Post Partum Blues, Depression and Psychosis
Post partum Blues
- The time from the delivery of the placenta through the first few weeks after the delivery
- 6 weeks in duration.
- By 6 weeks after delivery, most of the changes of pregnancy, labor, and delivery resolves and the body reverts to the non pregnant state.
The puerperium has been referred to as the “ fourth trimester” of pregnancy, encompassing the period between the delivery and complete physiologic involution and psychological adjustment.
- Puerperal Pyrexia
- postnatal psychosis and depression
P pyrexia is defined as temperature of 38oC ( 100.4oF) or higher on any two occasions persisting after the first 24 hrs of delivery, and within 10 days postpartum taken by mouth by a standard technique.
Cause of P. Pyrexia
- P. Sepsis- Genital tract infection
- Breast Complications
- Wound Infections
- Thrombophlebitis and DVT
- Respiratory infections
An infection of the genital tract which occurs as a complication of delivery is termed as P sepsis.
- L bacillus ( 60-70%)
- Yeast like fungus- Candida albicans ( 25%)
- Staph albus or aureus
- Strepto β haemolyticus
- E coli and bacteroids
- Cl welchii-rare
These organisms remain dormant and are harmless during normal delivery conducted in aseptic conditions.
Predisposing factors to P Sepsis
- Conditions lowering the resistance
- Malnutrition & anaemia
- Chronic debilitating diseases
- Repeated PV examination after rupture membrane
- Traumatic manipulative & operative delivery
- RPOC- retained product of conception
- Placenta previa
Organism responsible for P sepsis
- Aerobic- Staph, Ecoli, Klebsiella, Pseudomonas, Non-haemolyticus Strepto,
- Anaerobic- Anaerobic streptococcus, Bacteroids, Cl welchii and tetani
Pathology and the primary site of infection
Endomyometritis- is the most common and usually mildest form of genital infection.
4 Classical signs:
- Pyrexia 37.8-38o C
- Pulse 100-120
- Fundal height- not decreasing
- Lochia red &offensive smell
- High vaginal smear and endocervical swab for C/S
- MSU for R/M/E & C/S
- Blood for Hb,TC, DC & C/S
- Blood for MP
- Widal Test
- X-ray chest
1.Adequate fluids, rest and movement of bowel- Milk of magnesia
2.Correction of anaemia
3.Antibiotics- Broad spectrum
I/V Ampicillin 500mg 6 hrly
I/V Metronidazole 500 mg 8 hrly
I/V Gentamycin 3-5 mg/kg body wt in divide dose
I/V Ceftriaxone / Cefotaxim 1 gm 12 hrly
Change according to C/S
Urinary tract infection
- Incidence is 1-5%
- Organisms- E coli, klebsiella, Proteus, Staph aureus
- Causes- Frequent catheter, stasis of urine due to lack of bladder tone & less desire to pass urine, Asymptomatic bacteriuria becomes symptomatic,
- Present- Fever with chills & rigor, burning micturition, frequency, nausea, vomiting, acute pain in the loins radiating to groin.
- Investigation- Urine for R/M/E and C/S
- Treatment -Antibiotics
Causes of retention urine in puerperium
1.Bruising and oedema of the bladder neck
2.Reflex from the perineal injury
- General measures
- Indwelling catheter for 48 hrs- It helps in regaining the normal bladder tone and the sensation of fullness.
Common breast complications are
2.Cracked & retracted nipples
3.Mastitis and breast abscess
- Due to exaggerated normal venous & lymphatic engorgement preceding lactation, preventing escape of milk from lacteal systm.
- Manifest after the milk secretion- 3rd -4th PPD
- S/S- Pain, feeling of tenseness and heaviness in both breast, malaise, ↑tempt
- Treatment-Support breast with binder & brassiere, ice bag, express milk or frequent breast feeding, analgesic
- Prevention- Manual expression of the remaining milk & frequent breast feedings
- Due to a) loss of surface epithelium, causing a raw area b) fissure at the tip or base of nipple
- Caused by 1)unhygiene –crust over the nipple 2) retracted nipple 3) vigorous suckling
- Asymptomatic usually but if infection, it is painful due to mastitis
- Treatment-keep nipple clean & dry, nipple shield during each feed, rest if worst and feed by expression, antibiotics ( oral & applicant) and analgesic
- Prevention-Local cleanliness during pregn and puerperium
- If left uncorrected may predispose to cracked nipple- difficulty in breast feeding
- Manual lifting of the retracted nipple during pregnancy is advisable.
- After delivery, use of nipple shield is advisable.
Mode of infection
2 different types of mastitis
- Infection follows a cracked nipple to involve the breast parenchymal tissues leading to cellulites.
- Infection gains access through the lactiferous duct leading to development of primary mammary adenitis
- Responsible organism is Staph aureus- infection comes from nasopharynx of the baby.
- Symptom- Generalised malaise, headache, fever with chills
- Severe pain and tender, swelling in 1 quadrant of the breast.
- Sign- Wedge shaped swelling on the breast with the apex at the nipple
- Over lying skin is hot, flushed, tense and tender
- Antibiotics- Cloxacillin, Cefalosporin
- Antenatal-Wash the nipple periodically to keep the patency of the duct opening.
- Breast feeding on the affected is suspended
- Manual expression & prevention of engorgement of breast.
- Swinging tempt
- Reddened breast
- Marked tenderness with fluctuation.
- Incision and drainage
- Wound can be that of a CS or an episiotomy wound
- Infection in the wound usually develops around the 5th to 6th POD
- Take Swab from the wound and send for C/S
- Treat with antibiotics and daily dressing
- Followed by secondary suture,
- Usually following general anaesthesia in CS
- Take x-ray chest and sputum for C/S
- Treatment is with physiotherapy, warm saline gurgle, steam inhalation and antibiotics
Deep Vein Thrombosis (DVT)
- Usually occurs at around 7-10th PPD
- Begins in the deep veins of the calf or soles of the feet and extend upwards
- Often symptomless
- Sharp dorsiflexion of the foot elicit pain in the calf-Homan’s sign
- Slight rise of tempt & pulse.
- These early S/S may be missed and detected only when pulmonary embolism has developed or when the generalised oedema of the leg has set.
- Exercise in early puerperium is beneficial.
- The foot end of the bed is elevated to increase the venous flow from the leg.
- Antibiotics to prevent infection
- Anticoagulant to prevent clot formation-Heparin.
- After being afebrile the pt is encouraged to walk about with the affected leg supported by elastic bandage.
Post Partum Blues, Depression and Psychosis
Post partum Blues
- Occurs in around 50% of the women
- Around 4th to 5th PPD
- Usually self limiting though in rare circumstances progresses to postnatal depression.
- Cure by support of medical practitioner is all that is required
Post natal depression
- Onset at around 4th week PP
- Lasting for around 6 months
- Family H/O mental disorder is usually present.
- C/F are that of sleep disturbance, depression, social withdrawal, lack of worthiness of being a mother, suicidal thoughts, concern that she may harm her child
- Management- Social support, refd to psychiatrist
- Occurs in 0.2% of the mothers
- Onset is earlier than the postnatal depression
- The chance that a mother may harm her baby is very high.
- Serious condition the requires an expert psychiatric evaluation and treatment