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.

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Puerperal Thrombosis

Puerperal ThrombosisLeg vein & pelvic vein is one of the complication in western countries. However the prevalence is low in Asians & Africans.

EtiopathogenesisIn 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 & parityOperative deliveryObesityAnemia & 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.

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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

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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.

Lung scan:Lung

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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.

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Treatment

ResuscitationI.V.fluid supportThrombolytic therapyDigitalisRecurrent attack require embolectomy.

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Obstetric palsies

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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.

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• 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

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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.

SCHIZOPHRENIAAbout 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.