PUERPERIUM
• Uterine involution: This process mostly occurs as a result of reduction in myometrial cell sizes. Immediately after birth, the uterus is at the level of the navel. It descends to the symphysis pubis level in the 1st week postpartum and to the pelvis in the 2nd week. Uterine involution approximately postpartum
It is completed in the 6th week.
• Endometrium: While regeneration occurs in the stroma and glands in the decidua basalis, the decidua superficialis is excreted as lochia. It contains erythrocytes, fragmented decidua, epithelial cells, bacteria and leukocytes. It is called lochia rubra in the first few days, lochia serosa after 3 or 4 days, and lochia alba after the 10th day, and the total lochia lasts 24-36 days.
• Cervix: Complete healing and reepithelialization postpartum 6-12. It will be a week later.
• Vagina: The vagina returns to its antepartum state in the 3rd week. Torn hymen mucosa! It heals as fibrous nodules and is called caruncle mirtiformis.
• Urinary system: Blood urea nitrogen increases in the puerperium.
• Hormones: Placenta right after birth! blood levels of hormones decrease. Maternal serum levels of hPL decrease to undetectable levels at the end of the 1st day. hCG, postpartum 11-16. disappears completely in a day. Plasma prolactin level decreases during the 2nd week after delivery and returns to the pre-pregnancy level; however, in lactating women, an increase in its level is observed during lactation. FSH and LH levels rise to normal levels in the 2nd week.
PUERPERAL DISEASES
Puerperal Fever
• Having a fever of 38 °C after birth. Fever in the first 24 hours postpartum
While 20% are due to pelvic infections, the most common cause of persistent postpartum fever is genital tract infections.
• The most common cause of virulent pelvic infection that causes fever in the first 24 hours postpartum is group A streptococci. Other causes are breast engorgement, pyelonephritis and respiratory complications after cesarean section.
Breast Engagement
• Occurs due to vascular and lymphatic stasis. The breasts are heavy, hard, painful, warm and tender on palpation. The patient may have a fever of 37.8-39°C but rarely lasts more than 4-16 hours. 2-4 days after birth. It is seen especially in women who do not breastfeed during the day. It can occur at any time during the periods when breastfeeding is interrupted.
• It is treated with conservative methods such as tight bra, cold application, analgesics. Lactation suppression is not recommended in breast engorgement.
mastitis
• It is a regional infection of the breast parenchyma. Usually the causative Staph. aureus and the source is usually the baby's nose and throat flora. More than 50% of cases occur in primiparous cases and are almost always unilateral. It is characterized by fever, chills, focal unilateral breast erythema, edema, and tenderness. Usually 3-4 postpartum. seen in weeks.
• In treatment, resolution of ductal obstruction (breastfeeding, pumping), analgesics, antibiotics (dicloxacillin 10-14 days) are applied. of patients
Abscess formation is seen in 10% of them. Mastitis usually responds to treatment in 48-72 hours, if not, breast abscess should be considered.
Postprtum Endometritis
• Polymicrobial infection of the endometrium and often includes the underlying myometrium. The most common puerperal infection is endometritis.
• Streptococcus is the most common cause in those seen in the early postpartum period.
Chlamydia is the most common cause of late endometritis. Vaginal
seen less than 5% after birth; The risk increases 5-10 times with cesarean section.
Endometritis risk factors
1. Cesarean section (most important risk factor)
2. Premature rupture of membranes
3. Multiple vaginal exams
4. Manual removal of the placenta
5. Internal fetal monitoring
6. Prolonged labor
7. Multiple pregnancy
8. Birth at a young age
9. Nulliparity
10. Obesity
11. Prolonged induction 12. Cesarean section with meconium contamination
13. General anesthesia
• Fever (the most important finding in the diagnosis), uterine tenderness, foul-smelling vaginal discharge and increase in vaginal bleeding are seen. It is most commonly seen 5-10 days after birth. Placenta! D&C is applied if fragment retention is considered. Broad-spectrum antibiotics (clindamycin + gentamicin + ampicillin) are used until the patient recovers clinically and is afebrile for 24 hours.
• If the fever does not decrease or the general condition of the patient does not improve despite antibiotic treatment, MRI or CT should be performed for differential diagnosis. In patients treated for endometritis, the most common cause of persistent fever exceeding 48-72 hours despite antibiotic therapy is wound infection. Incisional abscess after cesarean section causes fever from the 4th day.
• Conditions to be considered in cases resistant to antibiotic therapy:
► Wound infection and incision abscess
► Parametrial phlegmon (dense cellulite area)
► Pelvic abscess
► Infected hematoma
► Septic pelvic thrombophlebitis
Septic Pelvic Thrombophlebitis (SPT)
• Bacterial infection of the placenta can lead to thrombosis and thrombophlebitis in the myometrial veins. Clinically, fever, sweating and chills and abdominal pain are observed. It is detected more frequently after cesarean sections. It is considered if the picture of endometritis does not regress despite antibiotic treatment and no abscess formation is observed in ultrasonography.
• Pelvic veins adjacent to uterus accompany the picture. It causes 30-40% septic pulmonary embolism. The most common involvement is ovarian veins (v.ovarica dextra).
• Diagnosis is made by pelvic computed tomography and magnetic resonance imaging. Today, the use of heparin in treatment is controversial.
Necrotizing Fasciitis
• It is a necrotic infection of the superficial fascia spreading to the abdominal wall, hips and thighs. Group A streptococci and anaerobes are the most common agents. Diabetes, obesity and hypertension are important risk factors for necrotizing fasciitis.
• Although the skin is normal, there is extensive necrosis in the superficial fascia and subcutaneous tissue. True gangrene occurs with skin edema, blue-brown discoloration, loss of sensation or hyperesthesia. It can cause septicemia and shock. Maternal mortality is close to 50%. Early diagnosis, aggressive surgical debridement and broad-spectrum antibiotics should be used.
Obstetric Neuropathy
• Nulliparity can be seen due to prolongation of the second stage of labor and prolonged straining in the semifowler position. The most common obstetric neuropathy is lateral femoral cutaneous neuropathy. In addition, common fibular nerve damage may occur due to external compression in long-term deliveries.
Postpartum Urinary Retention
• The patient should urinate within 4 hours after birth. Risk factors for retention; primiparity, perineal lacerations, oxytocin induction delivery, operative vaginal delivery, urinary catheterization during delivery, and delivery time exceeding 10 hours.
BREAST-FEEDING
• Conditions in which breastfeeding is contraindicated: Alcohol use, HIV infection, tuberculosis without active treatment, breast cancer treatment, presence of galactosemia in the baby, maternal infectious mononucleosis (if the fetus is preterm) and human T-cell leukemia virus Type 1 and 2 infection, maternal cocaine, heroin and marijuana use.
• Situations where breastfeeding is not contraindicated: CMV in the mother (if asymptomatic infection and fetus is term), HBV
(if the baby was given immunoglobulin) and HCV infection.