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puerperio en obstetricia
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PuerperiumFranzblau N, Witt K. Normal and Abnormal Puerperium. Emedicine available at www.emedicine.com/med/topic3240.htm; accessed 13 December 2005.
PuerperiumThe time from the delivery of the placenta through the first few weeks after the delivery
Usually considered to be 6 weeksBody returns to the nonpregnant state
UterusImmediately after the delivery, the uterus can be palpated at or near the umbilicusMost of the reduction in size and weight occurs in the first 2 weeks
2 weeks postpartum, the uterus should be located in the true pelvis
LochiaVaginal discharge, lasts about 5 weeks15% of women have lochia at 6 weeks postpartum
Lochia rubraRedDuration is variableLochia serosaBrownish red, more watery consistencyContinues to decrease in amountLochia albaYellow
Cervix, Vagina, PerineumTissues revert to a nonpregnant state but never return to the nulliparous state
Abdominal WallRemains soft and poorly toned for many weeksReturn to a prepregnant state depends greatly on exercise
OvulationBreastfeedingLonger period of amenorrhea and anovulationHighly variable50-75% return to periods within 36 weeks
Not breastfeedingAs early as 27 days after deliveryMost have a menstrual period by 12 weeks
BreastsChanges to the breast that prepare for breastfeeding occur throughout pregnancyLactation can occur by 16 weeks gestation
Colostrum1st 2-4 days after deliveryHigh in protein and immune factorsMilk matures over the first week*Contains all the nutrients necessary *Continues to change thoughout the period of breastfedeing to meet the changing demands of the baby
BreastfeedingBreastfeeding is neither easy nor automatic.
Should be initiated ASAP after deliveryFeed baby every 2-3 hrs to stimulate milk productionProduction should be established by 36-96 hrs
ConsiderationsVaginal Birth Swelling and pain in the perineumEpisiotomy? Laceration?HemorrhoidsOften resolve as the perineum recovers
Cesarean DeliveryPain from the abdominal incisionSlower to begin ambulating, eating, and voiding
Sexual IntercourseMay resume whenRed bleeding ceasesVagina and vulva are healedPhysically comfortableEmotionally ready
*Physical readiness usually takes ~3 weeks
Concerns - Puerperal Period
Hemorrhage
Postpartum HemorrhageExcessive blood loss during or after the 3rd stage of laborAverage blood loss is 500 mL
Early postpartum hemorrhage1st 24 hrs after deliveryLate postpartum hemorrhage1-2 weeks after delivery (most common)May occur up to 6 weeks postpartum
Postpartum HemorrhageIncidenceVaginal birth: 3.9%Cesarean: 6.4%
Delayed postpartum hemorrhage: 1-2%
Mortality5% of maternal deaths
Postpartum HemorrhageMay result from:Uterine atonyLower genital tract lacerationsRetained products of conceptionUterine ruptureUterine inversionPlacenta accretaadherence of the chorionic villi to the myometriumCoagulopathyHematomaMost common
Uterine AtonyLack of closure of the spiral arteries and venous sinuses
Risk factors:Overdistension of the uterus secondary to multiple gestationsPolyhydramniosMacrosomiaRapid or prolonged laborGrand multiparityOxytocin administrationIntra-amniotic infection
Lower genital tract lacerationsResult of obstetrical traumaMore common with operative vaginal deliveriesForcepsVacuum extraction
Other predisposing factors:MacrosomiaPrecipitous deliveryEpisiotomy
Infection
EndometritisAscending polymicrobial infectionUsually normal vaginal flora or enteric bacteria
Primary cause of postpartum infection1-3% vaginal births5-15% scheduled C-sections30-35% C-section after extended period of laborMay receive prophylactic antibiotics
EndometritisRisk factors:C-sectionYoung ageLow SESProlonged laborProlonged rupture of membranes
Multiple vaginal examsPlacement of intrauterine catheterPreexisting infectionTwin deliveryManual removal of the placenta
EndometritisClinical presentationFeverChillsLower abdominal painMalodorous lochiaIncreased vaginal bleedingAnorexiaMalaise
Exam findingsFeverTachycardiaFundal tenderness
TreatmentAntibiotics
Urinary Tract InfectionBacterial inflammation of the bladder or urethra
3-34% of patientsSymptomatic infection in ~2%
Urinary Tract InfectionRisk factorsC-sectionForceps deliveryVacuum deliveryTocolysisInduction of laborMaternal renal disease
PreeclampsiaEclampsiaEpidural anesthesiaBladder catheterizationLength of hospital stayPrevious UTI during pregnancy
Urinary Tract InfectionClinical PresentationUrinary frequency/urgencyDysuriaHematuriaSuprapubic or lower abdominal painORNo symptoms at allExam FindingsStable vitalsAfebrile Suprapubic tenderness
Treatmentantibiotics
MastitisInflammation of the mammary glandMilk stasis & cracked nipples contribute to the influx of skin flora
2.5-3% in the USANeglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)
MastitisClinical PresentationFeverChillsMyalgiasWarmth, swelling and breast tenderness
Exam FindingsArea of the breast that is warm, red, and tender
TreatmentMoist heatMassageFluidsRestProper positioning of the infant during nursingNursing or manual expression of milkAnalgesics
Antibiotics stasis
Wound InfectionPerineum (episiotomy or laceration)3-4 days postpartumrare
Abdominal incision (C-section)Postoperative day 43-15% prophylactic antibiotics2%
Wound InfectionPerineum Risk Factors:Infected lochiaFecal contaminationPoor hygiene
Abdominal incision Risk factors:DiabetesHypertensionObesityCorticosteroid treatmentImmunosuppressionAnemiaProlonged laborProlonged rupture of membranesProlonged operating timeAbdominal twin deliveryExcessive blood loss
Wound InfectionClinical Presentation
Perineal Infection:PainMalodorous dischargeVulvar edema
Abdominal InfectionPersistent fever(despite antibiotics)DiagnosisErythemaIndurationWarmthTendernessPurulent drainageWith or without fever
Endocrine Disorders
Postpartum Thyroiditis (PPT)Transient destructive lymphocytic thyroiditis occuring within the 1st year after deliveryAutoimmune disorder
Thyrotoxicosis1-4 months postpartum; self-limitedIncreased release (stored hormone)Hypothyroidism4-8 months postpartum
Postpartum Thyroiditis (PPT)~4% develop transient thyrotoxicosis66-90% return to normal33% progress to hypothyroid10-3% develop permanent thyroid dysfunction
Risk FactorsPositive antithyroid antibody testingHistory of PPTFamily or personal history of thyroid or autoimmune disorders
Postpartum Thyroiditis (PPT)Clinical PresentationFatiguePalpitationsEat intoleranceTremulousnessNervousnessEmotion liability
*mild & nonspecific (may go undiagnosed)
Hypothyroid Phase:FatigueDry skinCoarse hairCold intoleranceDepressionMemory & concentration impairment
Postpartum Thyroiditis (PPT)Exam findingsTachycardiaMild exopthalmosPainless goiter
Lab testingTSH i thyrotoxicosis TSH h hypothyroidTreatment
ThyrotoxicosisNo treatment (mild)Beta-blocker
HypothyroidNo treatment (mild)Thyroxine (T4)
Postpartum Graves DiseaseAutoimmune disorderDiffuse hyperplasia of the thyroid glandResponse to antibodies to the thyroid TSH receptorsIncreased thyroid hormone production and release
Les common than PPTAccounts for 15% of postpartum thyrotoxicosis
Psychiatric Disorders
Postpartum BluesTransient disorderLasts hours to weeksBouts of crying and sadness
Postpartum Depression More prolonged affective disorderWeeks to monthsS&S of depression
Postpartum PsychosisFirst postpartum yearGroup of severe and varied disorders (psychotic symptoms)
EtiologyUnknownTheory: multifactorial
Stress Responsibilities of child rearingSudden decrease in endorphins of labor, estrogen and progesteroneLow free serum tryptophan (related to depression)Postpartum thyroid dysfunction (psychiatric disorders)
Incidence50-70% develop postpartum blues10-15% of new mothers develop PPD0.14-0.26% develop postpartum psychosis
History of depression30% chance of develping PPDHistory of PPD or postpartum psychosis50% chance of recurrence
Postpartum BluesMild, transient, self-limitingCommonly in the first 2 weeks
Signs and symptomsSadnessCryingAnxietyIrritationRestlessness
Mood labilityHeadacheConfusionForgetfullnessInsomnia
Postpartum BluesOften resolves by postpartum day 10No pharmacotherapy is indicated
TreatmentProvide support and education
Postpartum Depression (PPD)Signs and symptomsInsomnia LethargyLoss of libidoDiminished appetitePessimism
Incapacity for familial loveFeelings of inadequacyAmbivalence or negative feelings towards the infantInability to cope
Postpartum Depression (PPD)Consult a psychiatrist ifComorbid drug abuseLack of interest in the infantExcessive concern for the infants healthSuicidal or homicidal ideationsHallucinationsPsychotic behaviorOverall impairment of function
Postpartum Depression (PPD)Lasts 3-6 months25% are still affected at 1 yearAffects patients ADLs
TreatmentSupportive care and reassurance (healthcare professionals and family)Pharmacological treatment for depressionElectroconvulsive therapy
Postpartum PsychosisSigns and symptomsAcute psychosisSchizophreniaManic depression
Postpartum PsychosisTreatmentTherapy should be targeted to the patients specific symptomsPsychiatristHospitalization
*Generally lasts only 2-3 months