OBS T.09 - Puerperal Complications PDF December 2021

O B S T E T R I C S II TOPIC 9. PUERPERAL COMPLICATIONS Dr. Marjorie Farinas December 18, 2021 1st Semester (Finals...

O B S T E T R I C S II TOPIC 9. PUERPERAL COMPLICATIONS Dr. Marjorie Farinas December 18, 2021 1st Semester (Finals) LEGEND LEGEND a. Puerperal Fever Black:PPT Blue:BOOK Red:AUDIO Violet:TAKE-NOTE! A temperature of 38.0C (100.4F) or higher in the puerperium TOPIC OUTLINE Cardinal manifestation of puerperal infection Infective and noninfective factors I. PUERPERAL COMPLICATIONS Most persistent fevers after childbirth are caused by genital A. PUERPERAL PELVIC INFECTION tract infection B. BREAST INFECTION Spiking fevers of 39C or higher that develop within the first C. ACUTE PYELONEPHRITIS 24 hours postpartum may be associated with virulent pelvic D. ATELECTASIS infection caused by Group A streptococcus E. DRUG FEVER Only 20% of women have fever after vaginal delivery in II. OTHER DISORDERS OF THE PUERPERIUM contrast to 70% post CS will have pelvic infections A. UTERINE SUBINVOLUTION That is why it is said that postpartum endometritis is more B. RETAINED PRODUCTS OF CONCEPTION common in post CS. C. VULVOVAGINAL LACERATIONS Other causes of puerperal fever include breast engorgement; D. PUERPERAL HEMATOMA infections of the urinary tract, of perineal lacerations, and of episiotomy or abdominal incisions; and respiratory E. POSTPARTUM HEMORRHAGE complications after cesarean delivery (Maharaj, 2007) F. POSTPARTUM URINARY RETENTION The 6 W’s for the causes of postpartum fever are the following: G. POSTPARTUM DEPRESSION 1. Wind: stands for your pneumonia and atelectasis H. OBSTETRICAL NEUROPATHIES 2. Water: for urinary tract infection I. MUSCULOSKELETAL INJURIES 3. Woobies: for breast infections such as mastitis or abscess III. REFERENCES AND CITATIONS A 4. Womb: for the uterine infections 5. Wound: for cellulitis and vulvar incisions, episiotomy I. PUERPERAL COMPLICATIONS infections and 6. Walking: for DVT PUERPERIUM And also, not here in the slide is another W which stands for o Puer – child, parus – bringing forth Wander drugs, drugs that can cause fever o Also known as the “Postpartum/ Fourth Trimester” o Time following delivery of the infant when the maternal and physiological changes related to pregnancy will return to nonpregnant state o Maternal anatomical and physiological changes return to non-pregnant state 4-6 weeks. However, not all organ systems do not return to baseline within these 4-6 weeks period o The end is less defined but usually 6-8 weeks after delivery. And for this reason, the American College of Obstetricians and Gynecologists consider postpartum care up to 12 weeks after delivery. Postpartum care should be needed to be emphasize and the physiologic care and medical issues may arise during this period. A. PUERPERAL PELVIC INFECTION Describes any bacterial infection of the genital tract after delivery One of the causes in the triad of maternal deaths – Figure 2. POSTPARTUM FEVER (PUERPERAL) preeclampsia and hemorrhage before and during the 20th century b. Postpartum Uterine Infection Effective antimicrobials have decreased the mortality from Other terms for postpartum infection are: infections o Puerperal sepsis 40% of infection – maternal deaths were preventable o Endometritis (most commonly used term to describe postpartum uterine infection) o Endomyometritis o Endoparametritis o Metritis with pelvic cellulitis (preferred term) because the infection involves not only the decidua but also the myometrium and parametrial tissues. Risk Factors ▪ Route of Delivery ▪ Duration of Labor ▪ Duration of Rupture of Membranes ▪ Number of Vaginal Examination ▪ Socioeconomic Factors ▪ Other factors Figure 1. LETHAL TRIAD OF MATERNAL DEATH 1 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications 1. Route of Delivery Pathogenesis o Single most significant risk factor for the development of uterine infection o Vaginal vs. Cesarean Delivery ▪ Relatively infrequent for vaginal delivery ▪ Postpartum uterine infection is more common in CS and rehospitalization rate is higher. 25-fold increased infection related mortality rate with cesarean versus vaginal delivery. ▪ Because of the significant morbidity following CS, a single- dose perioperative antimicrobial prophylaxis is recommended for all women undergoing cesarean delivery. o Important risk factors for infection following surgery: ▪ Prolonged labor ▪ Membrane rupture ▪ Multiple cervical examinations ▪ Internal fetal monitoring 2. Duration of Labor o Uterine cavity is sterile before rupture of amnionic sac o As the consequence of labor and delivery and associated manipulations, the amniotic fluid and the uterus become contaminated with anaerobic and aerobic bacteria. o Length and duration of labor is proportional with risk of uterine infection due to an increased number of examinations → increased contamination of the lower uterine segment Figure 5. PATHOGENESIS 3. Rupture of Membranes ▪ Puerperal infection following vaginal delivery involves the o Amniotic fluid cultures in women with ruptured membranes for placental implantation site, decidua and adjacent more than 6 hours contained pathogenic bacteria myometrium or cervicovaginal lacerations. 4. Vaginal Examinations and Internal Fetal Monitoring ▪ Bacteria that colonize the cervix gain access to the amniotic o Direct increase in postpartum endometritis that paralleled the fluid during labor. As the placenta is detached from its number of vaginal examinations and internal fetal monitoring attachment to the uterus, its site is composed of necrotic material and blood provide an excellent culture medium. 5. Socioeconomic Factors ▪ Postpartum, they invade devitalized uterine tissue. The o More frequent in women of lower socioeconomic status preponderance of devitalized tissue can be the result of o Differences in flora, hygiene, nutrition clamping, lacerations, tissue handling and too many 6. Other Factors unnecessary sutures. o Anemia and poor nutrition ▪ The necrotic material primarily at the placental site plus blood o Cesarean delivery or multifetal gestation provides an excellent culture medium for bacterial growth. o Young maternal age and nulliparity Infection once established may delay uterine involution. These o Prolonged labor induction coupled with microhematoma formation along the line of tissue o Obesity re-approximation creates a favorable anaerobic bacterial o Meconium – stained amniotic fluid condition for infection. o Intrapartum chorioamnionitis ▪ Following a cesarean section, uterine infection ensues o General anesthesia through an infected surgical incision and as the basalis layer of the endometrium is iatrogenically disrupted. Microbiology ▪ Parametrial cellulitis follows the parametrial retroperitoneum ▪ Bacteria native to the perineum, vagina, cervix, and bowels and early treatment, prompt antibiotics are given and results in cause most female genital tract infections the containment of infection within. Otherwise, it will result to ▪ Causative organism is polymicrobial and may depend upon extension of the infection to the parametrial or paravaginal the mode of delivery tissue and other tissues deep within the pelvis. ▪ Other factors that promote virulence are hematoma and devitalized tissues ▪ Group B streptococci, E. Coli, and enterococci are some of the more common blood culture isolates with metritis ▪ Clostridial species rarely cause puerperal infection but of importance due to the severity of infections they cause. ▪ Chlamydial infections have been implicated in late-onset, indolent metritis Figure 6. PATHOGENESIS ▪ In summary: Most pelvic infections are caused by the bacteria indigenous to the genital tract. Bacteria native to the perineum, vagina, cervix, and bowels cause most female genital tract infections. Figure 3 & 4. BACTERIA FOR FEMALE GENITAL INFECTIONS 2 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications Clinical Presentation ▪ Diagnosis of endometritis is based on the following signs and symptoms: ▪ Fever →Most important criterion for the diagnosis →Temperature of 38-39C →Degree of fever is proportional to the extent of infection and sepsis syndrome ▪ Abdominal pain and parametrial tenderness are elicited on abdominal and bimanual examination ▪ Chills (suggest bacteremia or endotoxemia) ▪ Leuokocytosis – 15-30,000/ulL ▪ Foul smelling lochia or for group B strep may be associated with scant odorless lochia. Although many women have foul smelling lochia without evidence of infection or vice versa. Diagnostics ▪ Routine genital tract cultures before treatment may be of Figure 7. ANTIMICROBIAL REGIMENS clinical utility ▪ Here is a list of the antimicrobials for IV treatment of pelvic ▪ Microbiologic tests may prove to be beneficial for septic infection following surgery. Gentamycin can be given as single patients with severe endometritis dose or multiple dosing. ▪ Routine blood culture: ▪ Ampicillin is added due to persistent positive enterococcal → Women with exceedingly high temperature spikes that may cultures either initially or if there is no response by 48-72 signify virulent infection with group A streptococci hours. ▪ Due to potential nephrotoxicity and ototoxicity with gentamicin, Treatment combination of clindamycin and second-generation ▪ Nonsevere metritis (following vaginal delivery) cephalosporin is considered. → Oral or intramuscular antimicrobial agent ▪ Beta lactam antimicrobials penicillins (piperacillin, ▪ Moderate to severe infections ticarcillin), cephalosporins, monobactam and carbapenems → Intravenous therapy with a broad-spectrum antimicrobial are inherently safe except for hypersensitivity and are free of regimen major toxicity. ▪ Choice of Antimicrobials ▪ Metronidazole is given with ampicillin and an aminoglycoside → Directed against elements of mixed flora provides coverage against most organisms encountered in serious pelvic infections and used to treat Clostridium difficile ▪ Vaginal Delivery colitis. → Ampicillin plus gentamicin ▪ Carbapenems offer broad-spectrum coverage against most → 90% of women respond to ampicillin – gentamicin regimen organisms associated with metritis. For infections following while for infections following cesarean delivery, anaerobic vaginal delivery as many as 90 percent of women respond to coverage is needed regimens such as ampicillin and gentamicin. ▪ Cesarean delivery → Anaerobic coverage Prevention ▪ If persistent fever, search for infection ▪ Perioperative prophylaxis ▪ If with intense cellulitis, consider a phlegmon, pelvic abscess, → Antimicrobial prophylaxis is commonly use in obstetrics abdominal incision abscess, infected hematoma and septic although for vaginal delivery and manual removal of the thrombophlebitis placenta, no rigorous studies done yet on the use of ▪ Continue V/S monitoring including temperature antimicrobial prophylaxis. ▪ Improvement in 48 hours to 72 hours in 90 percent of women → At the time of cesarean delivery, antibiotic prophylaxis treated with one of several regimens remarkably reduced the postoperative pelvic and wound ▪ When good clinical response is noted, parenteral treatment infection rates and it is suggested to be given should be continued for 24-48 hours until the patient is preoperatively (at least 15 mins to 1 hour prior to the completely afebrile and asymptomatic but, you must be vigilant procedure) of sepsis → Observed benefit applies to both elective and nonelective ▪ The woman may be discharged home after she has been cesarean delivery and also includes remarkably reduced afebrile for at least 24 hours, and further oral antimicrobial the postoperative pelvic and would infection rates therapy is not needed but traditional practice recommends → Predelivery administration (ACOG) completion of therapy with oral antibiotics for 7-10 days. But → Reduction in abdominal incision rate now, because of the emergence of antibiotic resistance, it is already advocated that we do not give any more oral ▪ Single-dose prophylaxis antibiotics. → Ampicillin 2 grams or first-generation cephalosporin such as cefazolin is ideal (although in our practice, we usually give 2nd gen cephalosporin such as cefuroxime) → Azithromycin is added for further reduced post cesarean metritis rates ▪ Abdominal preoperative skin preparation with chlorhexidine-alcohol is superior to iodine alcohol for preventing surgical site infections 3 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications ▪ The following are surgical technique maneuvers done to ▪ This is a serious complication and requires secondary alter the postpartum infection rate during cesarean delivery: closure of the incision in the operating room → Allowing the placenta to separate spontaneously lowers the TREATMENT infection risk ▪ Antimicrobials → Exteriorizing the uterus may decrease febrile morbidity ▪ Surgical drainage → Closure of subcutaneous tissue in obese women does not ▪ Debridement of devitalized tissue lower the wound infection rate, it does decrease the wound ▪ The fascia is carefully inspected to document integrity and separation incidence local wound care is done twice daily → Skin closure with staples versus suture has higher incidence of noninfectious skin separation Complications ▪ Evaluation of clinical response within 24-48 hours after initiation of treatment ▪ Failed therapy: assess for causes ▪ Persistent fever after this interval mandates a careful search for causes of refractory pelvic infection ▪ Despite this due diligence that we do, there can be complications and pelvic infections. In more than 90% of Figure 8 & 9. WOUND DEHISCENCE women, metritis responds to antimicrobial treatment within 48- ▪ Necrotic tissue is removed, and the wound is repacked with 72 hours. However, in the remaining cases, several moist gauze. complications may arise. ▪ At 4 to 6 days, healthy granulation tissue is typically present, ▪ Diagnostic considerations: and secondary en bloc closure of the open layers can usually → Parametrial phlegmon which is an area of intense cellulitis be accomplished. → Abdominal incisional or pelvic abscess or infected ▪ With this closure, a polypropylene or nylon suture of hematoma appropriate gauge enters 3 cm from one wound edge. It → Septic pelvic thrombophlebitis crosses the wound to incorporate the full wound thickness and emerges 3 cm from the other wound edge. These are placed in c. Complications of Uterine and Pelvic Infections series to close the opening. Abdominal incisional infections ▪ In most cases, sutures may be removed on postprocedural Necrotizing fasciitis day 10. Adnexal abscess and peritonitis 2. Necrotizing Fasciitis Parametrial phlegmon o Potentially fatal complication of perineal and vaginal infections, Septic thrombophlebitis although it is of rare occurrence Perineal infections – episiotomy dehiscence o Severe wound infection associated with high mortality rate Toxic shock syndrome RISK FACTORS 1. Abdominal Incisional Infections ▪ Diabetes ▪ Obesity o Wound Infections is a common cause of persistent fever in ▪ Hypertension women treated for metritis. o Incisional abscess that develops during cesarean delivery CAUSATIVE AGENT usually cause: ▪ Polymicrobial ▪ Fever ▪ Organisms that make up the normal vaginal flora → Persistent despite medications ▪ Group A – β hemolytic streptococci – necrotizing infections: → Begins on the fourth operative day asymptomatic until 35 days after delivery ▪ Wound erythema or drainage o In obstetrics, necrotizing fasciitis may involve abdominal CAUSATIVE AGENTS incisions/episiotomy/perineal lacerations o Significant tissue necrosis ▪ Generally the same as those isolated from amniotic fluid at o Infection may involve the skin, superficial and deep cesarean delivery or hospital acquired pathogens. Usually, antimicrobials had been given to treat pelvic infection, yet subcutaneous tissue and any of the abdominopelvic fascial fever persisted. The wound is erythematous and drains pus layer and even muscle (myofascitis) o Origin of infection: paravaginal hematoma RISK FACTORS o It can progress to septicemia and death in 25 % and so you ▪ Obesity have to do extensive debridement ▪ Prolonged rupture of membrane ▪ Diabetes TREATMENT (should be aggressive) ▪ Hypertension ▪ Cornerstones for the successful treatment: ▪ Anemia → Early diagnosis ▪ Corticosteroid use → Surgical debridement ▪ Immunosuppression → Antimicrobials ▪ Poor hemostasis with hematoma formation → Intensive care ▪ High index of suspicion with surgical exploration can prevent WOUND DEHISCENCE mortality ▪ Abdominal incisional infection may progress to wound ▪ Surgery includes extensive debridement of all infected tissue, dehiscence or disruption and this refers to the separation of leaving wide margins of healthy bleeding tissue. This may the wound involving the fascial layer include extensive abdominal or vulvar debridement with ▪ Serosanguinous discharge → noticed around the fifth unroofing and excision of abdominal, thigh, or buttock fascia. postoperative day ▪ Death is virtually universal without surgical treatment ▪ Risk factors: wound infection, obesity 4 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications 5. Septic Pelvic Thrombophlebitis o Suppurative thrombophlebitis was a frequent complication in the pre-antibiotic era however with the advent of antimicrobial therapy, the mortality rate and surgical therapy was already decreased. o Occur in association with pelvic surgery or as an extension of puerperal infection along venous routes o Inferior vena cava and renal veins: 25%. Septic pelvic thrombophlebitis occurs in association with pelvic surgery or as an extension of puerperal infection along venous routes. It will involve 1 or both of the ovarian venous plexuses and in 25% of women, it can extend to the inferior vena cava and to the renal vein. Figure 10. NECROTIZING FASCITIS o Ovarian veins: commonly involved because they drain the upper uterus and therefore the placental implantation site 3. Adnexal Abscesses and Peritonitis OVARIAN ABSCESS CLINICAL PRESENTATION ▪ Rare ▪ Fever of undetermined etiology with no demonstrable focus ▪ Caused by bacterial invasion through a rent in the ovarian of infection → high spiking capsule ▪ Chills ▪ The abscess is usually unilateral ▪ Tachycardia ▪ Typically present 1 – 2 weeks after delivery ▪ There is symptomatic improvement with antimicrobial PERITONITIS treatment, however, they continue to have fever. Although ▪ Uncommon following cesarean delivery there occasionally is pain in one or both lower quadrants, ▪ It is almost invariably preceded by metritis patients are usually asymptomatic except for chills ▪ It most often caused by uterine incisional necrosis and Watch out for OVARIAN VEIN THROMBOSIS dehiscence, but it may be due to a ruptured adnexal abscess ▪ Cardinal sign: pain manifested on the second or third or an inadvertent intraoperative bowel injury during cesarean postpartum day and lead to pulmonary embolism delivery (that is why, it is important to protect the bowels DIAGNOSTIC PROCEDURE during pelvic surgery) ▪ High level of suspicion ▪ Peritonitis is rarely encountered after vaginal delivery, and ▪ Pelvic CT or MR imaging (confirmatory) many such cases are due to virulent strains of group A β- hemolytic streptococci or similar organisms. ▪ Abdominal rigidity may not be prominent due to physiological abdominal wall laxity ▪ Adynamic ileus is the first symptom ▪ Marked bowel distention may develop which is unusual after an uncomplicated pregnancy ▪ TREATMENT → For the treatment, if infection begins from the uterus and extends into the peritoneum, antimicrobial alone will be enough 4. Parametrial Phlegmon o Complication after CS delivery o Parametrial cellulitis that forms an area induration within the leaves of the broad ligament o Usually unilateral (MC form of extension) o Limited to the parametrium at the base of the broad ligament Figure 12. SEPTIC PELVIC THROMBOPHLEBITIS o Extends laterally along the broad ligament → extend to the pelvic sidewall o Posterior extension → rectovaginal septum → firm mass posterior to the cervix o Fever: persists longer than 72 hours despite intravenous antimicrobial therapy. Typically, fever resolves in 5-7 days TREATMENT ▪ Broad-spectrum antimicrobial regimen ▪ Surgery (reserved for women in whom uterine incisional necrosis is suspected) Figure 13. SEPTIC OVARIAN VEIN THROMBOSIS—CONTRAST- ENHANCED COMPUTED TOMOGRAPHY SCAN o Make sure that if you realize that if you have fever and abdominal pain 1 week post-delivery, you have to request for a contrast enhance CT scan because it is difficult to visualize by ultrasound. o Septic ovarian thrombosis can be seen as enlarged ovarian vein filled with low density thrombus (as seen on the white Figure 11. LEFT-SIDED PARAMETRIAL PHLEGMON arrow) 5 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications 6. Perineal Infections EPISIOTOMY DEHISCENCE ▪ Perineal infections are not common nowadays because of selective episiotomy as compared before. Early episiotomy repair is advocated to avoid episiotomy infections ▪ Most commonly associated with infection ▪ Signs and symptoms (local pain, dysuria with or without urinary retention) ▪ Severe infections involves the entire vulva which may be described as edematous, ulcerated and covered with exudate. ▪ Risk factors (Coagulation disorder, smoking, HPV infection) ▪ May involves the entire vulva (edematous, ulcerated and covered with exudate) Figure 15. PERINEAL INFECTIONS ▪ Anal sphincter disruption: higher infection rate 7. Toxic Shock Syndrome VAGINAL LACERATIONS o Acute febrile illness with multisystem derangement ▪ Infected directly or by extension from the perineum o Case fatality rate of 10-15% with the following as the usual ▪ Epithelium becomes red and swollen and may then become findings. necrotic and slough off SIGNS AND SYMPTOMS CERVICAL LACERATIONS ▪ Fever, headache, mental confusion, diffuse macular ▪ Manifests as metritis erythematous rash, subcutaneous edema, nausea and ▪ Causes lymphangitis, parametritis, and bacteremia vomiting, watery diarrhea marked hemoconcentration TREATMENT ▪ Renal failure, hepatic failure, disseminated intravascular ▪ The management of infected episiotomies is similar to any coagulation, circulatory collapse other infected surgical wounds and drainage is important and CAUSATIVE AGENTS should be established in most cases ▪ Staphylococcus aureus ▪ Wound drainage Toxic shock syndrome toxin-1 (TSST-1) ▪ Removal of sutures ✓ Staphylococcal exotoxin ▪ Wound debridement ✓ Cause the clinical manifestations by provoking profound ▪ Intravenous antibiotics endothelial injury EARLY REPAIR OF INFECTED EPISIOTOMY ✓ Profound endothelial injury → T cells → cytokine storm ▪ 6 days from dehiscence ▪ B- hemolytic streptococcus ▪ Early repair of episiotomy after the infection has subsided is ▪ Clostridium sordellii and perfringens effective. What we don’t want to happen is the occurrence of rectovaginal fistula: high success rate of healing. TREATMENT ▪ Supportive while allowing reversal of capillary endothelial injury ▪ Antimicrobial therapy that includes staphylococcal and streptococcal coverage ▪ (+) pelvic infection → include agents used for polymicrobial infections ▪ Extensive wound debridement and possibly hysterectomy is needed. Otherwise, the mortality rate is so high because of the potent toxins, B. BREAST INFECTIONS a. Breast Infections: Mastitis Let’s now go to another the 2nd W’s of postpartum morbidity. The woobies for breast. Parenchymal infection of the mammary glands Puerperal mastitis is a rare antepartum complication which develops in 1/3 of breastfeeding women. In 1/3 of breastfeeding women incidence is 3% RISK FACTORS Figure 14. PREOPERATIVE PROTOCOLS FOR EARLY REPAIR OF o Difficulties in nursing EPISIOTOMY DEHISCENCE o Cracked nipples Diligent preparation of your episiotomy repair is important. So o Oral antibiotic therapy before performing your repair of infected episiotomy, the surgical ETIOLOGY wound must be properly cleaned and once the infection is o Staphylococcus aureus cleared of infection and exudate and already covered with pink ▪ Most commonly isolated organism especially its methicillin- granulation tissue, secondary repair can now be done. The resistant strain. 40% of women with mastitis will have this tissue must be adequately mobilized with special attention to o Coagulase-negative staphylococci identify and mobilize the sphincter muscle. Secondary closure of o Viridans streptococci episiotomy is done in layers same with the steps in the closure of o Immediate source of organism (infant’s nose and throat) primary episiotomy local wound care, stool softeners, nothing per o Bacteria enter the breast through the nipple at the site of a vagina or rectum until healed should be advised as a part of your fissure or small abrasion postoperative care. 6 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications SIGNS AND SYMPTOMS o Appear not until third or fourth week postpartum o Chills or actual rigors o Fever and tachycardia o Severe pain o Breast(s) becomes hard and red-marked engorgement- unilateral Figure 16. PUERPERAL MASTITIS WITH BREAST ABSCESS Figure 17, 18 & 19. BREAST ABSCESS TREATMENT o If appropriate therapy for mastitis is started before suppuration begins, the infection will resolve within 48 hours o Abscess formation is also present in Staph. aureus infection o Swab in the infected breasts before therapy for culture and sensitivities o Antimicrobial therapy (10-14 days) ▪ Dicloxacillin, 500 mg orally 4x/day ▪ Erythromycin, 500 mg orally 4x/day-penicillin sensitive women ▪ Vancomycin or another anti-MRSA antimicrobial (Infection caused by resistant, penicillinase producing Figure 20. ULTRASOUND FINDINGS IN PUERPERAL MASTITIS staphylococci or if resistant organisms are suspected) while A. US shows irregular margin and hypoechoic lesion waiting for your culture results, vancomycin, clindamycin and B. If abscess is developed, hypoechoic or anechoic fluid collections can Trimethoprim Sulfamethoxazole can be given for 10-14 days be seen. Irregular margin and echoic lesion can be also seen along with o Continued breast feeding acoustic enhancement Early-stage mastitis shows various features that is presented with ▪ In mastitis, breastfeeding is NOT A CONTRAINDICATION thickness of skin and subcutaneous layer, and irregular border between as breastfeeding is a treatment itself subcutaneous layer and parenchyma ▪ It is best to begin suckling on the uninvolved breast because it allows milk let-down to commence before moving to the c. Breast Engorgement tender breast ▪ Breast pumping to decrease edema and engorgement which Breast engorgement should be differentiated with mastitis can make the areola hard to grip and therefore the baby will which is an infection of the mammary parenchyma and it is not be able to nurse on the inflamed breast. relatively common among lactating women ▪ Breastfeeding in HIV infected women is not contraindicated. Common among women who do not breastfeed However, it is recommended to stop feeding from the Fever seldom persists for longer than 4-16 hours infected breast. This is because HIV RNA levels increase in Temperature does not exceed 39⁰C and lasts < 24hours affected breast milk Typified by milk leakage and breast pain Peak 3-5 days after delivery b. Breast Infections: Breast Abscess Cool packs and oral analgesics for 12 to 24 hours may aid If a well-defined area of the breast remains hard, red, and discomfort tender and then fluctuant despite appropriate management, then an abscess should be suspected Should be suspected when defervescence does not follow within 48 to 72 hours of mastitis treatment When a mass is palpable Sonographic imaging is valuable (it is a complex cystic structure with a thick wall) MANAGEMENT o Surgical drainage under general anesthesia o Sonographically guided needle aspiration using local analgesia which is less invasive with 80-90% success rate Figure 21. ENGORGED BREAST 7 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications C. ACUTE PYELONEPHRITIS A. UTERINE SUBINVOLUTION Also consider renal infection in your differentials for After delivery, the uterus contracts and the fundus is palpated postpartum fever. Dilated ureters and renal pelvis return to just below the umbilicus normal by 2-8 weeks postpartum Best estimates show that the uterus weighs approximately Residual urine in a previously dilated collecting system in 1000 gm immediately postpartum , 500 gm at one week , 300 traumatized bladder: Symptomatic UTI gm on the second week and 100 gm at 4 weeks Submucosal hemorrhage and edema common SUBINVOLUTION accompaniment of vaginal delivery o Defined as the arrest or retardation of involution or the Bladder trauma is associated with labor length process by which the puerperal uterus is normally restored to its original proportions Because of this dilated collecting system coupled with o Uterus is larger and softer than expected by bimanual residual urine in a previously traumatized bladder, examination symptomatic UTI remains a concern in the puerperium. o Prolonged lochia (>36 days) as well as irregular or excessive Any form of invasive manipulation of the urethra (eg. Foley bleeding catheterization) increases UTI rate o Late postpartum hemorrhage: 24 hours to 12 weeks SIGNS AND SYMPTOMS postpartum o Fever o Subinvolution maybe caused by infections and retained o Costovertebral angle tenderness products of placenta o Nausea and vomiting APPROACH o UA: bacteriuria and pyuria – frequently contains white blood o Good medical and peripartum history cells and bacteria o Speculum examination – bleeding from uterine cavity o Bimanual examination – uterus large and soft D. ATELECTASIS o Ultrasound of the uterus: to rule-out retained placental Another W of PPE is your wind, which pertains to any fragments and differentiate AV malformations pulmonary cause such as atelectasis and pneumonia MANAGEMENT Often used as an explanation for unexplained postoperative Medical – primary treatment fever o Methylergonovine (as uterotonic) 0.2 mg P.O every 3-4 During pregnancy the residual and expiratory volumes and hours for 24 – 48 hours functional residual capacity decreases o Mild infection: Azithromycin 500 mg tablet 2x a day Atelectasis and fever: frequently after surgery o Doxycycline 100 mg capsule 2x a day Concurrence is probably coincidental o Ampicillin – Clavulanate 75 mg 2x a day Caused by hypoventilation following abdominal delivery Suction curettage: reserved for sonologically proven Fever associated with atelectasis presence of clots o Follow infection by normal flora that proliferate distal to Curettage: NOT done unless significant bleeding is not obstructing mucus plugs. stopped by medical treatment o Ascribing a postoperative fever to atelectasis is probably false reassurance and may mislead the clinician from B. RETAINED PRODUCTS OF CONCEPTION pursuing the true cause of the fever Placental and/or fetal tissue that remains in the uterus after a o Prevented by coughing and deep breathing on a fixed spontaneous pregnancy loss (miscarriage), planned pregnancy schedule after surgery termination, or preterm/term delivery Retained small placental fragments seldom cause postpartum E. DRUG FEVER hemorrhage but is a common cause of bleeding late in the Fever: can be the sole manifestation of an adverse drug postpartum reaction PREVENTIVE MEASURES In 3-5% of cases o Routine inspection of placenta for missing cotyledons or Mechanism: for evidence of fetal vessels coursing to the placental edge o Hypersensitivity reactions and abruptly ending at a tear in the membranes suggesting a o Altered thermoregulatory mechanism retained succenturiate lobe o Reactions that are directly related to administration of drug o Uterine exploration has also been advocated to recognize o Idiosyncratic reactions and remove a retained cotyledon o Postpartum curettage using postpartum curette can be II. OTHER DISORDERS OF THE done to make sure they are all removed PUERPERIUM CLINICAL MANIFESTATIONS o Uterine bleeding Uterine subinvolution o Pelvic pain Retained products of conception o Fever Vulvovaginal lacerations o Uterine tenderness o Amenorrhea Puerperal hematoma Postpartum hemorrhage BLEEDING Postpartum urinary retention o RPOC (including placenta accrete) o Hematometra Postpartum depression o Uterine atony/subinvolution Obstetrical neuropathies o Ectopic pregnancy Musculoskeletal injuries o Trauma o GTD 8 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications INFECTION PREVENTION o Endometritis o Timed and ample episiotomy will prevent most tears, that is o Infected RPOC during crowning when the head is visible during contraction o Pelvic inflammatory disease to a diameter of 4 cms. o Other abdominopelvic infections o Restrictive episiotomy maybe done rather than routine GENERAL episiotomy. The use of episiotomy maybe limited to maternal o A thorough physical examination must be done. You should indications in order to avoid severe maternal lacerations or to assess the patient’s overall condition, whether the patient is facilitate difficult deliveries stable or not o Early episiotomy will cause considerable incisional bleeding o On general examination, the findings point out to hypovolemic while if it’s too late- lacerations will not be prevented shock from acute blood loos or septic shock as a consequence o Median episiotomy significantly increases the risk of anal of infection sphincter or rectal injury when compared to RMLE. o Restlessness, inability to move without pain, mental status o Mediolateral episiotomy should be indicated change o Operative vaginal delivery should only be done if with o Diaphoresis, pallor, dyspnea, sepsis indication to prevent the occurrence of severe perineal o Tachycardia, hypotension, orthostasis, tachypnea, hypoxemia trauma. If indicated, vacuum extraction is preferred over o Serious illness forceps delivery. o Abdomen: distention, rigidity, rebound, involuntary guarding SIGNS AND SYMPTOMS o Speculum exam: uterine bleeding o Postpartum bleeding despite a firm and contracted uterus o Bimanual exam: cervical motion tenderness, significant uterine added with history of operative vaginal delivery o Tenderness or enlargement, adnexal masses or tenderness o Strongly suggests genital tract lacerations, retained DIAGNOSTIC EVALUATION secundines or presence of uterine tear o CBC – evaluate the severity of blood loss DIAGNOSIS o β-HCG – rule out GTD/GTN o Inspection o Imaging studies ▪ Thorough inspection of both vagina and perineum is ▪ Ultrasound – confirm for presence of retained products of important so as not to overlook such lacerations. The conception vagina should be widely retracted. Attention should be o Sonohysterography given to the anterior and lateral walls and not only to the ▪ Costly, invasive posterior portion to check if lacerations are deep enough to ▪ Inadequate evidence to support management of RPOC need repair o Hysteroscopy ▪ A tear in the upper vagina is rare but a serious condition so ▪ Allows diagnosis and therapy during a single procedure is a lateral extension of the cervical tear: it opens up to the ▪ For patients with persistent (3 or more weeks) mild broad ligament and may affect descending branches of the symptoms uterine arteries with occurrence o profuse hemorrhage o NO sonohysterography or hysteroscopy if there is clinical evidence of infection D. PUERPERAL HEMATOMA o Treat with antibiotics and uterine evacuation Circumscribed, extravascular collection of blood usually clotted MANAGEMENT forming a mass as a result of trauma Medically stable patients with endometritis The ruptured vessels are concealed and if they are small, the o Surgical Intervention development is insidious and recognition is delayed. Failure to ▪ Uterine evacuation do an ample episiotomy or to ligate the bleeders at the angle of ▪ Hysteroscopic removal of RPOC the episiotomy wound or laceration can form a hematoma or o Medical Intervention the episiotomy itself. If it is severe, it can cause hypovolemic ▪ Misoprostol shock. o Expectant management RISK FACTORS ▪ For patients with stable VS and no signs of infections o Vaginal/perineal lacerations Patients who are hemodynamically unstable o Episiotomy o Stabilize with fluid and blood products – surgery o Operative delivery o Uterotonic drugs (misoprostol 800 mcg or o Inadequate hemostasis during repair of an episiotomy or methylergonovine 0.2 mg orally 3-4x/day) lacerations – most common risk factor o Intrauterine balloon catheter – for torrential bleeding o Any hematoma can also develop following stretch and o Uterine artery embolization rupture of blood vessel without an associated laceration o Exploratory laparoscopic or laparotomy and hysterectomy as last resort CLASSIFICATION Patients with sepsis 1.Vulvar hematomas o Prompt evacuation of uterus + IV antibiotic therapy 2.Vulvovaginal hematoma o Bleeding is then directed toward the skin and the loose subcutaneous tissues exert little resistance to hematoma C. VULVOVAGINAL LACERATIONS formation Most perineal tears extend to the vagina. These extensions are 3.Paravaginal easily overlooked unless the vagina is easily retracted. They 4. Supravaginal / Retroperitoneal are classified as 1st, 2nd, 3rd and 4th degrees. o Least common but most dangerous type ETIOLOGY: Perineal lacerations are caused by: o Can dissect retroperitoneally or develop within the broad o Rapid and sudden expulsion of the head ligament o Excessive size of the infant o It results from damage to the uterine artery branches o Difficult forceps (hypogastric artery) in the broad ligament o Breech extraction o It causes severe pain and differentiation from actual uterine o Lack of elasticity and friability of the maternal tissue rupture is difficult. o Inadequate episiotomy 9 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications CLINICAL COURSE AND MANAGEMENT MANAGEMENT o Hematomas are managed according to their size, location, o We need to know the usual vaginal postpartum and the duration since delivery and expansion. appearance of your lochia. Few will have delayed placental o Small to moderate hematomas: unless observed to be fragments, therefore curettage – is not advised, may cause enlarging maybe left alone to be eventually organized and avulsion of placental vessels/worsen bleeding by avulsing the absorbed implantation site o Expanding hematomas: may rupture from pressure necrosis. o Ultrasound Profuse hemorrhage may follow but in other cases, the ▪ If empty cavity and stable patient: uterotonics and hematoma drains in the form of large clots and old blood. antimicrobials o Massive retroperitoneal bleeding – in those that involve the ▪ If with cots: gentle suction curettage paravaginal space and extend above the levator sling o In some institutions, if large clots are present on ultrasound, o Surgical exploration (incision and evacuation); enlarging gentle suction curettage is done. hematomas and severe pain o Do curettage only after nonresponse to medical management o Repair is done through: ▪ Incision made at the point of maximal distention F. POSPARTUM URINARY RETENTION ▪ Evacuation of bleed and clots Bladder overdistention and urinary retention is common in the ▪ Bleeding point ligated early puerperium ▪ Closure of evacuated hematoma Postpartum bladder ▪ Vaginal packed for 12-24 hours o Increased capacity, insensitive to intravesical pressure ▪ Blood transfusion o Overdistention o Infrequent emptying E. POSTPARTUM HEMORRHAGE o Excessive residual time a. Early Postpartum Hemorrhage Urinary retention (narcotic analgesia) Occurs on the 1st 24 hours postpartum Urinary incontinence – late consequence of vaginal deliver Causes (4 T’s): 1. Tone G. POSTPARTUM DEPRESSION 2. Tissue Postpartum blues – a commonly depressed mood after 3. Trauma delivery which last rom 2-10 days 4. Thrombin Explanations The most frequent cause of postpartum hemorrhage is the o Excitement of delivery failure of the uterus to contract sufficiently and to arrest o Fears throughout pregnancy bleeding from vessels at the placental implantation site. o Discomfort of the puerperium With immediate postpartum hemorrhage, careful inspection is o Sleep deprivation done to exclude birth canal lacerations and because bleeding o Anxiety about providing newborn care can be caused by retained placental fragments, inspection of Suicidal and infanticidal ideation – should be treated as an the placenta after delivery should be routine and if a defect is emergency. It can recur in 25% of women in the next seen, the uterus should be manually explored and fragments pregnancies. removed. Pharmacologic prophylaxis in late pregnancy is subscribed by For uterine atony causing postpartum hemorrhage, this is due some or immediately postpartum if the patient has a history to the inherent inability of myometrial fibers in the lower uterine Postpartum hormonal changes affect brain function and this segment to contract and thereby constrict the avulsed vessel. functional decline in postpartum women do happen in some and it should be acknowledged Effective treatment: o Anticipation, recognition and reassurance H. OBSTETRICAL NEUROPATHIES Postpartum neuromuscular concerns are the obstetrical neuropathies from the normal spontaneous delivery (NSD). NERVE INJURIES WITH NSD a. Injury to Lumbosacral Plexus o When head descends into pelvis or by forceps o Sensory loss o Muscle paralysis b. Common Fibular Nerve (Common Peroneal Nerve) o Nerve compressed in stirrups o Prolonged second stage Figure 22. CAUSES OF EARLY POSTPARTUM HEMORRHAGE o May result to footdrop b. Late Postpartum Hemorrhage c. Lateral Femoral Cutaneous Neuropathy and Femoral 24 hours – 12 weeks after delivery Neuropathies (two most common) 1% will develop clinically worrisome PPH in 1-2 weeks o Risk factors: ▪ Nulliparity CAUSES ▪ Prolonged second stage o Suboptimal involution of placental site ▪ Pushing on long duration on semi-Fowler o Retention of placental fragments → necrosis with fibrin o Duration of symptoms: 2 weeks to 18 months deposition → placental polyp → detachment of eschar o Von Willebrand disease/inherited coagulopathies NERVE INJURIES WITH CS DELIVERY o The Iliohypogastric and Ilioinguinal Nerves 10 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN Puerperal Complications I. MUSCULOSKELETAL INJURIES III: REFERENCES AND CITATIONS Musculoskeletal tear William’s Obstetrics 25th ed. “Puerperal Complications” Powerpoint - Dr. Marjorie Farinas o Pain during delivery o Due to stretching/tearing injury o May lead to pyriformis muscle hematoma o MRI: diagnostic imaging of choice o Complete resolution with anti-inflammatory drugs and physical therapy Figure 23. MUSCULOSKELETAL TEAR Symphysis pubis separation o Is not frequent but it can happen o Separation of sacroiliac synchondrosis o Pain and mobility issues. The pain occurs without much symptoms but can occur often acutely during delivery and the onset may manifest either antepartum or 48 hours postpartum. o 0.4 – 0.5 cm distance: normal distance of the symphyseal joint o Separation of symphysis pubis (>1 cm diastasis) o Conservative management. We just advise the patient to lie in lateral decubitus position and wear an appropriate fitted binder but, if the separation is more than 4 cms, then surgery is needed. o Surgery if >4 cm separation o High recurrence therefore cesarean section in the subsequent pregnancy is recommended o Hormone relaxin causes the ligaments joining the symphysis pubis to soften and some women have this in excess. Figure 24. SYMPHYSIS PUBIS SEPARATION Fractures of the sacrum and pubic ramus o Rare o Caused by uncomplicated deliveries o Osteoporosis associated with heparin and corticosteroid therapy 11 | 11 Trans No. 09 Associate Editors ABADAY, ABAS, ABRENCILLO, ABEJON | Chief Editor AGUIDAN