Disorders in the puerperium

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Chapter 23 Disorders in the puerperium

POSTPARTUM HAEMORRHAGE

Primary postpartum haemorrhage is a blood loss per vaginam of more than 500 mL in the first 24 hours after birth. Secondary postpartum haemorrhage is defined as abnormal bleeding from 24 hours after birth until 6 weeks postpartum.

Primary postpartum haemorrhage (PPH)

Recently many centres are reporting an increase in the rates of postpartum haemorrhage. The reasons for this are not resolved but factors such as increased operative deliveries, multiple pregnancies, obesity and changes in obstetric practice including longer duration of labour and delays in administering prophylactic oxytocics have been postulated as possible contributors.

• If the placenta cannot be delivered or if, when it is delivered, inspection shows that it is incomplete, the uterine cavity must be explored. Unless the patient already has an epidural anaesthetic, a general anaesthetic is given and manual removal of the placenta is effected by inserting a gloved hand into the uterine cavity and controlling its actions with the other hand placed on the fundus (Fig. 23.2). The umbilical cord is followed to its insertion and the lower placental edge is identified. With the palm of the intra-uterine hand facing the uterine cavity, the obstetrician separates the placenta from its attachments with a sawing motion. When the placenta has been completely detached, the remainder of the uterine cavity is explored for further placental remnants and damage. This completed, the placenta is grasped by the hand in the uterus and the membranes are pulled out of the birth canal while the external hand massages the fundus. The placenta is inspected carefully to ensure that it is complete. Ergometrine 0.5 mg is then injected intravenously and 0.5 mg is given intramuscularly.

Fig. 23.2 Manual removal of the placenta.

True postpartum haemorrhage (placenta expelled)

Several stages are involved:

• Check the placenta to determine if it is complete.

• Massage the uterus with a slow, rotary movement.

• Set up an infusion of Hartmann’s solution and give 0.25 mg of ergometrine intravenously or Syntocinon by continuous infusion (10 IU in 500 mL Hartmann’s solution). Alternatives are Syntometrine or misoprostol 800 μg given rectally. As Syntometrine is contraindicated if the mother has hypertension, misoprostol may be preferred. In cases of severe PPH (a loss estimated at over 1000 mL) due to a hypotonic uterus, carboprost (15-methyl-PGF_2α) 5 mg diluted in 20 mL saline, i.e. 1 mg/4 mL, is given; 1 mL is injected directly into the myometrium and repeated every 15 minutes if there is no response. Gemeprost pessaries can be placed directly into the uterine cavity and are another effective uterotonic agent.

• If the blood loss is more than 1000 mL, a blood transfusion may be needed.

• Check blood samples for coagulation defects and, if present, treat.

• If bleeding continues in spite of firm uterine contractions induced by the oxytocics mentioned, inspect the genital tract for lacerations.

• If bleeding persists, try bimanual compression of the uterus (Fig. 23.3). This is painful to the patient and tiring to the obstetrician.

• If bleeding persists, insertion of an intrauterine balloon catheter can provide effective compression on the placental bed

• If bleeding persists then operative intervention including the placement of a B-Lynch suture to compress the uterine fundus, internal iliac artery ligation or hysterectomy may have to be performed.

• In situations where the bleeding is persistent or when major haemorrhage is anticipated such as with placental percreta, cannulation of the uterine arteries followed by embolization can be life saving and also enable retention of the uterus.

Fig. 23.3 Bimanual compression of the uterus.

Secondary postpartum haemorrhage

The most common causes of secondary postpartum haemorrhage are:

• Poor epithelialization of the placental site (80% of cases)

• A retained placental fragment and/or blood clots.

An ultrasound scan of the uterus will identify placental tissue or clots. The uterus may be bulky and tender and the cervix open. The initial treatment is to give ergometrine 0.5 mg intramuscularly, repeated if needed; and antibiotics are given to control any infection present. Curettage is only needed if placental tissue or clots are found in the uterus by ultrasound scanning, or if bleeding persists in spite of the oxytocics.

PUERPERAL INFECTION

Puerperal infection (puerperal pyrexia) is defined as a rise in temperature to 38 °C or more, maintained for 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion. In recent years, because of better obstetric care, better hygiene and better control of infection in hospitals, the incidence of puerperal pyrexia has fallen to 1–3% of all births or abortions.

The infection may be genital or non-genital. The main causes and the probable infecting agent are shown in Table 23.1.

Table 23.1 The main bacterial causes of infection in the puerperium

Genital infection	%
Potential pathogens which normally inhabit the vagina:
Anaerobic streptococci	65–85
Anaerobic Gram-negative bacilli	5
Haemolytic streptococci (other than group A)	1
Bacteria introduced from adjacent viscera:
E. coli	5–15
Cl. welchii	Rare
Bacteria introduced from distant organs or from outside:
Staphylococci	5–15
Streptococcus haemolyticus (group A)	3
Mycoplasma hominis	Rare
Non-genital infection
Urinary tract infection: E. coli Breast infection: Staphylococci (mainly from the baby)

Site and spread of the infection

Most cases of puerperal infection arising in the genital tract are ascending infections from the vagina or cervix that infect the placental bed. Spread from here is either into the parametrium or, via the uterine cavity, to the Fallopian tubes and, in some cases, onwards to cause pelvic peritonitis.

The severity of the infection depends on the virulence of the infective agent and the patient’s immune response.

Diagnosis

Any woman who develops puerperal pyrexia should be investigated and may require to be isolated. The breasts are examined for signs of mastitis and a midstream urine specimen is examined to exclude urinary tract infection. An abdominal examination may reveal a tender, bulky uterus. The lower genital tract is inspected for infected lacerations, tears or episiotomy wound. A high vaginal swab is made for bacteriological examination, and the lochia smelt for an offensive odour.

Treatment

Treatment consists of giving broad-spectrum antibiotics appropriate for the infecting agents. The combination of intravenous once-daily gentamicin (5 mg/kg) and clindamycin (2700 mg) or three times daily gentamicin 1.5 mg/kg and clindamycin 900 mg until the woman has been afebrile for 24–48 hours are both effective in most cases. If there is not a rapid response then the hospital infection disease control officer should be consulted, whether the woman is in hospital or is being treated by her general practitioner at home.

THROMBOEMBOLISM

Thrombosis of a vein may occur in pregnancy (see p. 125) or, more commonly, in the puerperium, usually between days 5 and 15 of the puerperium. With better obstetric care and early ambulation, fewer women nowadays develop thromboembolic disorders in the puerperium. The incidence is fewer than 1 per 1000 births. The condition is more likely to occur in women who are overweight, over the age of 35, or who have had a caesarean section. Other risk factors include cardiac disease, diabetes and smoking. In 50 % an inherited or acquired thrombophilia can be identified.

The thrombotic process usually starts in the deep veins of the lower leg, but may extend into the femoral or pelvic veins before being detected, or may arise de novo in the pelvic veins. If these veins are involved, pulmonary embolism may occur. Pulmonary embolism affects 1 puerperal woman in 6000 in most developed western nations, and 1 affected woman in 5 dies.