Normal and Abnormal Puerperium Liu Wei Department of Ob & Gy Ren Ji hospital
Normal Puerperium • Definition • The time from the delivery of the placenta through the first few weeks after the delivery. • 6 weeks in duration. • By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery have resolved and the body has reverted to the nonpregnant state.
Normal Puerperium • The relevant anatomy and physiology in the puerperium • Reproductive organs • Uterus • 1000g → 50-100g • The endometrial lining rapidly regenerates (16 days) • The placental site undergoes a series of changes in the postpartum period
Normal Puerperium • Cervix • it never returns to the nulliparous state. • the external os is closed to the extent that a finger could not be easily introduced. • Vagina • shrinks to a nonpregnant state • resolution of the increased vascularity and edema occurs by 3 weeks • the vaginal epithelium appears atrophic on smear. This is restored by weeks 6-10.
Normal Puerperium • Perineum • swelling and engorgement are completely gone within 1-2 weeks • the muscle tone may or may not return to normal, depending on the extent of injury. • Ovaries • ovulate as early as 27 days after delivery (not breastfeed ); 12 weeks (most); 7-9 weeks (mean). • the suppression of ovulation due to the elevation in prolactin
Normal Puerperium • Breasts • Lactation can occur by 16 weeks' gestation. • Lactogenesis is initially triggered by the delivery of the placenta (E↓P↓and prolactin). • the prolactin levels decrease and return to normal within 2-3 weeks (not breastfeeding) • The colostrum初乳(the first 2-4 days) • The milk continues to change throughout the period of breastfeeding to meet the changing demands of the baby.
Normal Puerperium • Systemic change • Cardiovascular system • Blood volume returns to nonpregnant levels by the tenth days of puerperium • Cardiac output ↑(immediately after delivery) → slowly declines→ reach late pregnancy levels 2 days postpartum→ normal 2-6 weeks. • Hematologic changes • Hemoglobin concentration↑on the firstpostpartum days • Several clotting factors (fibrinogen) ↑on the first days
Normal Puerperium • Manifestation • Fever (24 hours) • Pain (uterine contraction) • Sweat • Lochia 恶露 • a large amount of red blood initially flows from the uterus as the contraction phase rapidly occurs. (5 weeks) • lochia rubra; lochia serosa (brownish red, with a more watery consistency); lochia alba (yellow)
Normal Puerperium • Management • 2 hours after delivery • Bleeding • Uterine contraction • HR and Bp and R and T • 1 weeks after delivery • Bleeding
Normal Puerperium • Emiction and defecate • Lochia • Episiotomy and Laceration • Breast
Puerperal Infection • Puerperal Infection any bacterial infection of the genital tract after delivery. Incidence: 6%. The most important cause of maternal death. • Puerperal Morbidity temperature 38.0℃ or highter, the temperature to occur on any 2 of the first 10days postpartum, exclusive of the first 24 hours, and to be taken by mouth by a standard technique at least four times daily.
Puerperal Infection • Risk factors • PROM • Anemia • Hemorrhage • EP and CS • Placenta retain
Puerperal Infection • Common pathogens • Aerobes • Group A, B, and D streptococci溶血性链球菌 • Gram-negative bacteria: Escherichia coli大肠杆菌, Klebsiella克雷伯氏菌 • Staphylococcus aureus葡萄球菌
Puerperal Infection • Anaerobes • Petococcus species消化球菌 • Petostreptococcus species消化链球菌 • Bacteroides fragilis group脆弱类杆菌 • Clostridium species梭状芽孢杆菌 • Other • Chlamydia trachomatis沙眼衣原体 • Mycoplasma species支原体
Puerperal Infection • Manifestation • Acute vulvitis vaginitis and cervicitis • Uterine infection • Adnexal infections • Septic pelvic thrombophlebitis 血栓性静脉炎 • Sapremia 败血症
Puerperal Infection • Diagnosis • History • Physical examination and PV • Lab finding • Differential diagnosis
Puerperal Infection • Treatment • Nutrition: anemia prevention • Antimicrobial treatment broad-spectrum, high dose, long time • Drainage • Treatment of thrombophlebitis
Late Postpartum Hemorrhage • Definition Uterine bleeding by 24 hours after delivery. • Etiology • Placenta or membrane or decidua retain • Abnormal redintegration • Infection • Problems of incision