1. NORMAL & ABNORMAL PUERPERIUM Undergraduate Teaching Programme Dr G Holding ST3 02/09/2015

2. Introduction Puerperium is defined as the period from delivery of placenta through to six weeks after delivery The various changes that occurred during pregnancy revert to the non-pregnant state

3. Postnatal care Uterus/genital tract Vaginal loss (lochia) Perineum Wound Bladder Bowels Breasts Pain Fatigue Emotions

4. Normal Puerperium Cardiovascular system – extra load on heart disappears by second week Uterus - pregnant term uterus weighs about 1000g; at 6/52 weighs about 100g Vaginal loss (lochia) – volume and duration of vaginal discharge is variable and changes, average 3-6 weeks Perineum – vagina & perineum initially increase in oedema; most muscle tone regained by 6/52

5. Normal Puerperium Bladder - passing urine can initially be painful, stress incontinence Bowels - constipation common, haemorrhoids Breasts - engorged and tender 2-3 days post delivery, usually resolves, milk replaces colostrum

6. Normal Puerperium Pain – ‘after pains’ as uterus contracts, postoperative pain, back ache Fatigue – disturbed sleep, recovering from birth Emotions – baby blues, anxiety

7. Abnormal Puerperium Bleeding Sepsis Thromboembolism Pre-eclampsia/hypertension Psychiatric disorders

8. Post Partum Haemorrhage (PPH) Primary PPH is blood loss of 500ml or more occurs within the first 24 hours after delivery Secondary PPH is ‘excessive’ loss occuring between 24 hours and 6 weeks postpartum

9. PPH Causes – Early PPH: uterine atony, retained placenta, lower genital tract trauma, uterine rupture, inversion, coagulopathy, haematoma Incidence – Vaginal delivery: 4% incidence – Caesarean delivery: 10% incidence – Delayed ‘secondary’ PPH occurs in 1-2% of patients, usually due to infection, retained products, or both

10. Management – History – how much bleeding? Risk factors – Examination – Inspection lower genital tract, bimanual examination – Investigations – FBC/clotting/X-match – Treatment – resuscitation/uterine massage/ pharmacological therapy/surgery

11. Sepsis Number 1 cause of maternal death in the UK Endometritis Group A streptococci E. coli Chlamydia Incidence: Vaginal delivery 1-3% Elective LSCS 5-15%

12. Urinary tract infections - bacteruria 33%, symptomatic infection 2% Wound infection - perineal infection 0.5 – 10%, LSCS wound 3-15% reduced to 2% with abx Mastitis – staph aureus, abscess complicates 5-11% cases

13. Thromboembolism VTE is number three ‘direct’ cause of maternal death in the UK Statutory VTE assessment on everyone admitted to UK hospitals High index of suspicion, not just in obvious presentations such as chest or calf pain

14. Pre-eclampsia/hypertension Pre-eclampsia - usually settles in the first 24 hours after delivery but can be unpredictable 50% cases of eclamptic fit, the first fit is post partum Treatment: – BP control (nifedipine; labetolol infusion) – Magnesium sulphate for prevention of further fits Common to have a residual hypertension lasting some weeks – Aim to keep BP at less than 140/90

15. Psychiatric disorders Four disorders Postpartum blues – transient disorder – lasts hours to weeks – characterized by bouts of crying and sadness PND – more prolonged affective disorder – weeks to months, and even years – Not well defined in terms of diagnostic criteria, but signs and symptoms same as depression in other settings Postpartum psychosis – first postpartum year, usually begins abruptly at 5-15 days – refers to a group of severe and varied disorders that elicit psychotic symptoms

16. Incidence – 50-70% develop symptoms of postpartum blues – PND occurs in 10-15% – PTSD affects 1% of mothers but most will not report it Often, may only materialise years later, for instance when the woman experiences emotional or physical symptoms surrounding planning of a future pregnancy – Puerperal psychosis in 0.2% Morbidity and mortality – Can have hugely deleterious effects on the mother, the relationship with the partner, the family, and on social, cognitive, and emotional development of the newborn – Suicide is one of the top causes of maternal death within a year of childbirth

17. Treatment Postpartum blues - little effect on a patient's ability to function, often resolves by day 10 – No pharmacotherapy is indicated – Providing support and education has been shown to have a positive effect PND generally lasts for 3-6 months – 25% of patients still affected at 1 year – Affects ADLs – Supportive care/reassurance is first-line but low threshold for drug therapy Postpartum psychosis – Supervised by a psychiatrist and may involve hospitalisation – Generally lasts only 2-3 months

18. Other issues Breast feeding Sexual intercourse Contraception Resuming normal activities

19. Any Questions ?