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.