Puerperal venous thrombosis, pulmonary embolism, obstetric palsies, psychiatric disorders during the puerperium, and psychological responses to perinatal death are some complications of the abnormal puerperium. Venous thrombosis is caused by genetic and acquired thrombophilias as well as risk factors like obesity, infections, and trauma. Pulmonary embolism is a leading cause of maternal death and can cause sudden collapse. Obstetric palsies like foot drop are caused by pressure on the lumbosacral trunk during labor. Psychiatric disorders include the blues, postpartum depression, and postpartum schizophrenia. Psychological support is important to facilitate grieving when perinatal death

1. Continued…….
Abnormal
puerperium
Dilip Kumar H.R.
VIII Term

2. • Puerperal venous thrombosis
• Pulmonary embolism
• Obstetric palsies
• Psychiatric disorder during puerperium
• Psychological response to perinatal death.
2

3. Puerperal
Thrombosis

4. Puerperal Thrombosis
Leg vein & pelvic vein is one of the
complication in western countries.
 However the prevalence is low in Asians
& Africans.
Etiopathogenesis
In normal pregnancy there is rise in
concentration of coagulation factors 1, 2,
7, 8, 9, 10, 12. plasma fibrinolytic inhibitors
produced by placenta.
Alteration in blood constituents- increased
number of platelet & their adhesiveness.

5. Venous stasis is increased due to
compression of gravid uterus to IVC & iliac
veins. This stasis cause damage to
endothelial cells.
Thrombophilias are the genetic condition
associated with deficiencies of
antithrombin3 protein C .
Acquired thrombophilias are due to
presence lups anticoagulant &
antiphospholipids antibodies.

6. Risk factors:
Advanced age & parity
Operative delivery
Obesity
Anemia & heart disease.
Trauma to venous vessel wall.
Infections
DVT.
C/F: Asymptomatic,pain in calf muscle,
edema of leg, rise skin temperature.
Homan’s sign.

7. Investigations:
Doppler ultrasound.
Duplex Doppler ultrasound.
Venography.
Pelvic Thrombophlibits.
 C/F:usually develop after 2nd
weeks of
puerperium.
 Fever with chills & rigors.
Feature of toxemia i.e. headache, malaise
& rising pulse.
Affected leg is painful, swollen & cold.
Polymorph nuclear leucocytosis.

8. Prophylaxis for VTEPreventive measures.
 low & high risk woman.
Management
 bed rest & foot is raised.
 Analgesics, Abs
 Anticoagulants
 Gentle movements of the leg after relief of
pain.
 Vena caval fillers
 Fibrinolytic agents
 Venous thrombectomy.

9. Pulmonary
Embolism.
..............

10. 10
Pulmonary Embolism.
It is leading cause of maternal death.
Because of decline of maternal mortality
due to hemorrhage, hypertension &
sepsis.
Death occurs with in short time from shock
& vagal inhibition.

11. Clinical feature
Sudden collapse, acute chest pain & air
hunger these are classical symptoms of
massive pulmonary embolism.
Tachyponea,dysponea,pleuritic chest
pain, cough , tachycardia, haemoptysis &
rise in temperature > 37 degree Celsius
11

12. Diagnosis
X-ray of the chest shows decreased
vascular marking in area of infraction,
elevation of dome of diaphragm & often
pleural effusion.
It is useful to rule out
pnemonia,atelactasis.
ECG:tachycardia.
 Doppler ultrasound : ? DVT.
12

13. Lung scan : ? Area of diminished blood
flow.Diminised in perfusion with
maintenance ventilation indicate PE.
MRI: risk of radiation is absent.
Pulmonary angiography: most accurate
method of diagnosis.
13

14. Treatment
Resuscitation
I.V.fluid support
Thrombolytic therapy
Digitalis
Recurrent attack require embolectomy.
14

15. ………………..
Obstetric palsies

16. 1
Obstetric palsies
• The commonest form of palsy
encountered in puerperium is FOOT
DROP.
• It is usually unilateral & appears shortly
after the delivery.
Etiology
• Streching of the lumbo-sacral trunk by
prolapsed inter vertebral disc b/w L5&s1.

17. • Backward rotation of the sacrum during
labour
• Direct pressure by fetal head or by
forceps blade on lumbosacral cord.
Clinical feature.
1.Asymptomatic.
2.Flacidity & wasting of muscle.
3.Loss sensation.
2

18. • Management
• Bed rest for 6 wks.
• A splint is applied to prevent damage of
over stretch muscle.
• Massage & electric stimulation of the
muscle.

19. Psychiatric disorder
during Puerperium

20. 20
 1st 3 month after delivery the incidence of
mental illness is high.
 Overall incidence is 15-20%
Risk factors:
 Past H/O: mental illness, puerperal
psychiatric illness.
 Family H/O: psychiatric illness, marital
conflict.
 Present pregnancy: Caesarean section,
difficult labour, neonatal complication.
 Idiopathic.

21. Puerperal BLUES
 It is transient state of mental illness observed 4-5
days after delivery & it last for few days.
 50% of the postpartum women suffer from
problem.
 Clinical manifestation:
 Depression, anxiety, tearfulness, insomnia,
helplessness & negative feelings towards infant.
 No specific metabolic or endocrine abnormalities
have been detected. But lowered tryptophan level
is observed.
 It suggest altered neurotransmitter function.
 Treatment reassurance & psychological support
by the family.

22. Postpartum DEPRESSION
It is seen 10-20% of mothers.
It is more gradual onset, occurs 1st
4-6
months after delivery or abortion.
Changes in HypoThalamopitutaryarenal
axis may the cause.
Manifested by loss appetite, insomnia,
social withdrawal, irritability & even
suicidal tendency.
Risk of recurrence is high (50-100%) in
subsequent pregnancy .

23. Treatment
Fluoxetin or paroxetine.
General support is essential.
Overall prognosis is good.

24. SCHIZOPHRENIA
About 1in 500-1000 mothers.
 Seen in woman with past H/O psychosis or with
positive family H/o.
 Relatively sudden in onset with in 4 days after
delivery.
 Manifestation:
 Fear, restless, confusion followed by
hallucination, delusion and disorientation.
 Suicidal, infanticidal impulse may be present.
 Risk of recurrence in subsequent pregnancy is
20-20%.

25. Treatment
Psychiatrist consulted urgently.
Admission needed.
Chlorpromazine 150mg stat & 50-150mg
thrice daily.
ECT: needed if unresponsive case.
Lithium is indicated in manic depressive
psychosis & breast feeding
contraindicated.

26. Psychological response
to perinatal death.

27. Psychological response to
perinatal death.
Most perinatal events are joyful.
But when perinatal death occurs special
attention must given to grieving patient &
her family.
Perinatal grieving may also be due to
unexpected hysterectomy, birth
malformed, critically ill infant.
Obstetrician, nurse & attending staff must
understand the patient reaction.

28. Management.
Facilitating the grieving process, support &
sympathy.
Supporting the couple in holding or taking
photograph of the infant .
Requesting for autopsy .
Follow up visits & plan for subsequent
pregnancy.