Normal & patological puerperium

Marek Bilar

Duration

• From the end third period of labor - deliver of the whole afterbirth, to return all biological action of the ovaries.

• usually 6 - 8 weeks.

Processes occur in puerperium

• Come back systemic and local changes form in time pregnancy and labor - involution.

• Healing puerperal wounds.• Starting and continuation

lactation.• Return of the biological function

of ovaries.

Range of involution

• Genital ways, uterus.• Bottom of pelvis, abdominal walls,

pelvic girdle, urinary bladder, rectum.

• Change in systems :- circulation,- respiratory,- alimentary,- endocrine,- excretory (urinary).

Involution of uterus

Reasons:• Loss of hormonal stimulation after

deliver of placenta,• Lower of flow of blood from

reason :tonic contractions ( to 5. days after

labor -steels intensive tension)puerperal cramps ( to 3. day ) reflexive cramps – lactational

during feedings with brest

Puerperal wounds

•Damage of soft tissues of genital ways – uterine cervix, vagina, perineum, wound after episiotomy and perineal rupture.

•Wound abdominal walls after cesarean section .

•Wound of the uterus cavity - place separation of the placenta (in the zona spongiosa) - diameter about 20 cm .

Puerperal wounds

Stages of healing wound in uterus : I - cleaning wound by inflowing granulocytes, macrophages, lymphocytes ( this cells create protective barrier)II - epithelialization - inflow of epithelium from bottom of glands endometrium (the bottom the endometrial glands are the sources of the new endometrium)

Lactation – stages• Mammogenesis – create chest's glands to functionally

efficient organ (under working of estrogens and progesterone onto elements of gland)

• Laktogenesis - preparation to emanation of milk during of pregnancy ( preparation of secernent epithelium).

• Galaktogenesis - begin of production of milk - (sudden decrease level of estrogens and progesterone ).

• Galaktopoesis – continual production of the milk during puerperium by hormonal and neurogenic factors (reflex of sucking – grow secretion prolactin and oxytocin).

• Galaktokinesis - secretion milk out of the gland (OXY)

Return biological function ovaries

After deliver placenta (level of estrogens and progesterone falls down) comes secretion gonadotropins by pituitary back. It activate all feedback loop between hypothalamus, pituitary and ovaries.

Return of the period• Return of menstruation cycles :not breast-feeding - first menstruation of

5 -6 weeks after laborbreast-feeding :

- Lactational amenorrhea,- Appearing single episode of bleeding in 6-8 week of puerperium,- Appearing regularly menstruation cycles after 6-8 week's pause from labor,

(first cycles are non-ovulatory, cause of the bleeding is relative deficit of estrogens)

Puerperal pathology

• Infections• Bleeding• Puerperal inflammation of

chest's gland (nipple)• Thrombus disease• Dispersing pubic symphysis• Psychical disorder

Puerperal contagions

• Definition - all sickness-processes in puerperium running with fever, which point of exit is infection puerperal wounds.

• Infecting microbes - almost always mixed flora :

aerobes : E.Coli, Proteus, Staphylococcus, Kliebsiella, Pseudomonas, Streptococcus,

anaerobes : Peptostreptococcus, Bacterioides, Clostridia,

Factors that predispose to postpartum infections

Maternal:Obesity Low socioeconomic statusAnemia ImmunosupressionChronic disease – DMVaginal infection – bacterial vaginosis

Factors that predispose to postpartum infections

Associatet with delivery: Rupter of fetal membranes Intra-amniotic infection Prolonged labor Multiple vaginal examionation durin labor Internal electronic fetal monitoring – fetal scalp

electrode Cesarean section – if prolonged operating time Manual removal of the placenta Retained placental fragments

Endometritis puerperalis = metritis

•Most common puerperal infection of the uterin cavity and adjacent tissue

•Symptoms:- subfebrile states,- stinking puerperal excrements (fetid lochia), often stop of excrements (lochiometra)

- in 2 - 7 days postpartum,- late involution of uterus, compression painfulness,- small bleeding,•Treatment : - spasmolytic medicines – widen cervical canal (Drotaverine),

- medicines that enlarge contractility of uterus (Methergin),

- antibiotic

Endometritis puerperalis - extend

• Endometrial infection extend well beyond into myometrium = myometritis

↓parametritis (take up

perimetrim)

↓pelvic abscess / pelvic peritonitis

Septicemia puerperal

• Develop , when in relationship with labor or abortion in women’s body form focus septicemia. From this focus constantly or with pauses liberate pathogenic bacteria, and in image of disease dominate clinical effects this process ,and not symptoms of local infection.

• In course of septicemia we find :- gates of infection,- primitive focus septicemia,- secondary focuses of septicemia

Septicemia puerperal (I)

• Gate of infection - often place after separating placenta.

• Primitive focus - vascular primitive focus ( infected thromboses in vessels running

through damage place)• Secondary focuses septicemia in : - lungs, kidneys, spleen, liver,

articulations, muscles, osseous medulla, eyes, skin, brain, heart valves (endocarditis )

Septicemia puerperal (II) High fever over 39 degrees Celsius Shiver – in moment dissemination

bacterium to blood Accelerated breath – tachypnoe Accelerated pulse - 130-160 hits per min. Motor agitation Pallor, cyanosis Disorder consciousness Morphology : leukocytosis 20-30 x 109 /l

or leukopenia, anaemia Hb-9g%, trombocytopenia,

Septicemia puerperal - management and

treatment• Intensive medical care - control

pressures of blood, pulses, diuresis, saturation.

• Quickly initiating treatment with antibiotic – at first wide spectrum, later guided drugs against definite kind of bacterium,

• Transfusion of electrolyte liquids, plasmas and blood

Puerperal bleeding• This is blood loss excess 500 ml from genital

ways after vaginal delivery and blood loss excess 1000 ml after c. section.

• Early - step out in first 2 hours after labor and they are connected with course of delivery:- uterus atony and hypotony, rupture of uterus,- puerperal wounds of genital ways- separating placenta,

• Late - from 2 hour to 6 week after delivery :- placenta retained- puerperal endometritis

Etiology of postpartum hemorrhage (PPH)

1. Uterine atony 2. Retained placenta tissue3. Genital tract trauma4. Coagulation disorders 5. Uterine inversion

Factors predisposing to uterine atony

• Precipitous labor• General anasteshia• Prolonged labor• Uterine

leiomyomas• Macrosomia• Polihydramnions• Twins• Amnioitis (sepsis)

• Multiparity• Oxytocin use in labor• History of

postpartum hemorrhage

• Amniotic fluid embolus

• Magnesium sulfate in laboring patient

• Mismanagement of 3rd stage of labor

Retained placenta tissue

• Simple adhesion• Morbid adhesion: Accreta,Increta Percreta

• Placenta accreta is defined as an abnormal implantation of the placenta in the uterine wall, of which there are three types:

(1) accreta vera, in which the placenta adheres to the myometrium without invasion into the muscle.

(2) increta, in which it invades into the myometrium. (3) percreta, in which it invades the full thickness of the uterine wall and possibly other pelvic structures, most frequently the bladder.

Retained placenta tissue(simply adherens)

• Cause - muscular fibres can’t compress spiral vessels because compress fragments of placenta

• Retained placental fragments are a leading cause of early and delayed postpartum hemorrhage.

• Symptoms: it appears under end 1. week of puerperium,

• it is abundant and sudden,• medicines that enhance uterus contractibility are

ineffective• Treatment:- curettage cvavity of the uterus - Antibiotic If placenta accreta – Observation, Cytotoxic

drugs – Methotrexate, Hysterectomy

Trauma

• Large episiotomy and extensions• Lacerations of perineum, vagina or

cervix• Haematoma• Uterine rupture • C.section

Coagulation disorders

• Abruptio placentae• Sepsis - PROM• Massive blood loss• Massive blood transfusion• Severe PET/ Eclampsia• Amniotic fluid embolism

Uterine inversion

• Is the „turing inside out” in the uterus in the 3rd stage of labor

• Mostly iatrogenic due to mismanagement of 3rd stage - strong traction on the cord with a relaxed uterus before compleate placenta separation.

Symptoms and signsBlood loss (% B Vol)

Systolic BP( mm of Hg)

Signs and symptoms

10 -15 Normal postural hypotension

15 - 30 slight fall thirst, weakness

30- 40 60-80 pallor,oliguria, confusion

40 + 40-60 anuria, air hunger, coma, death

Prevention

• Correction of anaemia• Identification of high risk cases• Delivery in hospital with facility for

Emergency Obstetric Care. • Active management of 3rd stage of labor• 4th stage of labour - Observation,

Oxytocin

Active management of 3rd stage of labour (WHO-

1989)• Oxytocics - Routine use in third stage blood

loss by 30 - 40% – 5 units Oxytocin iv bolus– Syntometrine 1 Amp iv– Ergometrine 1 Amp IV (0,2-0,5 mg iv)– Carboprost ( better than Ergometrine) 0.125 –

0.25 mg im

• Early cord clamping• Controlled cord traction• Inspection of placenta and lower genital

tract

• TEAM - Obstetrician, Anesthesiologist, Haematologist and Blood Bank

• Correction of hypovolaemia• Ascertain origin of bleeding• Ensure uterine contraction• Surgical management

Management of PPH

CORRECTION OF HYPOVOLEMIA

• Large bore iv line (two)• Crystalloids - 3ml / ml of blood

loss• Urine output (desired) –30ml / hr

Management of PPH

ENSURE UTERINE CONTRACTION

• Palpate fundus• Uterine massage• Bimanual compression • Compression of aorta against

sacral promontory

Management of PPH

• Oxytocin: – Bolus of 10 units iv followed by continuous

infusion 100 mu / min

• Ergometrine 0.2 - 0.5mg iv• Prostaglandins-

– Carboprost- 0.25mg start, rpt.15-30 min, Maximum 2.0 mg, route-IM / intramyometrial

Management of PPH

SURGICAL TREATMENTDepends on

• Extent and cause of haemorrhage

• General condition of patient

• Future reproduction

• Experience and skill

Management of PPH

SURGICAL TREATMENT

• Repair of trauma if any• Uterine arteries ligation• Utero-ovarian arteries ligation• Internal iliac arteries ligation• Hysterectomy• Angiographic embolisation

Management of PPH

ACUTE INVERSION OF UTERUS• Manual

replacement

• Surgical method (Usually delayed procedure)

Management of PPH

Puerperal inflammation nipple

• 90 % - cause by Staphylococcus aureus from nasopharyngeal cavity of newborn.

• has two forms – interstitial and parenchymatous (intracanalicular)

• It concerns breast-feeding mothers • Factors - maceration and rupture nipples and milk

stagnation.• Symptoms: pain, redden, swelling, fever.• Treatment : limitation of lactation, antibiotic,

emptying of chests' glands, surgical treatment.• Prophylaxis : protection the nipples from damage,

exclusion to milk stagnation, hygiene in puerperium,

Puerperal thrombus disease

Factors of risk :• pregnancy and puerperium (change in range of

hemostatic factors)* maternity hydremia during pregnancy and

condensation in puerperium,* Height concentration of fibrynogen and blood

platelet (PLT) * height activities coagulation factors (VII,VIII,X, von

Willebranda)* limited physical activity, reduced venous return

from pelvis,• puerperal contagion• varixes of bottom limbs and smaller pelvis,• diabetes , gestosis EPH, • C.section and operativ delivery (forceps)

Puerperal thrombus disease (I)

Thrombus inflammation superficial veins of bottom limbs

Symptoms:

•pain and hardening in course of varix, •redden and height temperature skin above changed vessel, swelling limb, •height temperature body •acceleration pulse.

Puerperal thrombus disease (II)

• Thrombus inflammation deep veins of bottom limbs - symptoms:

• Swelling of limb (difference of circumferences limbs over-2-5 cm), compression painfulness (Homans’s symptom), extension of superficial veins, height temperature skins, redden of limb , fever, acceleration pulse.

• Thrombus inflammation veins of small pelvis - symptoms

* Poorly or asymptomatic, fever of septic type and painfulness in time gynecological examination

Thrombus inflammation veins in puerperium – management and

treatment• High elevation of limb - facilitates outflow

blood and swelling diminishes.• Compression stockings or bandaging

limbs.• Analgesic medicines and antiphlogistic.• Antibiotic.• Anticoagulant –Low Molecular Weight

Heparin (LMWH) :* 500 u.i. / kg mass of body / day what 4 - 6

hours* continuous infusion- first dose 5000 u.i.

later 1200 - 1600 u.i. / hour* Prophylaxis - 5000 u.i what of 12 hours

Dispersing joint pubic

• Cause : loosen joint pubic by estrogens during pregnancy

• Symptoms :* Painfulness in region pubic joining, intensifying in time

of walking ( "Duck walk”) and lying on side of body* Radiation pain to thighs and buttocks,• Treatment :* Medicine analgesic* Limitation of activity motive* Pelvic belt * Orthopedic treatment (suturing joint)

Psychical disorder

• postpartum blues - most frequent - about 50 % women after delivery

• cause - sudden hormonal change• symptoms – sleeplessness,

irritability, mood swings• starts in 2. day and finishes in 2

week after delivery• It does’t demand treatment

Drugs and pregnancy

Effect of pregnancy on drug pharmakokinesis

• All the pharmacokinetic variables are affected by the physiologic changes that occur during pregnancy. These variables incloude :

AbsorptionDistributionBiotransformationExcretion

Absorption• In pregnancy: stomach emptying time is longerDecreased gastrointenstinal

motylity (due to influence of high levels of progesterone)

Chenges of pH in stomach – due vomit or brash (pyrosis)

Distribution• During pregnancy there is a large increase in total

body water – plasma volume increase by 50%, while the concentration of plasma albumin falls (20%).

• Decrease of plasma protein results in an increase of unbound drug fractions to cause pharmacologic effects.

• Increase distribution volume (placenta, fetus) results in a reduction in the peak plasma drug concentration after a dose.

• Elimination is increased during pregnancy therefore thera isn’t an increase in tissue concentration.

• The results during pregnancy are lower total drug concentrations in the pregnant woman’s plasma

Biotransformation

• 2/3 drugs are metabolited in the liver• During pregnancy decrease

metabolism activity in the liver pregnant woman

• Increase of levels of estrogens make difficult conect with sulphuric and glucuronic acid

Excretion• The flow of blood through the liver isn’t

changed during pregnancy; therefore, drugs that are dependent only on liver blood flow to be cleared from the body are cleared at the same rate as in the nonpregnant women unless the volume of distribution is higher

• The renal plasma blood flow during pregnancy is alamost twice that of the prepregnant state, and there is a substantial increase in the glomerular filtration rate and creatinine clearence. Drugs that are excreated unchanged are cleared in proportion to the creatinine cleareance

Placental transfer of drugs

• Placental barrier – is only „theoreticall” barrier because more drugs pass through this barrier easily

• The placental unit contribution to drug metabolism is very small

• Drug concentration in fetal get from 50 to100% concentration in woman’s plasma

Placental transfer of drugs

• The significant variables that determin the transfer of drugs across the placenta are;

Physicochemical characteristics of the compound

Physiologic properties of the placental tissue

Maternal and fetal placental blood flow

Placental transfer of drugs

• Physicochemical characteristics (f.e.:molecular weight, configuration, degree of ionization, lipid solubility)

• If the molecular weight :is less than 600 unit – it crosses the

placenta with ease (warfarin sodium)between 600 – 1000 crosses more

slowlygreater than 1000 – meet

impermeable barrier

Effects of drugs on fetusDuring the first trimester of fetal development, drugs may produce major effects. The degree of teratogenicity is diefferent at various times during gestation:

Preimplantation period = resistand period – the effects range from damage that can be repaired by the developing embryo to demise resulting in abortion – „all or none” phenomen. This the period of the predifferentiaton when the aggregate of totipotential cells can recover from an injury and continue to multiply.

Organogenesis (embroyonic) period – maximum susceptibility; is the developmental period when the greatest damage can occur with regard to malformations. From day 7th to day 60th of gestation, the fetus is undergoing organ differentiation and, at the time, is most susceptible to the adverse effects of teratogens. The particular malformations is dependent on the time of exposure f.e.: since the neural tube closes between day 22-28 postconception, a teratogen must be active befor or during this period to initiate development of neural tube defect – spina bifida .

Fetal period – lowered susceptibility– drugs don’t produce gross structural abnormalities, but they can affect the growth and functional development of the fetus. A teratogen at thise stage may cause a reduction in cell size and number, wich is manifested by:- growth retardation- reduction of organ size

Classification system for risk factors of drug usage during pregnancy (FDA-

USA) Category Level of know risk

A Not indicated a risk to the fetus

B Animal studies haven’t demonstrated a fetal risk, but there are no controlled studies in pregnent women.

CDrugs should be utilized by a pregnant woman ONLY if the potential benefit outweighs the risk to the fetus as indicated by studies with animals

DIdentifies a drug for wich there is documented evidence of human fetal risk. These drugs may be used in life-threating situations

X Harmful. Drugs should not be used by women any time there is the possibility of pregnancy

Category Drugs (e.g)

A vitamins

B penicillins, digoxin, epinephrine.

C purosemid, verapamil, β-blokers

D phenytoin

X isotretinoin

Breastfeeding

• Advantages of Breastfeeding for the Baby: • Provides nutrients, hormones, and proteins that are

essential for growth, brain development and digestion. • Reduces the risk of infections of the middle ear,

digestive system and respiratory tract by providing natural antibodies (proteins that fight infection).

• Reduces the risk of food allergies. • Babies experience fewer digestive problems than with

formula; breast milk includes enzymes to aid digestion and absorption of nutrients.

• Babies are less likely to experience anemia (lower than normal red blood cell levels).

Breastfeeding

Advantages of Breastfeeding for the Mother: • Helps the uterus return to its normal size more

quickly after delivery. • Helps the mother lose weight after delivery more

quickly, because the body burns more calories when you are lactating.

• May help reduce risk of breast cancer, if you nurse for at least three months.

• Can be more convenient; when you are with your baby, breast milk is always available.

When You Should Bottle-feed with Formula:

• If you are infected with HIV • If you are infected with hepatitis B • If you have tuberculosis and have not yet been treated for the

disease • If you are receiving certain cancer treatments • If you smoke, drink heavily or use drugs (breast milk can pass

nicotine, alcohol and other drugs to your baby) • If you are taking medications, check with your physician about

the best timing for breastfeeding. Since many medications are passed in breast milk, it might be better to take some medications after a breastfeeding session.

• You should tell your doctor about any of the above situations as soon as you know you are pregnant. If you think you are at risk of being infected with HIV, hepatitis B, or tuberculosis, your doctor can test for these diseases and let you know if it is safe to breastfeed.