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Puerperal Disorders — Comprehensive 10-Mark Answer

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Definition

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Classification of Puerperal Disorders

PUERPERAL DISORDERS
│
├── 1. Puerperal Pyrexia / Sepsis
├── 2. Puerperal Hemorrhage
│     ├── Primary (< 24 hours)
│     └── Secondary (24 hrs – 6 weeks)
├── 3. Puerperal Endometritis
├── 4. Wound & Perineal Infections
├── 5. Puerperal Mastitis & Breast Abscess
├── 6. Septic Pelvic Thrombophlebitis
└── 7. Puerperal Psychiatric Disorders
      ├── Baby Blues
      ├── Postpartum Depression
      └── Postpartum Psychosis

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1. Puerperal Pyrexia and Sepsis

• Incidence: 6–80 cases per 100,000 live births
• Case-fatality rate: ~3.5%
• Transmission: may be nosocomial or from household contacts with streptococcal pharyngitis

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2. Puerperal Endometritis

Epidemiology

Pathogenesis

• GBS (Group B Streptococcus)
• Anaerobic gram-positive cocci (Peptostreptococcus spp.)
• Aerobic gram-negative bacilli (E. coli, K. pneumoniae, Proteus)
• Anaerobic gram-negative bacilli (Bacteroides, Prevotella)
• Chlamydia trachomatis (late-onset endometritis)

Risk Factors

Clinical Features

• Fever ≥38°C within 36 hours of delivery
• Malaise, tachycardia
• Uterine tenderness, lower abdominal pain
• Malodorous lochia
• ± Tender inflammatory mass (broad ligament, cul-de-sac)

Treatment

• ~90–95% of patients defervesce within 48–72 hours
• IV antibiotics discontinued once afebrile and asymptomatic for ~24 hours
• Extended oral antibiotic course after discharge is not routinely necessary

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3. Postpartum Hemorrhage (PPH)

Classification

Because of maternal plasma volume expansion during pregnancy, the patient may not show signs of shock until >1500 mL of blood is lost.

The "Four Ts" — Causes of Primary PPH

Uterine Atony (Most Common)

• Uterus feels soft and boggy on examination
• Predisposing factors: multiple gestation, fetal macrosomia, polyhydramnios, prolonged labor, chorioamnionitis, tocolytic use, general anesthesia with halogenated agents

1. Bimanual uterine massage
2. Uterotonics: Oxytocin 10 units IM → IV infusion (up to 40 units total)
3. Misoprostol, carboprost, ergometrine if oxytocin fails
4. Balloon tamponade
5. Surgical: B-Lynch suture, uterine artery ligation, emergency hysterectomy

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4. Wound and Perineal Infections

• Extensive, rapidly spreading necrosis of skin and deep fascia
• Skin progresses: red → purple → blue → blisters/bullae → frank gangrene
• "Pain out of proportion" to injury is a key clinical clue
• Management: Broad-spectrum IV antibiotics (clindamycin + vancomycin + gentamicin/aztreonam) plus aggressive surgical debridement — life-saving

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5. Puerperal Mastitis and Breast Abscess

• Severe pain, tenderness, swelling, redness of breast
• Fever, chills, myalgias

• Staphylococcus aureus (40% of cases) — including community-acquired MRSA
• E. coli, Streptococcus spp.

• Frequent analgesia
• Continued breast emptying / breastfeeding (do not interrupt)
• Antibiotics: Antistaphylococcal penicillins or cephalosporins
• Do not give sulfamethoxazole-trimethoprim to lactating mothers with infants <2 months

• Complicates mastitis in ~3% of cases
• Ultrasound-guided drainage is first-line
• Surgical drainage reserved as last resort (risk of milk fistula)

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6. Septic Pelvic Thrombophlebitis

1. Acute thrombosis of one ovarian vein — fever, flank pain, palpable tender mass
2. Enigmatic fever — persistent fever despite adequate antibiotics, no localizing signs

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7. Puerperal Psychiatric Disorders

A. Postpartum Blues ("Baby Blues")

• Affects up to 65% of mothers
• Onset: day 2–5 postpartum
• Features: tearfulness, mood lability, anxiety
• Self-limiting within 2 weeks
• Management: reassurance and support

B. Postpartum Depression (PPD)

• Affects 3–6% of women (DSM-5)
• Onset: during pregnancy or within 4 weeks of delivery (DSM-5 specifier: "with peripartum onset")
• Features: sustained depressed mood, anhedonia, guilt, sleep disturbance, cognitive impairment
• Risk factors: prior depressive episodes, bipolar disorder, family history, poor social support
• Management: psychotherapy, SSRIs, social support

C. Postpartum Psychosis

• Most severe form; rare (~1–2 per 1000 deliveries)
• Onset: within first 2 weeks postpartum
• Features: confusion, disorganized behavior, hallucinations (command hallucinations to harm infant), delusions
• Infanticide risk — psychiatric emergency requiring urgent hospitalization
• Strongly associated with bipolar disorder
• Management: antipsychotics, mood stabilizers, psychiatric hospitalization

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Summary Table — Puerperal Disorders at a Glance

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Prevention Highlights

• Antibiotic prophylaxis at cesarean delivery significantly reduces endometritis and wound infections
• Intrapartum GBS prophylaxis reduces chorioamnionitis and neonatal sepsis
• Chlorhexidine skin preparation preferred over povidone-iodine
• Skilled birth attendance and proper obstetric technique reduce birth trauma
• Early psychiatric screening in the postpartum period for PPD

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• Creasy & Resnik's Maternal-Fetal Medicine, Blocks 11 & 18
• Rosen's Emergency Medicine, Block 32
• Tintinalli's Emergency Medicine, Block 8
• Goldman-Cecil Medicine, Block 44
• Adams & Victor's Principles of Neurology, Block 18

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Puerperal Disorders — Complete Tabular Reference

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Table 1: Infectious Puerperal Disorders

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Table 2: Hemorrhagic Puerperal Disorders

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Table 3: Thromboembolic Puerperal Disorders

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Table 4: Puerperal Psychiatric Disorders

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Table 5: Other Puerperal Complications

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Quick-Reference Summary Card

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Puerperal Disorders — Complete Reference Table (Definition · Causes · Clinical Features · Management)

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Table 1: Infectious Puerperal Disorders

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Table 2: Hemorrhagic Puerperal Disorders

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Table 3: Thromboembolic Puerperal Disorders

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Table 4: Puerperal Psychiatric Disorders

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Table 5: Other Puerperal Complications

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Master Quick-Reference Summary

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Puerperal Disorders — Complete Point-wise Presentation

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PRELIMINARY NOTE

Puerperium = The 6-week period following delivery during which the maternal body returns to its pre-pregnant state. Puerperal disorder = Any pathological condition arising during this period.

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SECTION 1: INFECTIOUS PUERPERAL DISORDERS

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1. PUERPERAL PYREXIA / PUERPERAL SEPSIS

📌 Definition

• Temperature ≥ 38°C (100.4°F) occurring on any two of the first 10 days postpartum, excluding the first 24 hours
• Any fever ≥ 38.5°C in the first 24 hours is also significant
• Caused by Group A Streptococcal (GAS) bacteraemia in classical puerperal sepsis

🔴 Causes

• Primary organism: Streptococcus pyogenes (Group A Streptococcus)
• Nosocomial transmission from healthcare workers
• Household transmission from children/family with streptococcal pharyngitis
• Women are discharged at 48 hours, so home acquisition is common
• Other organisms: E. coli, anaerobes, Staphylococcus aureus

🟡 Clinical Features

• Fever — high grade, rapid onset
• Abdominal pain — severe, diffuse
• Hypotension — disproportionate to apparent severity
• Deceptively absent tachycardia or leukocytosis in early GAS sepsis
• Onset typically within 4 days of delivery
• Incidence: 6–80 cases per 100,000 live births
• Case-fatality rate: approximately 3.5%
• Higher risk: vaginal delivery, young age, prior streptococcal exposure

🟢 Management

• Blood cultures before starting antibiotics
• IV Penicillin G or ampicillin — first-line
• Clindamycin added if toxic shock syndrome suspected (inhibits toxin production)
• IV fluid resuscitation
• ICU admission if septic shock develops
• Source control — drain any abscess
• Notify public health if nosocomial cluster suspected

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2. PUERPERAL ENDOMETRITIS

📌 Definition

• Infection of the uterine endometrium (and often extending to myometrium)
• Arises within the first 10 days postpartum
• Most common cause of puerperal fever
• Incidence: 5–35% depending on mode of delivery and prophylaxis

🔴 Causes

• Polymicrobial ascending infection from normal vaginal flora
• Key organisms:
  • Group B Streptococcus (GBS)
  • Anaerobic gram-positive cocci (Peptostreptococcus)
  • Aerobic gram-negative bacilli (E. coli, K. pneumoniae, Proteus)
  • Anaerobic gram-negative bacilli (Bacteroides, Prevotella)
  • Chlamydia trachomatis — late-onset endometritis
  • Mycoplasma hominis, Ureaplasma urealyticum — minor role
• Risk factors:
  • Caesarean delivery (greatest single risk factor)
  • Intraamniotic infection (chorioamnionitis)
  • Prolonged labour and ruptured membranes
  • Multiple vaginal examinations during labour
  • Internal fetal monitoring
  • Young maternal age
  • Pre-existing GBS, gonorrhoea, or bacterial vaginosis

🟡 Clinical Features

• Fever ≥ 38°C within 36 hours of delivery
• Uterine tenderness on palpation
• Malodorous (foul-smelling) lochia — hallmark
• Lower abdominal pain
• Tachycardia
• Malaise, lethargy
• ± Tender indurated mass in broad ligament or posterior cul-de-sac
• Raised WBC count
• Differential includes: UTI, perineal infection, mastitis, wound infection, atelectasis, DVT

🟢 Management

• First-line regimen:
  • Clindamycin 900 mg IV q8h + Gentamicin 5 mg/kg IV q24h
• Add Ampicillin 2 g IV q6h if Enterococcus suspected or GBS with clindamycin resistance
• Alternative single agents: ampicillin-sulbactam, piperacillin-tazobactam, imipenem
• 90–95% of patients defervesce within 48–72 hours
• Discontinue IV antibiotics once afebrile and asymptomatic for ~24 hours
• No routine oral antibiotics required after discharge
• Failure to respond → suspect: resistant organism, wound abscess, pelvic abscess, septic pelvic thrombophlebitis, or drug reaction

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3. PUERPERAL MASTITIS

📌 Definition

• Inflammatory infection of the breast parenchyma occurring in the postpartum lactating period
• Typically presents in the second postpartum week
• Caused by bacterial infection secondary to milk stasis and retrograde ductal spread

🔴 Causes

• Staphylococcus aureus — 40% of cases (most common)
• Community-acquired MRSA — increasingly recognised
• Escherichia coli
• Streptococcus species
• Predisposing factors:
  • Milk stasis
  • Cracked or damaged nipples
  • Improper breastfeeding technique / poor latch
  • Infant separation
  • Prior history of mastitis

🟡 Clinical Features

• Severe unilateral breast pain
• Localised tenderness, swelling, redness
• Warmth over affected area
• Fever, chills, myalgias (systemic features)
• Usually affects one breast/quadrant
• USS: hypoechoic fluid surrounding subcutaneous fat lobules — no discrete collection
• Differentials: breast engorgement, plugged duct, inflammatory carcinoma (rare)

🟢 Management

• Continue breastfeeding — do NOT interrupt
• Frequent breast emptying (breastfeeding or pumping)
• Antibiotics:
  • Antistaphylococcal penicillin (flucloxacillin) or cephalosporins (first-line)
  • Clindamycin if penicillin-allergic
  • Vancomycin IV if MRSA suspected
  • Note: Sulfamethoxazole-trimethoprim contraindicated in lactating mothers with infants < 2 months
• Analgesics (ibuprofen/paracetamol)
• Warm compresses before feeding
• Reassess in 48 hours — if no improvement, evaluate for abscess

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4. BREAST ABSCESS

📌 Definition

• A localised collection of pus within breast tissue
• Complicates mastitis in approximately 3% of cases
• Characterised by discrete encapsulation of purulent material

🔴 Causes

• Staphylococcus aureus including MRSA
• Inadequate/delayed treatment of mastitis
• Milk stasis with bacterial superinfection
• Risk factors: cracked nipples, poor drainage, delayed antibiotic therapy

🟡 Clinical Features

• Discrete tender, fluctuant mass in breast
• Pointing/discharging pus through skin
• Persistent fever despite antibiotic treatment
• Ultrasound shows:
  • Hypoechoic (dark) fluid collection
  • Absence of vascular signals within collection
  • This distinguishes it from mastitis (no discrete collection)

🟢 Management

• Ultrasound-guided needle aspiration or drainage — first-line
• Antibiotics: cephalosporin, clindamycin, or IV vancomycin for MRSA
• Continue breastfeeding throughout treatment unless antibiotic is contraindicated in newborn
• Surgical drainage — reserved as last resort only
  • Risk of milk fistula in lactating patients
• Repeat USS to confirm resolution

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5. POST-CAESAREAN WOUND INFECTION

📌 Definition

• Infection of the abdominal surgical incision following caesarean delivery
• Occurs in approximately 3–5% of caesarean deliveries
• May be superficial (skin/subcutaneous) or deep (fascia/muscle)

🔴 Causes

• Staphylococcus aureus — most common
• MRSA — increasingly important
• Aerobic streptococci
• Aerobic and anaerobic gram-negative bacilli
• Risk factors:
  • Prolonged labour and ruptured membranes
  • Pre-existing intraamniotic infection
  • Obesity (major independent risk factor)
  • Insulin-dependent diabetes
  • Immunodeficiency or corticosteroid therapy
  • Poor surgical technique

🟡 Clinical Features

• Erythema, induration, tenderness at incision margins
• Purulent discharge from wound
• Onset typically day 3–8 postpartum
• ± Extensive cellulitis without frank pus in some patients
• Fever persisting despite antibiotic therapy for endometritis should raise suspicion
• Wound culture: routinely performed to exclude MRSA

🟢 Management

• Open wound completely to provide drainage
• Irrigate and repack with moist gauze 2–3 times daily
• Initial healing by secondary intention
• Antibiotics — modify to include antistaphylococcal coverage
• Vancomycin 1 g IV q12h if MRSA confirmed on culture
• In morbidly obese patients: suction wound device to enhance healing
• Secondary closure considered once healthy granulation tissue develops
• Prevention: chlorhexidine skin prep, preoperative antibiotic prophylaxis, clippers (not razor) for hair removal

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6. NECROTIZING FASCIITIS

📌 Definition

• A rapidly progressive, life-threatening deep-tissue infection involving subcutaneous tissue and fascia
• Characterised by extensive and rapidly spreading necrosis (gangrene) of skin and underlying structures
• Rare but potentially fatal complication of episiotomy or abdominal wound

🔴 Causes

• Mixed anaerobes + Streptococcus pyogenes
• Portal of entry: surgical incision, episiotomy, or cryptic (no visible entry point)
• Risk factors:
  • Insulin-dependent diabetes
  • Morbid obesity
  • Cancer or immunodeficiency
  • Corticosteroid therapy

🟡 Clinical Features

• "Pain out of proportion" to wound appearance — cardinal early sign
• Rapid spread both proximally and distally within 24 hours
• Skin progression:
  • Red → Purple → Blue (within 24–48 hrs)
  • → Blistering/bullae with clear yellow fluid
  • → Frank gangrene by day 4–5
  • → Extensive skin sloughing
• High fever, extreme prostration, tachycardia
• Bacteraemia frequently present
• Metastatic abscesses may form
• Elevated creatine phosphokinase (CK) — important clue
• Unexplained tachycardia + marked left shift on CBC
• CT/MRI: soft tissue swelling, no frank gas (not definitive)
• Biopsy with frozen section may confirm

🟢 Management

• SURGICAL EMERGENCY — immediate aggressive action required
• Wide surgical debridement of ALL necrotic tissue — most critical step
• Often requires repeated debridements
• IV antibiotics:
  • Clindamycin 900 mg IV q8h (or metronidazole 500 mg IV q12h)
  • + Vancomycin 1 g IV q12h
  • + Gentamicin 5 mg/kg IV q24h or Aztreonam 1–2 g IV q8h
• Maintain intravascular volume with crystalloid infusions
• Correct electrolyte abnormalities
• ICU admission and haemodynamic monitoring
• Consult experienced general or plastic surgeon

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7. URINARY TRACT INFECTION (UTI / PYELONEPHRITIS)

📌 Definition

• Bacterial infection of the lower (cystitis) or upper (pyelonephritis) urinary tract occurring in the puerperium
• Facilitated by catheterisation, bladder trauma, and urinary stasis during labour

🔴 Causes

• Escherichia coli — most common (80%)
• Klebsiella pneumoniae, Proteus mirabilis, Enterococcus
• Predisposing factors: urinary catheterisation, bladder overdistension, perineal trauma, urinary retention

🟡 Clinical Features

• Cystitis: dysuria, frequency, urgency, suprapubic pain, haematuria
• Pyelonephritis: fever, rigors, nausea/vomiting, costovertebral angle tenderness, flank pain
• Urinalysis: pyuria, bacteriuria, ± nitrites positive
• Raised WBC; urine culture confirms organism

🟢 Management

• Mid-stream urine (MSU) culture and sensitivity before starting antibiotics
• Cystitis: oral nitrofurantoin, trimethoprim, or cefalexin — 5–7 days
• Pyelonephritis: IV cephalosporin (ceftriaxone) or gentamicin
• Adequate oral/IV hydration
• Monitor for septicaemia
• Follow-up urine culture to confirm clearance

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8. PERINEAL / EPISIOTOMY INFECTION

📌 Definition

• Infection of the perineal body or episiotomy repair site characterised by wound breakdown, cellulitis, or abscess formation in the postpartum period

🔴 Causes

• Staphylococcus aureus, E. coli, mixed anaerobes, GBS
• Predisposing factors: haematoma formation, poor tissue apposition, prolonged labour, obesity, anaemia, immunosuppression

🟡 Clinical Features

• Perineal pain, swelling, purulent discharge from wound
• Wound dehiscence (wound edges separating)
• Foul-smelling discharge
• Fever
• Risk of extension to deeper fascia → necrotizing fasciitis

🟢 Management

• Wound debridement and opening of infected area
• Broad-spectrum antibiotics (covering gram-positives, gram-negatives, and anaerobes)
• Perineal hygiene — sitz baths, regular cleaning
• Delayed secondary repair after infection completely resolved
• Monitor for necrotizing fasciitis

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SECTION 2: HAEMORRHAGIC PUERPERAL DISORDERS

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9. PRIMARY POSTPARTUM HAEMORRHAGE (PPH)

📌 Definition

• Blood loss > 500 mL after vaginal delivery or > 1000 mL after caesarean delivery
• Occurring within the first 24 hours of delivery
• Most common complication of labour and delivery
• Accounts for up to 11% of obstetric deaths

🔴 Causes — "The Four Ts"

• Uterine atony risk factors: multiple gestation, fetal macrosomia, polyhydramnios, prolonged labour, chorioamnionitis, tocolytics, halogenated anaesthetic agents, multiparity
• Note: maternal plasma volume expansion means shock may not appear until > 1500 mL blood lost

🟡 Clinical Features

• Heavy, continuous vaginal bleeding
• Soft, boggy, enlarged uterus (atony)
• Visible perineal/vaginal/cervical tears (trauma)
• Signs of haemorrhagic shock: pallor, tachycardia, hypotension, cold clammy skin, reduced consciousness
• Failure to deliver placenta within 30 minutes (retained placenta)

🟢 Management

1. Bimanual uterine massage — stimulates contractions
2. Uterotonics:
   • Oxytocin 10 units IM immediately after delivery → IV infusion up to 40 units
   • Carboprost (prostaglandin F2α)
   • Misoprostol 800 mcg rectally
   • Ergometrine (avoid in hypertension)
3. IV fluids and blood transfusion — O-negative in emergency
4. Balloon tamponade (intrauterine balloon)
5. Surgical:
   • B-Lynch compression suture
   • Uterine artery ligation
   • Internal iliac artery ligation
   • Emergency peripartum hysterectomy — last resort
6. Interventional radiology — uterine artery embolisation
7. Repair lacerations with absorbable suture
8. Manual removal of retained placenta

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10. SECONDARY POSTPARTUM HAEMORRHAGE

📌 Definition

• Abnormal or excessive uterine bleeding occurring between 24 hours and 6 weeks postpartum

🔴 Causes

• Retained placental fragments — most common
• Subinvolution of placental site
• Endometritis
• Uterine arteriovenous malformation
• Coagulopathy (rare)

🟡 Clinical Features

• Heavy vaginal bleeding after initial normal recovery
• Uterine tenderness if infection coexists
• ± Offensive lochia
• Fever if endometritis present
• USS: echogenic material in uterine cavity (retained products)

🟢 Management

• Oxytocics (ergometrine, oral misoprostol)
• Antibiotics if infection present
• USS-guided surgical uterine evacuation (ERPC) if retained products confirmed
• Blood transfusion if severe haemorrhage
• Follow-up USS to confirm clearance

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11. UTERINE INVERSION

📌 Definition

• Rare but life-threatening condition where the uterine fundus collapses into or beyond the uterine cavity
• Occurs during the third stage of labour

🔴 Causes

• Mismanaged third stage — cord traction before placental separation
• Excessive fundal pressure (Credé manoeuvre)
• Fundal placentation
• Short umbilical cord
• Uterine atony
• Connective tissue disorders (rare)

🟡 Clinical Features

• Sudden severe abdominal pain
• Heavy haemorrhage
• Failure to palpate uterine fundus abdominally — key sign
• Visible or palpable mass at cervix, vaginal introitus, or protruding externally
• Profound haemorrhagic shock — often disproportionate to visible blood loss (vasovagal mechanism)

🟢 Management

• Do NOT remove placenta if still attached (causes massive haemorrhage)
• Manual replacement — Johnson manoeuvre:
  • Push fundus upward through cervix with palm
  • Apply steady continuous pressure
• Tocolytics to relax uterus: terbutaline, magnesium sulphate, or nitroglycerin
• IV fluids and blood transfusion
• Hydrostatic method (O'Sullivan technique) — warm saline into vagina under pressure
• Surgical correction (Huntington/Haultain procedure) if manual replacement fails
• Oxytocics only AFTER successful replacement

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12. UTERINE RUPTURE

📌 Definition

• A full-thickness disruption of all layers of the uterine wall
• A life-threatening obstetric emergency occurring during labour or early postpartum

🔴 Causes

• Previous uterine scar — LSCS (most common), myomectomy
• Obstructed labour
• Oxytocin misuse (excessive stimulation)
• Grand multiparity (thin myometrium)
• Uterine trauma
• Congenital uterine anomaly

🟡 Clinical Features

• Sudden severe abdominal pain — often with sudden cessation of contractions
• Fetal parts palpable outside uterus abdominally
• Fetal heart rate abnormalities or sudden loss of fetal heart rate
• Maternal haemorrhagic shock
• Vaginal bleeding (may be minimal if intraperitoneal)
• Scar tenderness before rupture (impending rupture)
• Recession of presenting part on vaginal examination

🟢 Management

• Emergency laparotomy — immediate
• Uterine repair (if feasible and patient desires future fertility)
• Peripartum hysterectomy — if repair not possible or bleeding uncontrollable
• Massive blood transfusion protocol
• ICU admission post-operatively
• Neonatal resuscitation team on standby

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SECTION 3: THROMBOEMBOLIC PUERPERAL DISORDERS

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13. DEEP VEIN THROMBOSIS (DVT)

📌 Definition

• Formation of a thrombus within the deep venous system (typically femoral or iliac veins)
• Puerperium is a high-risk period due to Virchow's triad

🔴 Causes — Virchow's Triad

• Stasis: immobility, bedrest, prolonged labour, C-section
• Hypercoagulability: increased clotting factors during pregnancy (I, VII, VIII, X, XII, vWF); decreased Protein S
• Vessel injury: pelvic/surgical trauma during delivery
• Additional risk factors: obesity, dehydration, prior VTE, thrombophilia, age > 35

🟡 Clinical Features

• Unilateral leg pain, swelling, warmth, erythema
• Pitting oedema of affected limb
• ± Homans sign (calf pain on dorsiflexion — unreliable)
• Low-grade fever
• Doppler USS — confirms diagnosis

🟢 Management

• Low Molecular Weight Heparin (LMWH) — enoxaparin (first-line, safe in breastfeeding)
• Graduated compression stockings
• Early mobilisation
• Adequate hydration
• Convert to warfarin after 6 weeks if not breastfeeding
• Minimum treatment duration: 3–6 months
• Screen for underlying thrombophilia (antiphospholipid syndrome, Factor V Leiden, etc.)

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14. PULMONARY EMBOLISM (PE)

📌 Definition

• Life-threatening obstruction of pulmonary arterial circulation by a dislodged thrombus
• Most commonly arises from pelvic or femoral DVT in the puerperium
• A leading cause of direct maternal mortality

🔴 Causes

• Dislodged DVT from pelvic or leg veins
• Hypercoagulable puerperal state
• Immobility post-C-section
• Prior VTE history
• Thrombophilia

🟡 Clinical Features

• Sudden onset dyspnoea — most common symptom
• Pleuritic chest pain
• Haemoptysis
• Tachycardia, hypoxia
• ± Syncope/collapse (massive PE)
• Raised D-dimer (limited utility in postpartum)
• ABG: hypoxia + hypocapnia (type 1 respiratory failure)
• ECG: sinus tachycardia; S1Q3T3 pattern (classic but rare)
• CTPA — diagnostic gold standard

🟢 Management

• LMWH or unfractionated heparin — immediate anticoagulation
• Thrombolysis (alteplase) — if massive PE with haemodynamic instability
• Oxygen supplementation
• ICU admission for massive PE
• Surgical embolectomy — rare, last resort
• Long-term anticoagulation for 3–6 months

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15. SEPTIC PELVIC THROMBOPHLEBITIS

📌 Definition

• Thrombosis of the ovarian or pelvic veins superimposed with bacterial infection
• Complicates < 1% of puerperal endometritis cases
• Presents as two distinct clinical forms:
  1. Acute ovarian vein thrombosis
  2. "Enigmatic fever" — persistent fever with no localising signs

🔴 Causes

• Extension of endometritis causing septic thrombus in pelvic/ovarian veins
• Common organisms: E. coli, Bacteroides, mixed gram-negative anaerobes

🟡 Clinical Features

• Persistent/spiking fever despite adequate antibiotic therapy — hallmark sign
• Flank or lower abdominal pain
• ± Palpable tender mass (ovarian vein thrombosis form)
• No other identifiable source of persistent fever
• CT scan may show thrombus in ovarian/pelvic vein

🟢 Management

• IV heparin anticoagulation + continued broad-spectrum antibiotics
• Fever typically resolves within 24–48 hours — this therapeutic response confirms the diagnosis
• Continue antibiotics until afebrile
• Long-term anticoagulation for 4–6 weeks debated

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16. CEREBRAL VENOUS THROMBOSIS (CVT)

📌 Definition

• Aseptic thrombosis of the cerebral venous sinuses (most commonly superior sagittal sinus)
• Occurs in the hypercoagulable puerperal state

🔴 Causes

• Puerperal hypercoagulability
• Dehydration
• Sepsis
• Thrombophilia (antiphospholipid antibodies, Factor V Leiden)
• Prior OCP use

🟡 Clinical Features

• Progressive headache worsening over several days — earliest and most common symptom
• Behavioural or personality change
• Focal neurological deficits
• Convulsive seizures
• Papilloedema (raised ICP)
• ± Focal motor deficits, aphasia
• ± Coma in severe cases

🟢 Management

• Anticoagulation with LMWH or heparin — even if haemorrhagic infarct present
• Antiepileptics for seizures
• ICP management (head elevation, mannitol if needed)
• MRI/MRV — diagnostic gold standard (CT may miss early CVT)
• Long-term anticoagulation for 3–12 months
• Screen for thrombophilia

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SECTION 4: PUERPERAL PSYCHIATRIC DISORDERS

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17. POSTPARTUM BLUES ("BABY BLUES")

📌 Definition

• A mild, transient, self-limiting mood disturbance affecting up to 65% of mothers
• Arises in the first week postpartum and resolves spontaneously within 2 weeks
• Considered a normal physiological response — NOT a psychiatric disorder

🔴 Causes

• Rapid postpartum fall in oestrogen and progesterone
• Sleep deprivation
• Psychological adjustment to new maternal role
• Emotional vulnerability in the perinatal period

🟡 Clinical Features

• Onset: day 2–5 postpartum (correlates with peak hormonal withdrawal)
• Tearfulness — most characteristic feature
• Mood lability and emotional sensitivity
• Mild anxiety and irritability
• Fatigue
• Mild insomnia
• No functional impairment
• No psychotic features
• Symptoms mild and intermittent

🟢 Management

• Reassurance and emotional support — only intervention needed
• Psychoeducation of mother and partner
• No pharmacotherapy required
• Encourage adequate rest and sleep
• Monitor: if symptoms persist beyond 2 weeks → screen for postpartum depression

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18. POSTPARTUM DEPRESSION (PPD)

📌 Definition

• A major depressive episode occurring during pregnancy or within 4 weeks of delivery (DSM-5)
• Affects 3–6% of women (major depression); broader postpartum depressive symptoms in up to 10–15%
• DSM-5 specifier: "with peripartum onset"

🔴 Causes

• Rapid hormonal shifts (oestrogen/progesterone/allopregnanolone withdrawal)
• HPA axis dysregulation
• Prior history of depression or bipolar disorder (strongest risk factor)
• Poor social support and social isolation
• Stressful life events
• Sleep deprivation and exhaustion
• Relationship difficulties
• Unplanned pregnancy
• Postpartum thyroid dysfunction

🟡 Clinical Features

• Persistent low mood for > 2 weeks
• Anhedonia — loss of interest or pleasure
• Excessive guilt, worthlessness, hopelessness
• Cognitive impairment — poor concentration, indecisiveness
• Sleep disturbance beyond that attributable to infant care
• Fatigue and loss of energy
• Poor bonding with infant — important clinical feature
• Anxiety and panic symptoms (common in postpartum depression)
• Suicidal ideation in severe cases
• No psychotic features (distinguishes from postpartum psychosis)

🟢 Management

• Screen using Edinburgh Postnatal Depression Scale (EPDS) — score ≥ 13 is positive
• Mild-to-moderate:
  • Psychotherapy — cognitive-behavioural therapy (CBT), interpersonal therapy (IPT)
  • Peer support groups
  • Social support enhancement
• Moderate-to-severe:
  • SSRIs — Sertraline (first-line — safest in breastfeeding)
  • Paroxetine (second-line)
  • Brexanolone IV (neuroactive steroid — FDA-approved for PPD)
• Psychiatric referral if severe or suicidal
• Father/partner screening — fathers also at risk of PPD

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19. POSTPARTUM PSYCHOSIS

📌 Definition

• The most severe puerperal psychiatric disorder
• Acute onset psychosis within the first 2 weeks postpartum (often days 3–5)
• Affects 1–2 per 1000 deliveries
• A psychiatric emergency with significant risk of infanticide and maternal suicide

🔴 Causes

• Bipolar disorder — strongest risk factor (20–50× increased risk)
• Prior postpartum psychotic episode (50% recurrence risk)
• Family history of bipolar disorder or postpartum psychosis
• First-time motherhood
• Sudden oestrogen and progesterone withdrawal
• Severe sleep deprivation
• Dopaminergic system dysregulation

🟡 Clinical Features

• Onset: first 2 weeks (most commonly days 3–5)
• Confusion and disorientation — often the earliest sign
• Command auditory hallucinations (to harm infant or self)
• Delusions (often about the infant — e.g., baby is evil, possessed, or must be saved)
• Rapidly fluctuating mood (manic, depressed, mixed)
• Bizarre behaviour, agitation, restlessness
• Severe insomnia
• Risk of infanticide — always assess
• Risk of maternal suicide
• May appear superficially well between episodes ("lucid intervals")

🟢 Management

• PSYCHIATRIC EMERGENCY — immediate action required
• Urgent psychiatric hospital admission
• Never leave mother alone with the infant — safeguarding priority
• Antipsychotics:
  • Haloperidol, olanzapine, quetiapine
• Lithium — treatment of choice for bipolar-related postpartum psychosis
• Benzodiazepines for acute agitation
• ECT (Electroconvulsive Therapy) — highly effective if refractory
• Mother-and-baby unit (MBU) admission — if available, maintains mother-infant bond
• Discontinue breastfeeding if medication unsafe for infant
• Psychoeducation of family

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SECTION 5: OTHER PUERPERAL COMPLICATIONS

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20. POSTPARTUM URINARY RETENTION

📌 Definition

• Inability to void spontaneously within 6 hours of delivery
• Due to impaired bladder function from perineal and bladder trauma during labour

🔴 Causes

• Perineal oedema compressing urethra
• Pain inhibiting micturition reflex
• Epidural anaesthesia impairing bladder sensation
• Bladder overdistension during prolonged labour
• Regional anaesthesia (spinal/epidural)
• Perineal trauma or haematoma

🟡 Clinical Features

• Inability to void despite urge
• Suprapubic fullness and discomfort
• Bladder palpable/percussible above pubic symphysis
• ± Overflow incontinence (dribbling of urine)
• Bladder scan/USS: post-void residual > 150 mL confirms retention

🟢 Management

• Intermittent clean catheterisation — preferred
• Indwelling catheter if unable to void repeatedly
• Adequate analgesia
• Trial of voiding after 24–48 hours
• Pelvic floor physiotherapy
• Monitor closely for associated UTI

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21. BREAST ENGORGEMENT

📌 Definition

• Painful bilateral overfilling of the breasts with milk due to inadequate milk removal
• Typically occurring on days 3–5 postpartum
• A physiological problem, not infection

🔴 Causes

• Inadequate milk removal
• Infant separation from mother
• Sore or cracked nipples preventing proper feeding
• Improper breastfeeding technique/poor latch
• Sudden cessation of breastfeeding
• Milk stasis

🟡 Clinical Features

• Onset: day 3–5 postpartum
• Bilateral painful, hard, enlarged breasts
• Warmth and skin tightness
• ± Low-grade fever (< 38.5°C)
• Nausea
• Compressed, flattened nipple-areola complex → difficulty with infant latch
• Distinguish from mastitis: bilateral, no systemic features, resolves with feeding

🟢 Management

• Frequent breastfeeding or pumping to empty breasts
• Correct latch technique — most important intervention
• Warm compresses before feeding to facilitate let-down
• Cold compresses after feeding to reduce oedema
• Manual massage to facilitate milk release
• Analgesics — ibuprofen, paracetamol
• Cabbage leaf application — evidence limited but commonly used

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22. SUBINVOLUTION OF THE UTERUS

📌 Definition

• Failure of the puerperal uterus to return to its normal pre-pregnant size within the expected timeframe (usually by 6 weeks)
• Due to incomplete physiological regression of the uterus

🔴 Causes

• Retained placental fragments — most common
• Endometritis (infection prevents normal involution)
• Uterine fibroids
• Polyhydramnios
• Multiple gestation
• Grand multiparity
• Prolonged labour

🟡 Clinical Features

• Uterus larger and softer than expected for postpartum day
• Prolonged or excessive lochia (lochia persisting beyond normal)
• ± Offensive/purulent lochia if endometritis coexists
• ± Pelvic pain and heaviness
• Fever if infection present
• USS confirms enlarged uterus ± echogenic material

🟢 Management

• Oxytocics: ergometrine tablets, oral misoprostol
• Antibiotics if infection (endometritis) coexists
• Ultrasound-guided ERPC (Evacuation of Retained Products of Conception) if retained products confirmed
• Follow-up USS to confirm complete involution
• Monitor for secondary PPH

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23. POSTPARTUM THYROIDITIS

📌 Definition

• An autoimmune inflammatory thyroid condition occurring within the first year postpartum
• Characterised by a transient hyperthyroid phase followed by a hypothyroid phase
• Affects approximately 5–10% of postpartum women

🔴 Causes

• Autoimmune rebound following postpartum reversal of pregnancy-induced immune tolerance
• Anti-TPO (anti-thyroid peroxidase) antibody positivity — primary marker
• Underlying Hashimoto's thyroiditis — predisposing condition
• Genetic predisposition (HLA-DR3/DR5)
• Type 1 diabetes mellitus — associated risk

🟡 Clinical Features

• Phase 1 — Hyperthyroid (months 1–4):
  • Fatigue, palpitations, tremor, anxiety
  • Heat intolerance, sweating
  • Weight loss
  • TSH low, free T4 elevated
• Phase 2 — Hypothyroid (months 4–8):
  • Fatigue, cold intolerance, constipation
  • Weight gain, dry skin, hair loss
  • Depression (may mimic/exacerbate PPD)
  • TSH elevated, free T4 low
• Phase 3 — Recovery (by 12–18 months): majority recover
• ~25% develop permanent hypothyroidism

🟢 Management

• Hyperthyroid phase:
  • Beta-blockers (propranolol) for symptomatic relief
  • Do NOT use antithyroid drugs (carbimazole/PTU) — destructive process, not Graves'
• Hypothyroid phase:
  • Levothyroxine replacement therapy
  • Especially important if breastfeeding or planning further pregnancy
• Monitor TFTs every 3–6 months
• Annual TFT screening — 25% risk of permanent hypothyroidism
• Screen for PPD — hypothyroid phase can precipitate depressive episodes

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24. PUERPERAL / POSTPARTUM ECLAMPSIA

📌 Definition

• Occurrence of grand mal tonic-clonic seizures in a woman with pre-eclampsia or de novo hypertension
• Arising within 48 hours postpartum (occasionally up to 4 weeks postpartum)
• Without other neurological cause (e.g., epilepsy, meningitis)

🔴 Causes

• Persistence of severe hypertension postpartum
• New-onset hypertension after delivery (de novo)
• Cerebral vasospasm
• Endothelial dysfunction (hallmark of pre-eclampsia pathophysiology)
• Failure of pre-eclampsia to resolve after delivery
• Cerebral oedema

🟡 Clinical Features

• Grand mal tonic-clonic seizures
• Severe headache (frontal/occipital)
• Visual disturbances — blurring, scotomata, flashing lights, diplopia
• Hypertension — BP ≥ 160/110 mmHg
• Proteinuria (≥ 2+ on dipstick)
• Facial and peripheral oedema
• Epigastric/right upper quadrant pain (liver involvement)
• ± HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets)
• Altered consciousness after seizure (postictal state)

🟢 Management

• IV Magnesium Sulphate — treatment of choice
  • Loading dose: 4–6 g IV over 15–20 minutes
  • Maintenance: 1–2 g/hr IV infusion
  • Monitor: urine output, reflexes, respiratory rate (toxicity signs)
  • Antidote: Calcium gluconate 10 mL of 10% IV if toxicity occurs
• Antihypertensives:
  • IV Labetalol (first-line)
  • IV Hydralazine
  • Oral Nifedipine (if IV access difficult)
• Strict fluid balance monitoring (restrict IV fluids — risk of pulmonary oedema)
• Oxygen supplementation
• ICU/HDU admission
• Rectal diazepam for breakthrough seizures
• Continue MgSO₄ for 24 hours after last seizure

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MASTER SUMMARY — ALL 24 DISORDERS AT A GLANCE

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