Puerperium 2

Question 1

What is secondary PPH?

Answer 1

excessive blood loss occurring between 24hrs and 6 weeks after delivery
due to endometritis, with or without retained placental tissue, incidental gynaecological pathology of gestational trophoblastic disease
the uterus is enlarged and tender with an open internal os
• Vaginal swabs and FBC are taken, with cross-match in severe cases- USS may help detect retained products although differentiation from blood clots is difficult

Question 2

What is the management for secondary PPH?

Answer 2

• If bleeding is heavy, then ERPC is used
if bleeding is more chronic, then antibiotics are initially used alone
• Characteristically, endometritis due to retained tissue causes bleeding that slows, but does not stop with antibiotics and gets worse again after the course is finished

Question 3

What is postpartum pyrexia?

Answer 3

• This is a maternal fever of ≥38oC in the first 14 days-infection is the most common cause
• Genital tract sepsis is a major cause of maternal mortality, it is most common after C-section, but prophylactic antibiotics have considerably reduced this- Group A streptococcus, staphylococcus and E.Coli are the most important pathogens in severe cases, lochia may be offensive and the uterus enlarged and tender
DVT can cause low grade pyrexia

Question 4

What are the other common infections which cause postpartum pyrexia?

Answer 4

o	Urinary tract infection (10%)
o	Chest infection
o	Mastitis
o	Perineal infection
o	Wound infection after C-section

Question 5

How does thromboembolic disease affect the puerperium?

Answer 5

• Deep vein thrombosis and pulmonary embolism is a leading cause of maternal mortality, although less than 0.5% of women are affected
• ½ the deaths are postnatal, usually after discharge from hospital
• Early mobility and hydration is important for all women

Question 6

What are the hypertensive complications?

Answer 6

• Pre-eclampsia and it complications are a major cause of maternal mortality- most deaths occur postpartum
• Although delivery is the only cure for pre-eclampsia, it often takes at least 24hrs before the illness improves-BP usually peaks 4-5 days after delivery, may need treatment for weeks
• In all pre-eclamptic patients, attention is paid to fluid balance, renal function and urine output, BP and the possibility of hepatic & cardiac failure
• Blood pressure measurement continues for 5 days postnatally

Question 7

What occurs with retention of urine

Answer 7

may present with frequency, stress incontinence or severe abdominal pain
infection, overflow incontinence and permanent voiding difficulties may follow post-micturition USS can be used to assess the residual volume non-invasively treatment is catheterisation for at least 24hrs

Question 8

What occurs with urinary infection?

Answer 8

occurs in 10% of women, usually asymptomatic, but often leads to symptomatic infection or pyelonephritis, routine urine culture is advised

Question 9

What occurs with incontinence?

Answer 9

occurs in 20% of women, overflow and infection should be excluded using postmicturition USS or catherisation and mid-stream urine sample respectively
obstetric fistulae are very rare in developed countries symptoms of stress incontinence usually improve, particularly with formal pelvic floor exercises, but these have little preventive role

Question 10

What occurs with perineal trauma?

Answer 10

• Perineal trauma is repaired after delivery of the placenta, pain can persist for >8 weeks in 10% of women-
superficial dyspareunia is common
• NSAIDs are best- USS, salt baths and Megapulse are of no benefit
• Paravaginal haematoma- rarely, a women experiences excruciating pain in the perineum a few hours after delivery
this is almost always due to paravaginal haematoma, which is usually identifiable only on vaginal examination drained under anaesthetic

Question 11

What occurs with bowel problems?

Answer 11

• Constipation and haemorrhoids both occur in 20% of women- laxatives are helpful
• Incontinence of faeces or flatus- underreported symptom affecting 4% of women, mostly transiently
both pudendal nerve and anal sphincter damage can be responsible- forceps delivery, large babies, shoulder dystocia and persistent OP positions are the main risk factors
affected women are evaluated using anal manometry and USS, and managed according to symptoms
formal repair may be required, after which all pregnancies should be by C-section