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What are physiological changes in Puerperium?
- Urinary tract - Bladder wall becomes edematous and hyperemic and often shows evidence of submucous extravasation of blood.
- Stagnation of urine along with a devitalized bladder wall contribute to UTI in puerperium.
GIT - slight intestinal paresis leads to constipation.
Blood values - Decrease in blood volume; RBC and hematocrit values returns to normal by the end of first week, Platelet count decreases
soon after the separation of the placenta, Fibrinogen level remains high upto the second week of puerperium.
Involution of uterus is stimulated by vasospasm.
How do you clinically assess the involution of uterus?
In a woman in the 10th postpartum day, the uterus is felt just above symphysis pubis
- Following delivery, the fundus lies about 13.5 cm above the symphysis pubis.
- During first 24 hours, the level remains constant.
- Thereafter, there is a steady decrease in height by 1.25 cm in a day so that by the end of second week the uterus becomes pelvic organ.
- The rate of involution thereafter slows down until 6 weeks, the uterus becomes almost normal in size.
. [IOM 05]
How long does it take for the uterus to involute completely? [AI 95, IOM 11]
What is Lochia?
- Lochia is the discharge from the uterus of blood, mucus, and tissue during the puerperal period. [AI 97]
- Lochia rubra - for first 6 days, blood tinged
- Lochia serosa - next 3-4 days, brown
- Lochia alba - after loachia serosa, white
What is early and late postpartum hemorrhage?
- Early - blood loss of >500ml during first 24 hours after delivery.
- Late - blood loss after 24 hours has passed.
What is the most common cause of Postpartum hemorrhage?
- 4Ts:1. Tone - Uterine atony (50%) - most common cause [UP 98,IOM 09]
- 2. Trauma - Genital lacerations (20%)
- 3. Tissue - Retained placenta (10%)
- 4. Thrombin - DIC
- Other rare causes - Uterine inversion
What are the causes of Uterine atony? [AI 06]
- 1. Overworked uterus – Rapid labor, Prolonged labor,
- 2. Infected uterus – Chorioamnionitis
- 3. Relaxed uterus - MgSO4, Beta-adrenergic agonists (Ritodrine, Terbutaline), Halothane
- 4. Overdistended uterus – Multiple pregnancy, Polyhydraminos, Macrosomia
What is the most common clinical finding of Uterine atony?
Doughy soft uterus above the umbilicus
What is the management of Uterine atony?
- Bimanual uterine massage should be done before any medications are used.
Uterotonics – Oxytocin, Methergine, PGF2α
Which of the following drugs is not useful in the management of PPH? [AI 08]
Mifeprostone is an anti-progesterone, used in early pregnancy to induce abortion.
(this multiple choice question has been scrambled)
What is B-Lynch suture?
- Is done if the uterus doesnot contract after C/S
- - It helps to preserve the uterus sometimes if otherwise needs to be removed.
What are the risk factors for Retained placenta?
- - Accessory lobe (common),
- - Placenta accreta
What is most common cause of retained placenta? [IOM 2059]
What is the clinical finding of DIC leading to PPH?
- - Generalized oozing of blood
- – Bleeding even from sites of suture needle prick
- - Petechiae
- – Contracted uterus
In PPH, you cannot palpate the uterus, what is your diagnosis?
- Inverted uterus – normally it should be palpable upto the umbilicus.
- BEEFY BLEEDING MASS IS seen – the beefy color is of the endometrium seen that is inverted.
What is the management of Inverted Uterus?
- Management is to elevate the uterus and replace the uterus in its anatomic position and give IV oxytocins to contract.
- It should be done before cervix closes because after cervix closes, it is almost impossible to replace the uterus back.
What is Sheehan's syndrome?
Sheehan syndrome is hypopituitarism caused by ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth.
- Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply.
- Secondly, the anterior pituitary is supplied by a low pressure portal venous system.
- These vulnerabilities, when affected by major hemorrhage or hypotension during the peripartum period, can result in ischaemia of the affected pituitary regions leading to necrosis.
- The posterior pituitary is usually not affected due to its direct arterial supply.
What is the first symptom of Sheehan syndrome?
Failure of lactation due to lack of prolactin hormone
What is the management of Sheehan's syndrome?
- Maintainence regimen of:
- - Thyroxin,
- - Adrenal cortical hormones [AI 95]
- - and possibly gonadotropin
What is the management of Unexplained bleeding?
- Ligation of uterine arteries or
- TAH(Total Abdominal Hysterectomy)
What are the causes of Pospartum Fever by Postpartum days?
- Day 0 - Wind (Atelectasis)
- Day 1-2 - Water (UTI)
- Day 2—3 - Womb (endometritis)
- Day 4-5 - Wound (Wound infection)
- Day 5-6 - Walk (Septic pelvic thrombophlebitis)
Fever on Post partum day 0, emergency C/S with general anesthesia, rales on lungs on auscultation, Diagnosis?
- - Atelectasis is more common on general anesthesia use.
- - Management is pulmonary exercise.
Fever on PP day 1-2, Multiple labor catheters, costovertebral angle tenderness, Diagnosis?
UTI with pyelonephritis.
- Multiple vaginal examination and multiple catheterization due to prolonged labor is the cause of UTI.
- Management is with IV antibiotics.
What is your diagnosis in PP fever and exquisite tender uterus?
Post partum day - 5-6, triple antibiotics patient not responding, Diagnosis? Management?
- – There is picket fence type of fever.
- - Managemennt is IV heparin - for 7-10 days
What is infectious mastitis?
- Infectious mastitis develops on day 7-21 because of Lactational Nipple trauma.
- Most common organism for infection is Staphylococcus aureus. [UP 97]
- The immediate source of organism that cause mastitis is almost always the infants nose and throat.
- Fissures, abrasions or cracks predispose to infections.
What is the management of Infectious mastitis? [AI 08]
- The drug of choice for mastitis is Flucloxacillin.
- If patient is allergic, use erythromycin.
- Breast feeding should be continued even with infected breasts.
- Breast should be incised and drained if the infection does not resolve within 48 hours. [UP 94]
Fever on Post partum 14, unilateral breast swollen, red, tender. Diagnosis?
Fever on postpartum day 3, Bilateral breast findings, entire breast swollen, red and tender, Diagnosis?
- Congestive mastitis or Breast engorgement.
- Some breast engorgement is found in almost every women.
- Encourage emptying the breast either by feeding or by breast pump.
Which hormone is responsible for milk ejection reflex or Let down reflex? [UP 97, IOM 08]
Is is easier for the baby to suck the milk from the breast or from the bottle?
- It is much easier to suck the milk from the bottle – so once it finds that it is easier from the bottle, the baby forgets the breast.
- So, you should exclusively breast feed and not bottle feed at least for 6 weeks.
What is the most common cause of Post partum fever?