Puerperium

Question 1

What are the genital tract changes that occur after delivery?

Answer 1

Takes 4 - 6 weeks to return back to normal
- involution of the uterus & placenta
- uterus returns to non-gravid size by 8 weeks
- immediately after delivery uterus is at or below umbilicus

If placenta is retained -> sub involution

Question 2

What is after pain?

Answer 2

Labour like pain secondary to involution -> becomes mild by day 3

• occurs more with breastfeeding -> secondary to oxytocin release

Question 3

What are the types of lochia?

Answer 3

1- Lochia rubra -> erythrocytes, bacteria, decidua, epithelial cells
2- Lochia serosa-> pale after 3 - 4 days
3- Lochia Alba -> less fluid more leucocytes (yellow) -> white after 10th day

Continues till 24 - 36 days postpartum

Question 4

What are the causes of maternal morbidity during puerperium?

Answer 4

• puerperal infections & sepsis
• secondary postpartum hemorrhage
• venous thromboembolic disorders

Question 5

What is puerperal fever?

Answer 5

38 C or 100.4 F or higher

• 80% of ladies develop fever in first 24 hours
  -> 70% after CS
  -> 20% pelvic infection

Spiking fever > 39C due to group A streptococcal infections

Question 6

WhatWhat are the causes of postpartum fever?

Answer 6

1- breast engorgement
2- atelectasis (complication of anesthesia post CS)
3- pelvic infections
4- urinary tract infections
5- abdominal incisions & perineal lacerations

Question 7

What are the types of uterine infections?

Answer 7

• endometritis
• endomyometritis
• endoparametritis

Occurs after delivery

Question 8

What are the risk factors for uterine infections?

Answer 8

Maternal
- DM
- obesity
- HIV infections

Intrapartum
- prolonged labour
- rupture membranes
- multiple vaginal exams
- retained products of conception

Procedure
- manual removal of placenta
- operative vaginal delivery
- cervical cerclage
- C section

Question 9

How do uterine infections present?

Answer 9

• fever
• headache
• malaise
• lower abdominal pain & uterine tenderness
• offensive lochia
• secondary PPH

Question 10

What are the pathogens that cause uterine infections?

Answer 10

Gram +ive
- group A B D streptococci
- staph aureus

Gram - ive
- E. coli
- Klebsiella
- Proteus

Mycoplasma, Chlamydia trachomatis, Niesseria gonorrhea

Anaerobic (with C section)
- bacteroids
- Pepto cocci
- Pepto streptococci

Question 11

What investigations are done in suspected uterine infection?

Answer 11

1- CBC: anemia, leukocytosis 15 000 - 30 000, low PLT
2- Renal function tests: urea & electrolyte
3- High vaginal swab
4- blood culture if there are systemic features
5- Coagulation profile: DIC
6- Pelvic ultrasound: retained products or abscess

Question 12

How are uterine infections treated?

Answer 12

AFTER C SECTION -> clindamycin + gentamicin
AFTER VAGINAL -> oral treatment if mild
-> if moderate or severe: IV Ampicillin + gentamicin

Question 13

What are the complications of metritis?

Answer 13

1- pelvic abscess
2- peritonitis
3- parametritis
4- septic pelvic thrombophlebitis

Question 14

How can incidence of wound infection be reduced?

Answer 14

1- prophylactic antibiotics 2g 1st generation cephalosporin before skin incision
2- skin cleaning before operation with chlorhexidine

Question 15

What are the risk factors for wound infections?

Answer 15

• immunosuppression
• hematoma formation
• diabetes
• obesity
• hypertension
• anemia

Question 16

What is the presentation of wound infection?

Answer 16

• fever on the 4th day usually
• wound erythematous
• drains pus

Question 17

How are wound infections managed?

Answer 17

1- antimicrobial therapy
2- surgical drainage
3- debridement of devitalized tissue
4- wound dressing twice daily till clear
5- secondary wound closure

Question 18

What is mastitis & what are its causes?

Answer 18

Infection of breast parenchyma -> 3rd or 4th week

Due to
- Staph aureus esp MRSA
- cracks at nipple & breast engorgement

Question 19

What is the presentation & treatment of mastitis?

Answer 19

Fever, pain, swelling, & painful breast feeding

Treat with -> Dicloxacillinb 500mg 4 times a day for 10 days
-> for MRSA: vancomycin

Question 20

When is breastfeeding contraindicated?

Answer 20

1- maternal HIV or active TB
2- breast cancer treatment
3- infant galactosemia
4- women taking street drugs & uncontrolled alcohol use

Question 21

What are the risk factors for urinary retention post partum?

Answer 21

1- primiparity
2- operative vaginal delivery
3- perineal lacerations
4- epidural analgesia
5- prolonged labour

Question 22

How is bladder dysfunction diagnosed postpartum?

Answer 22

1- enlarged bladder is felt suprapubically
2- if lady doesn’t void for 4 hours after delivery -> urine is emptied and left for 24hrs by urinary catheter
3- voiding trial done again -> residual volume > 200ml (failed)

Question 23

What vaccinations should be taken during puerperium?

Answer 23

• rubella
• varicella
• COVID 19

Question 24

When can a lady return to coitus & what are the problems she might face?

Answer 24

By 2nd month postpartum, most by 4 months

Problems
- Pain -> due to episiotomies & lacerations
- Dryness -> due to hypoestrogenic state
- Dyspareunia -> after C section