives
IV ATBs ≥ 2 wks
Pelvic
abscess
Antimicrobial + Percutaneous
drainage
may required
Stages of :small_red_triangle: : Parametrial phlegmon → Suppurate → Abscess
Pelvic thrombophlebitis
PathoPSO
Infection along
Venous
route → Thrombosis
*Ovarian vein is M/C
Clinical: Some clinical improvement after Antimicrobial Rx but continue to have fever
Diagnosis
Pelvic CT
MRI
Heparin challenge test
Necrotizing fasciitis (NF)
Surgical (C/S) wound infection
Incidence: 5% of Primary C/S
Predisposing factors :grapes:
Obesity, DM
Prolonged ROM
Poor hemostasis with Hematoma formation
Immunocom. pt
Corticosteroid therapy
Anemia
:leaves:
S&S
Fever
Spreading cellulitis
Erythema
Discoloration of Skin
Purulent D/C
Disruption of wound
:christmas_tree:
Mx
Small lesion: Expectant Mx
not Small lesion: Stitch off & exploration → make sure fascia is intact → Debride wound →
Delayed suturing + IV ATBs
*Must ddx with Hematoma (infection of episiotomy)
Hematoma of episiotomy
Cause: often fr Tear of pudendal branch
:leaves:
S&S
Swelling, tense, fluctuation
Excrucriating pain
Extravasation of blood beneath skin
Tissue necrosis
:evergreen_tree:
Mx
Expand sign? (expand into ischiorectal fossa/perineum)
NO → Expectant Mx
YES → must Drain
Then, Resuture with Adequate exposure
Cold compression
within First 24 hrs
:shaved_ice:
ATBs for prophylaxis
Pain relief
Infection of episiotomy
Def: Local infection involves
only skin & subcu. tissue
:leaves: Signs
Local edema
Pain
Erythema
Exudate
Rupture of suture
Complication
NF
TSS (Toxic shock syndrome)
Sepsis
*Pre-op Protocol for Early Repair of Episiotomy Dehiscence
Open wound → Remove sutures + begin IV ATBs
Wound care
Sitz bath several times daily or Hydrotherapy
Adequate Analgesia/Anesthesia (regional anes or GA mayb needed for 1st few debridements)
Scrub wound x 2 times daily with 'Povidine-Iodine solution'
Debride necrotic tissue (if seen pink granulation tissue → แปลว่าแผลดี)
Closure when Afebrile c Pink, healthy granulation tissue
± 4. Bowel preparation for 4th degree repairs
:evergreen_tree:
Mx
Wound: Stitch off → Explore wound → Debride wound → wait until Properly cleaned + Infection free → Episiotomy resuturing
IV ATBs
Wound care: Hot sitz bath
Note that most wounds healed by granulation
Psychiatric disorders in PP
Normal emotional changes in preg
Anxiety
about Physical health, Fetal development, Delivery
:arrow_up: emotional lability
Alternation of sexual interest
Fear for ability to cope with the baby
Risk factors for post-natal psychiatric disorders :grapes:
Postpartum Blues
#
Onset
50-80% found
within 1 wk PP
Mild & self-limited condition → usu resolve
within 1-2 wk
Associated with Progesterone withdrawal
:leaves:
S&S
Depressed mood
Tearfulness
Insomnia
Fatigue
Irritability
Poor concentration
:deciduous_tree:
Mx
Reassurance that
it's PP blue and NOT psychiatric ds
Support fr Profressionals, Fam, Friends
Prevention: Educate abt baby care before delivery
Severe blues
→ progresses into
PP depression
Postpartum Depression
Incidence: 3% of preg
Onset
within 3 - 6 mo after delivery
peak of occurrence @ 6 wks
Predisposing factors
Previous psychiatric disorder
Depression during preg
Poor social support
Lack of confiding relationship
Recent adverse life events
Severe PP blues
:leaves:
S&S
Quite same as PP blues
Obsessional worries/fears
may cause harm to her bb tho Infanticidal & self-harm ideas are not common
Prolonged symptoms → may affect Mom&Child relationship
:deciduous_tree:
Mx
Reassurance & Psychological support
Multidisciplinary approach by Psychiatrist
Hospitalization (in some cases)
Medical Rx: Antidepressants, Anxiolytic drugs
Antipsychiatric durgs → Bottle feeding is considered
Electroconvulsive in Severe cases
Postpartum psychosis
Incidence: 0.2% of preg
Onset:
within 1st month of PP
Predisposing factors
Previous puerperal psychosis
Personal Hx or Fam Hx of psychosis
:leaves:
S&S
Delusion, Hallucination
Marked behavior disturbance
Loss of insight
Rapid fluctuation of mood
Idea of self harm
(Tho infanticidal area is rare)
:deciduous_tree:
Mx
Rx like
PP depression