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Continued…….
Abnormal
puerperium
Dilip Kumar H.R.
VIII Term
• Puerperal venous thrombosis
• Pulmonary embolism
• Obstetric palsies
• Psychiatric disorder during puerperium
• Psychological response to perinatal death.
2
Puerperal
Thrombosis
Puerperal Thrombosis
Leg vein & pelvic vein is one of the
complication in western countries.
 However the prevalence is low in Asians
& Africans.
Etiopathogenesis
In normal pregnancy there is rise in
concentration of coagulation factors 1, 2,
7, 8, 9, 10, 12. plasma fibrinolytic inhibitors
produced by placenta.
Alteration in blood constituents- increased
number of platelet & their adhesiveness.
Venous stasis is increased due to
compression of gravid uterus to IVC & iliac
veins. This stasis cause damage to
endothelial cells.
Thrombophilias are the genetic condition
associated with deficiencies of
antithrombin3 protein C .
Acquired thrombophilias are due to
presence lups anticoagulant &
antiphospholipids antibodies.
Risk factors:
Advanced age & parity
Operative delivery
Obesity
Anemia & heart disease.
Trauma to venous vessel wall.
Infections
DVT.
C/F: Asymptomatic,pain in calf muscle,
edema of leg, rise skin temperature.
Homan’s sign.
Investigations:
Doppler ultrasound.
Duplex Doppler ultrasound.
Venography.
Pelvic Thrombophlibits.
 C/F:usually develop after 2nd
weeks of
puerperium.
 Fever with chills & rigors.
Feature of toxemia i.e. headache, malaise
& rising pulse.
Affected leg is painful, swollen & cold.
Polymorph nuclear leucocytosis.
Prophylaxis for VTEPreventive measures.
 low & high risk woman.
Management
 bed rest & foot is raised.
 Analgesics, Abs
 Anticoagulants
 Gentle movements of the leg after relief of
pain.
 Vena caval fillers
 Fibrinolytic agents
 Venous thrombectomy.
Pulmonary
Embolism.
..............
10
Pulmonary Embolism.
It is leading cause of maternal death.
Because of decline of maternal mortality
due to hemorrhage, hypertension &
sepsis.
Death occurs with in short time from shock
& vagal inhibition.
Clinical feature
Sudden collapse, acute chest pain & air
hunger these are classical symptoms of
massive pulmonary embolism.
Tachyponea,dysponea,pleuritic chest
pain, cough , tachycardia, haemoptysis &
rise in temperature > 37 degree Celsius
11
Diagnosis
X-ray of the chest shows decreased
vascular marking in area of infraction,
elevation of dome of diaphragm & often
pleural effusion.
It is useful to rule out
pnemonia,atelactasis.
ECG:tachycardia.
 Doppler ultrasound : ? DVT.
12
Lung scan : ? Area of diminished blood
flow.Diminised in perfusion with
maintenance ventilation indicate PE.
MRI: risk of radiation is absent.
Pulmonary angiography: most accurate
method of diagnosis.
13
Treatment
Resuscitation
I.V.fluid support
Thrombolytic therapy
Digitalis
Recurrent attack require embolectomy.
14
………………..
Obstetric palsies
1
Obstetric palsies
• The commonest form of palsy
encountered in puerperium is FOOT
DROP.
• It is usually unilateral & appears shortly
after the delivery.
Etiology
• Streching of the lumbo-sacral trunk by
prolapsed inter vertebral disc b/w L5&s1.
• Backward rotation of the sacrum during
labour
• Direct pressure by fetal head or by
forceps blade on lumbosacral cord.
Clinical feature.
1.Asymptomatic.
2.Flacidity & wasting of muscle.
3.Loss sensation.
2
• Management
• Bed rest for 6 wks.
• A splint is applied to prevent damage of
over stretch muscle.
• Massage & electric stimulation of the
muscle.
Psychiatric disorder
during Puerperium
20
 1st 3 month after delivery the incidence of
mental illness is high.
 Overall incidence is 15-20%
Risk factors:
 Past H/O: mental illness, puerperal
psychiatric illness.
 Family H/O: psychiatric illness, marital
conflict.
 Present pregnancy: Caesarean section,
difficult labour, neonatal complication.
 Idiopathic.
Puerperal BLUES
 It is transient state of mental illness observed 4-5
days after delivery & it last for few days.
 50% of the postpartum women suffer from
problem.
 Clinical manifestation:
 Depression, anxiety, tearfulness, insomnia,
helplessness & negative feelings towards infant.
 No specific metabolic or endocrine abnormalities
have been detected. But lowered tryptophan level
is observed.
 It suggest altered neurotransmitter function.
 Treatment reassurance & psychological support
by the family.
Postpartum DEPRESSION
It is seen 10-20% of mothers.
It is more gradual onset, occurs 1st
4-6
months after delivery or abortion.
Changes in HypoThalamopitutaryarenal
axis may the cause.
Manifested by loss appetite, insomnia,
social withdrawal, irritability & even
suicidal tendency.
Risk of recurrence is high (50-100%) in
subsequent pregnancy .
Treatment
Fluoxetin or paroxetine.
General support is essential.
Overall prognosis is good.
SCHIZOPHRENIA
About 1in 500-1000 mothers.
 Seen in woman with past H/O psychosis or with
positive family H/o.
 Relatively sudden in onset with in 4 days after
delivery.
 Manifestation:
 Fear, restless, confusion followed by
hallucination, delusion and disorientation.
 Suicidal, infanticidal impulse may be present.
 Risk of recurrence in subsequent pregnancy is
20-20%.
Treatment
Psychiatrist consulted urgently.
Admission needed.
Chlorpromazine 150mg stat & 50-150mg
thrice daily.
ECT: needed if unresponsive case.
Lithium is indicated in manic depressive
psychosis & breast feeding
contraindicated.
Psychological response
to perinatal death.
Psychological response to
perinatal death.
Most perinatal events are joyful.
But when perinatal death occurs special
attention must given to grieving patient &
her family.
Perinatal grieving may also be due to
unexpected hysterectomy, birth
malformed, critically ill infant.
Obstetrician, nurse & attending staff must
understand the patient reaction.
Management.
Facilitating the grieving process, support &
sympathy.
Supporting the couple in holding or taking
photograph of the infant .
Requesting for autopsy .
Follow up visits & plan for subsequent
pregnancy.
Abnormal puerperium

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Abnormal puerperium

  • 2. • Puerperal venous thrombosis • Pulmonary embolism • Obstetric palsies • Psychiatric disorder during puerperium • Psychological response to perinatal death. 2
  • 4. Puerperal Thrombosis Leg vein & pelvic vein is one of the complication in western countries.  However the prevalence is low in Asians & Africans. Etiopathogenesis In normal pregnancy there is rise in concentration of coagulation factors 1, 2, 7, 8, 9, 10, 12. plasma fibrinolytic inhibitors produced by placenta. Alteration in blood constituents- increased number of platelet & their adhesiveness.
  • 5. Venous stasis is increased due to compression of gravid uterus to IVC & iliac veins. This stasis cause damage to endothelial cells. Thrombophilias are the genetic condition associated with deficiencies of antithrombin3 protein C . Acquired thrombophilias are due to presence lups anticoagulant & antiphospholipids antibodies.
  • 6. Risk factors: Advanced age & parity Operative delivery Obesity Anemia & heart disease. Trauma to venous vessel wall. Infections DVT. C/F: Asymptomatic,pain in calf muscle, edema of leg, rise skin temperature. Homan’s sign.
  • 7. Investigations: Doppler ultrasound. Duplex Doppler ultrasound. Venography. Pelvic Thrombophlibits.  C/F:usually develop after 2nd weeks of puerperium.  Fever with chills & rigors. Feature of toxemia i.e. headache, malaise & rising pulse. Affected leg is painful, swollen & cold. Polymorph nuclear leucocytosis.
  • 8. Prophylaxis for VTEPreventive measures.  low & high risk woman. Management  bed rest & foot is raised.  Analgesics, Abs  Anticoagulants  Gentle movements of the leg after relief of pain.  Vena caval fillers  Fibrinolytic agents  Venous thrombectomy.
  • 10. 10 Pulmonary Embolism. It is leading cause of maternal death. Because of decline of maternal mortality due to hemorrhage, hypertension & sepsis. Death occurs with in short time from shock & vagal inhibition.
  • 11. Clinical feature Sudden collapse, acute chest pain & air hunger these are classical symptoms of massive pulmonary embolism. Tachyponea,dysponea,pleuritic chest pain, cough , tachycardia, haemoptysis & rise in temperature > 37 degree Celsius 11
  • 12. Diagnosis X-ray of the chest shows decreased vascular marking in area of infraction, elevation of dome of diaphragm & often pleural effusion. It is useful to rule out pnemonia,atelactasis. ECG:tachycardia.  Doppler ultrasound : ? DVT. 12
  • 13. Lung scan : ? Area of diminished blood flow.Diminised in perfusion with maintenance ventilation indicate PE. MRI: risk of radiation is absent. Pulmonary angiography: most accurate method of diagnosis. 13
  • 16. 1 Obstetric palsies • The commonest form of palsy encountered in puerperium is FOOT DROP. • It is usually unilateral & appears shortly after the delivery. Etiology • Streching of the lumbo-sacral trunk by prolapsed inter vertebral disc b/w L5&s1.
  • 17. • Backward rotation of the sacrum during labour • Direct pressure by fetal head or by forceps blade on lumbosacral cord. Clinical feature. 1.Asymptomatic. 2.Flacidity & wasting of muscle. 3.Loss sensation. 2
  • 18. • Management • Bed rest for 6 wks. • A splint is applied to prevent damage of over stretch muscle. • Massage & electric stimulation of the muscle.
  • 20. 20  1st 3 month after delivery the incidence of mental illness is high.  Overall incidence is 15-20% Risk factors:  Past H/O: mental illness, puerperal psychiatric illness.  Family H/O: psychiatric illness, marital conflict.  Present pregnancy: Caesarean section, difficult labour, neonatal complication.  Idiopathic.
  • 21. Puerperal BLUES  It is transient state of mental illness observed 4-5 days after delivery & it last for few days.  50% of the postpartum women suffer from problem.  Clinical manifestation:  Depression, anxiety, tearfulness, insomnia, helplessness & negative feelings towards infant.  No specific metabolic or endocrine abnormalities have been detected. But lowered tryptophan level is observed.  It suggest altered neurotransmitter function.  Treatment reassurance & psychological support by the family.
  • 22. Postpartum DEPRESSION It is seen 10-20% of mothers. It is more gradual onset, occurs 1st 4-6 months after delivery or abortion. Changes in HypoThalamopitutaryarenal axis may the cause. Manifested by loss appetite, insomnia, social withdrawal, irritability & even suicidal tendency. Risk of recurrence is high (50-100%) in subsequent pregnancy .
  • 23. Treatment Fluoxetin or paroxetine. General support is essential. Overall prognosis is good.
  • 24. SCHIZOPHRENIA About 1in 500-1000 mothers.  Seen in woman with past H/O psychosis or with positive family H/o.  Relatively sudden in onset with in 4 days after delivery.  Manifestation:  Fear, restless, confusion followed by hallucination, delusion and disorientation.  Suicidal, infanticidal impulse may be present.  Risk of recurrence in subsequent pregnancy is 20-20%.
  • 25. Treatment Psychiatrist consulted urgently. Admission needed. Chlorpromazine 150mg stat & 50-150mg thrice daily. ECT: needed if unresponsive case. Lithium is indicated in manic depressive psychosis & breast feeding contraindicated.
  • 27. Psychological response to perinatal death. Most perinatal events are joyful. But when perinatal death occurs special attention must given to grieving patient & her family. Perinatal grieving may also be due to unexpected hysterectomy, birth malformed, critically ill infant. Obstetrician, nurse & attending staff must understand the patient reaction.
  • 28. Management. Facilitating the grieving process, support & sympathy. Supporting the couple in holding or taking photograph of the infant . Requesting for autopsy . Follow up visits & plan for subsequent pregnancy.