4. Análisis e interpretación de resultados
6.13 La universidad como contexto
A number of serious complications and majority of maternal deaths occur in the post partum period especially in developing countries. Post partum hemorrhage, puerperal infections, venous thrombosis and post partum psychological problems account for majority of the cases. Some antenatal complications notably pre eclampsia- eclampsia may also continue to manifest in the post partum period. Urinary tract and breast problems also cause significant morbidity in the post partum period. HIV infected mothers deserve special attention because they are at a significant risk of developing some post partum complications like puerperal sepsis, massive codylomata accuminata and reactivation of TB.
Because of the practice of early discharge of mother and baby, it is essential that the women receive adequate verbal and written instructions regarding danger signs. Caregivers should be able to detect these complications early and manage accordingly. If necessary, the care may include transport to a place where appropriate treatment can be provided.
8.4.2. Puerperal sepsis
8.4.2.1. Definition
8.4.2.2. Risk factors
• Low socio economic status
• Use of unsterile delivery technique • Operative delivery
• Premature rupture of the membranes • Long labors with ruptured membranes • Multiple pelvic examinations
• Retained products of conception • Genital lacerations
• Medical disorders (anemia, diabetes mellitus, HIV infection)
8.4.2.3. Etiology
Majority is caused by mixed organisms (aerobic and anaerobic bacteria) ascending from the vagina. Occasionally, exogenous organisms from unclean delivery may be the cause.
8.4.2.4. Types and presentation
I) Endomyometritis
• Infection of the endometrium and myometrium which usually starts from the placental site
• If untreated it will progress to pelvic peritonitis, generalized peritonitis, septicemia, septic shock and pelvic abscess.
• Patient presents with fever associated with lower abdominal pain and offensive lochia. There is tachycardia, temperature of greater than 38 0 C, and soft tender
uterus.
II) Wound infection
This includes infections of both abdominal wound and episiotomy Signs of episiotomy site infection include
• Persistent pain and offensive discharge from the site • Tender, indurated , swollen and reddened wound edges Signs of abdominal wound infection include
• Persistent pain,
• Fever with no apparent cause which persists to the fifth post operative day • Tender, indurated , swollen and reddened wound edges
8.4.2.5. Management
a. Endomyometritis
• Give a combination of antibiotics until the woman is fever free for 48 hours.
• Ampcillin 500 mg IV every 6 hours; PLUS gentamycin 80 mg lV TID PLUS Metronidazol 500 mg lV every 8 hours (do not give gentamicin if there is renal failure)
• If a retained placental fragment is suspected, perform evacuation and curettage under the umbrella of oxytocin using large curette.
• If fever is still present 72 hours after initiation of treatment, re-evaluate the patient and revise the diagnosis (Consider peritonitis, pelvic abscess and other febrile
b. Wound infection
• Remove sutures and drain abscess if any • Local wound care with anti septic solutions
• Antibiotics are not usually needed unless there are systemic signs • Secondary closure may be needed after signs of infection has cleared
8.4.2.6. Management of complicated cases (Peritonitis and pelvic
abscess)
• Provide nasogastric suction • Infuse IV fluids
• Give a loading dose of combination of antibiotics
• Refer the patient to a hospital where appropriate treatment can be provided
8.4.3. Breast complications
8.4.3.1. Breast engorgement
• Breast engorgement occurs secondary to lymphatic and venous congestion (not from over distension of the breast with milk).
• Both breasts are swollen, tender, tense, and warm.
• Temperature may be mildly elevated but does not exceed 38oC.
• Management includes expression of milk by hand or with a pump or breast- feeding the neonate.
• Support breast with a binder or brassiere and apply cold compress to the breasts.
8.4.3.2 Acute postpartum mastitis
• Is an infectious condition of the breast caused by staphylococcus aureus • Usually presents near the end of the first week post partum
• Involves one of the breasts (unilateral). • If not treated may end up in breast abscess
• Presenting complainants include fever, chills, and painful swelling of the breast • Patient is tachycardic with temperature greater than 38oC hot and tender swollen
breast. In case of abscess formation there will be tender fluctuant mass
• Management includes Cloxacillin 500 mg per mouth QID for seven days, antipyretics, and support of breast with bra and cold compress. Breast feeding can be continued. If abscess is diagnosed in addition to the above measures incision and drainage will be done.
8.4.4. Deep vein thrombosis
• Pregnant women are at increased risk of deep vein thrombosis because of increased coagulation factor during pregnancy and are dangerous because it may lead to pulmonary embolism.
• The most important single predisposing factor is prolonged bed rest.
• Presenting symptoms include painful swelling of the legs, occasionally associated with fever. Thighs and calves are swollen and tender with positive “Hofman’s sign”(pain on dorsi flexion of the foot)
• Early ambulation of mother in post partum period largely prevents this complication.
8.4.5. Acute urinary retention
A post partum women is liable to develop acute urinary retention because of • Massive post partum diuresis
• Atonic bladder from prolonged labor or operative deliveries • Laceration of the genital tract causing pain on micturation
Women may complain of increasing constant dull pain in lower abdomen with occasional overflow incontinence. Uterus is pushed up in the abdomen with cystic tender supra pubic mass.
Management includes
- Encouraging the mother to void in sitting position. (Sound of tap water may help) - If not, intermittent catheterization of the bladder.
8.4.6. Psychosocial Complications
Three different types of postpartum psychosocial disorders have been described.
i. Postpartum blues
It is characterized by mild mood disturbances, marked by emotional instability (crying spells apparently with no cause, insomnia, exaggerated cheerfulness, anxiety, tension, head ache, irritability, etc). Usually the complaints develop with in the first postpartum week and continue for several hours to a maximum of ten days and then disappear spontaneously. The management is for one of the medical or nursing staff to talk with the woman, explaining what is occurring, and restricting visitors.
ii. Postpartum depression
- It is a more protracted depressive mood with complaints of affective nature; the woman is gloomy, depressed, irritable, sad, insomniac, anorexic, poor concentration, and loss of libido.
- Management requires support and encouragement & treatment may include referral for psychotherapy and antidepressants,
iii. Puerperal Psychosis
- Symptoms usually start at the end of the first week, sometimes in the second week, seldom later and tend to recur in the next pregnancy.
- The woman is anxious, restless, and sometimes manic with paranoid thoughts or delusions. She reacts abnormally towards her family members
- Management is referral for psychotherapy and anti psychotic treatment. The neonate should be isolated from the mother.