Overview
A collective term for a wide range of illnesses during the 6 weeks following childbirth, including puerperal infections, hemorrhage, depression, and venous thromboembolism.
The puerperium is one of the periods of rapid physical and psychological changes in women, which may lead to related diseases.
It may be characterized by fever, abnormal vaginal bleeding, depression, pain and swelling of the lower limbs, etc.
Aggressive treatment of the cause of the disease can improve the symptoms significantly and the prognosis is good.
Definition
The puerperium is the period of time, usually 6 weeks, between the delivery of the placenta and the return of the mother’s organs (except the mammary glands) to their normal non-pregnant state.
It is a period of rapid physical and psychological changes for women. Most women recover well, but a few may develop puerperal diseases.
Common puerperal diseases include:
Puerperal infection: the reproductive tract is attacked by pathogens during labor and puerperium, causing local or systemic infection. The main manifestations are fever, pain and abnormal discharge. The incidence rate is about 6%.
Late postpartum hemorrhage: massive uterine bleeding that occurs in the puerperium 24 hours after delivery. It is most common 1~2 weeks after delivery, manifested by active vaginal bleeding, which may be accompanied by low-grade fever, chills, and hemorrhagic shock in severe cases.
Puerperal depression: Symptoms usually appear 2 weeks postpartum and are characterized by persistent and severe moodiness during the puerperium.
Puerperal venous thromboembolism: most often occurs in the lower limbs and is characterized by pain and swelling of the lower limbs, with or without elevated skin temperature and redness. The presence of neck pain and headache should be alert to embolism of the jugular and intracranial veins, and the presence of dyspnea and chest pain should be alert to pulmonary embolism [1-4].
Etiology
The special physiologic and anatomic changes during pregnancy and puerperium are the main causes of puerperal diseases.
Causes
Causes of puerperal infections
β-hemolytic streptococcus is the most common pathogen, and most often a mixed infection of multiple pathogens.
Postpartum weakness, combined with malnutrition, anemia, and long duration of labor may increase the chance of infection.
Common sites of infection are: surgical site infection, such as perineal incision, laceration, abdominal incision infection; endometrial infection; urinary tract infection, such as cystitis, pyelonephritis and so on.
Causes of late postpartum hemorrhage
Retained placenta and fetal membranes are the most common causes of late postpartum hemorrhage after vaginal delivery; poorly healed uterine incision is the most common cause of late postpartum hemorrhage after cesarean delivery.
Residual meconium and incomplete restoration of the uteroplacental attachment surface can lead to endometrial inflammation, causing late postpartum hemorrhage.
Causes of puerperal depression
Abnormal levels or activity of neurotransmitters due to postpartum hormonal changes.
Causes of puerperal venous thromboembolism
Hypercoagulability, slow blood flow, and damage to blood vessel walls during pregnancy and puerperium may lead to peripartum venous thromboembolism.
Risk factors
Risk factors for peripartum depression
Previous history of perinatal or non-perinatal depression, family history of mental illness.
Stressful life events during pregnancy or postpartum, such as marital conflict and labor pains.
Lack of social and economic support during the puerperium.
Poor pregnancy and neonatal outcomes, such as preterm labor, neonatal death, etc.
Risk factors for venous thromboembolism in the puerperium
History of previous venous thromboembolism, hereditary or acquired thrombophilia.
Comorbidities associated with the development of venous thromboembolism: active autoimmune or inflammatory diseases, nephrotic syndrome, heart failure, diabetic nephropathy, sickle cell disease.
Others: obesity, smoking, cesarean section and postpartum hemorrhage [5-7].
Symptoms.
Puerperal diseases encompass a wide range of disorders with different symptoms for different disorders.
The main symptoms
Puerperal infection
Fever, pain, and abnormal discharge are the main symptoms. Depending on the location of the infection, there may be different specific manifestations:
Perineal laceration or perineal lateral incision wound infection, manifested as pain in the perineum and difficulty in sitting. The local wound is red, swollen, cracked, with obvious pressure and pain, accompanied by purulent discharge.
Vaginal laceration and contusion may have mucosal congestion, edema, ulceration, and increased purulent discharge.
Cervical fissure infection spreads to the deeper part of the uterus, which can cause pelvic connective tissue inflammation, manifested by pain and swelling sensation in the lower abdomen.
Uterine infections include acute endometritis and myometritis. There may be a large amount of purulent vaginal discharge with foul odor. Abdominal pain, uterine pressure, and poor recuperation.
Acute pelvic connective tissue inflammation and acute tubulitis may form pelvic inflammatory masses, manifested by lower abdominal pain with anal swelling, obvious pressure, rebound pain, muscle tension in the lower abdomen; thickening of connective tissues on one or both sides of the parietal uterus, pressure and pain and/or inflammatory masses.
Acute pelvic peritonitis and diffuse peritonitis systemic symptoms are obvious, high fever, nausea, vomiting, abdominal distension. A limited abscess may form in the recto-uterine trap.
Thrombophlebitis, caused by infection involving the uterine veins, ovarian veins, internal iliac veins, common iliac veins, and vaginal veins, is most often an anaerobic infection. There may be persistent pain in the area supplied by the involved vessels and obstruction of blood return.
Pathogens enter the blood circulation in large quantities, multiply and release toxins, which can lead to sepsis, infectious shock, multi-organ failure, manifested by persistent high fever, chills, obvious symptoms of systemic toxicity, and even life-threatening.
Late postpartum hemorrhage
Vaginal bleeding, mostly moderate to heavy bleeding. Or the duration of bloody discharge is prolonged and repeated bleeding.
Examination reveals: incomplete uterine restoration, loose uterine opening, sometimes residual tissue is visible.
Abdominal pain and fever: often combined with infection, accompanied by an increase in the amount of malodor with a foul odor.
Systemic symptoms: secondary anemia and hemorrhagic shock may also occur in severe bleeding.
Puerperal depression
Mood changes: persistent emotional depression, frustration, apathy, anxiety, irritability, tearfulness, etc.
Decreased self-esteem: self-loathing, hostility toward those around them, and discordant relationships with family members.
Impaired creative thinking and reduced initiative.
Lack of confidence in life, feeling that life is meaningless, anorexia, insomnia, fatigue, etc. Severe cases may even commit self-inflicted suicide or harm the baby.
Puerperal venous thromboembolism
More common after cesarean section than after vaginal delivery. It mostly occurs in the lower limbs, with iliac and femoral veins being the most common.
Most patients have no obvious symptoms in the early stage, and there are different manifestations depending on the site of obstruction:
Deep vein thrombosis in the lower limbs manifests as pain and swelling in the lower limbs, which is aggravated by standing and walking, as well as increased skin temperature and change in skin color.
Jugular vein and intracranial venous system embolism may be characterized by neck swelling and pain, unconsciousness, headache, vomiting and other symptoms.
Pulmonary embolism presents with unexplained dyspnea, chest pain, and cyanosis, which can be life-threatening in severe cases [1,5-13].
Seek medical attention.
Puerperal fever, abnormal vaginal bleeding, depression, pain and swelling of the lower limbs should be consulted in the obstetrics department, and other departments according to the diagnosis.
Department of Obstetrics and Gynecology
Obstetrics
Obstetrics should be consulted for fever, abnormal vaginal bleeding, depression, pain and swelling of the lower limbs during puerperium.
Vascular Surgery/Respiratory Medicine
If thrombosis is suspected during puerperium, please consult the Department of Vascular Surgery or the Department of Respiratory Medicine at the same time.
Psychiatry
Emotional problems during the puerperium may require psychiatric consultation.
Emergency Medicine
In case of emergency such as difficulty in breathing, confusion, shock, etc., it is recommended to consult the Emergency Department or call the 120 emergency number immediately.
Preparation for medical treatment
Information on how to get to the doctor: registration, preparation of documents, and frequently asked questions.
Tips
You can bring the relevant documents of the labor and delivery examination to the doctor.
Family members should accompany puerperal women to the doctor.
Preparation List
Symptom list
Pay particular attention to the time of onset of symptoms, special symptoms, etc.
Is there fever, pain in the surgical wound/lower abdomen, increased or foul-smelling discharge?
Are there high fever and chills? What is the extent and degree of abdominal pain?
Is there increased vaginal bleeding? How long does it last? Does it stop on its own? Are there any blood clots?
Is there depression, insomnia, recurrent tears, hostility toward family members, etc.?
Is there any pain in the lower extremities, dyspnea, nausea and vomiting?
List of medical history
Pregnancy health information, mode of delivery and special circumstances.
Previous pregnancies, any history of puerperal illness.
History of previous medical and surgical diseases and surgeries, special family genetics and other related medical history.
Breastfeeding during the puerperium, infant feeding, etc.
Checklist
Laboratory and imaging tests for puerperal discomfort, such as blood tests, gynecological ultrasound, pelvic CT and MRI, Edinburgh Postpartum Depression Scale results, venous ultrasound, etc.
List of medications used
Whether self-medication was used during the puerperium.
Whether medication was used for puerperal discomfort, name of medication, dosage, mode of administration and efficacy.
Diagnosis
Diagnosis of puerperal diseases requires a combination of medical history, clinical manifestations, and relevant examinations.
Diagnostic basis
Puerperal infection
Medical history: history of anemia during pregnancy, prolonged labor, hemorrhage before and after delivery.
Clinical manifestations: fever, localized pain, abnormal discharge.
Physical examination: Examination of abdominal and pelvic perineal wounds reveals abnormal discharge, redness and swelling of the wounds, and pressure and pain in the lower abdomen, which can help determine the source and severity of the infection.
Ancillary tests: ultrasound, CT or MRI to assess inflammatory masses or abscesses; laboratory tests to see elevated blood leukocytes and C-reactive protein.
Determine the pathogen: vaginal and uterine secretions, abscess puncture material for bacterial culture + drug sensitivity test can identify the pathogen of infection and guide anti-infection treatment.
Late postpartum hemorrhage
History: presence of retained placenta and fetal membranes, uterine infection, etc.
Clinical manifestations: recurrent or increased vaginal bleeding.
Physical examination: gynecological examination of the uterus is poorly restored and soft, and the uterine opening is flaccid. There may also be uterine pressure and pain, etc.
Auxiliary examination: blood routine may have decreased hemoglobin and increased leukocytes, suggesting anemia and infection; blood human chorionic gonadotropin (hCG) measurement helps to exclude placental remnants and choriocarcinoma. Ultrasonography evaluates for poor uterine recovery.
Pathogen examination, pathologic examination: after clearing the uterine remnants, relevant examinations are also required.
Puerperal depression
History: Family history of previous depression or psychiatric illness.
Clinical manifestations: persistent depressed mood, lowered self-evaluation, and lack of confidence in life.
Assessment: Postpartum depression risk factors are mostly assessed using the Edinburgh Postpartum Depression Scale.
Diagnostic criteria: There is no uniform diagnostic criteria. The diagnostic criteria developed by the American Psychiatric Association are usually adopted. Diagnosis needs to be made by a specialized psychiatrist.
Puerperal Venous Thromboembolism
History: History of previous venous thromboembolism, hereditary or acquired thrombophilia. History of postpartum hemorrhage.
Clinical manifestations: progressive pain in the lower extremities with elevated skin temperature.
Physical examination: elevated skin temperature and swelling on the affected side compared to the contralateral side.
Auxiliary examination: coagulation function may be abnormal, vascular compression ultrasonography is preferred when deep vein thrombosis is suspected. If pulmonary embolism is suspected, electrocardiogram and chest X-ray should be performed first. When pulmonary embolism is highly suspected, pulmonary angiography should be perfected.
Differential diagnosis
Puerperal infection
It is mainly differentiated from upper respiratory tract infection, mastitis or breast abscess. Upper respiratory tract infection may have respiratory symptoms such as coughing and sputum, and mastitis or breast abscess may have breast pain, redness and swelling.
Late postpartum hemorrhage
It is mainly differentiated from bleeding caused by choriocarcinoma and other tumor diseases. Occupying lesions can be seen in gynecological examination or imaging, and pathology can make a clear diagnosis.
Puerperal depression
It is mainly differentiated from normal postpartum mood changes. It is necessary to exclude organic mental disorders or depression due to psychoactive and non-addictive substances.
Puerperal venous thromboembolism
When the disease is suspected, it is mainly necessary to identify the possibility of life-threatening pulmonary embolism and intracranial venous embolism [6-15].
Treatment
Aim of treatment: to remove the cause of the disease, improve the symptoms, help the mother to pass through the puerperium smoothly, and return to the pre-pregnancy state as soon as possible.
Treatment principle: early identification of potentially life-threatening diseases, such as sepsis, shock, self-injury, pulmonary embolism, etc., and active causative and symptomatic treatment.
Treatment of puerperal infection
Antibiotic treatment
Once diagnosed, broad-spectrum, adequate and effective antibiotic treatment should be given; after the result of drug sensitivity is clear, the medication should be adjusted in due course.
Supportive treatment
Strengthen nutritional support, correct water and electrolyte disorders, and transfuse fresh blood or plasma if necessary.
Take semi-recumbent position to facilitate the discharge of malodor.
Treatment of etiology
Treatment of placenta and fetal membrane residues: effective anti-infection and at the same time, remove intrauterine residues; during the acute infection period, the infected tissues can be clamped out of the uterus, and the uterus can be completely cleared after infection control.
Wound infection: treatment includes timely incision, drainage, irrigation and debridement. Secondary suturing is required when necessary.
Other treatments
Anticoagulation therapy: thrombophlebitis requires additional anticoagulation therapy with sodium heparin and monitoring of coagulation function.
Hormone therapy: adrenocorticotropic hormone can be used for a short period of time if the symptoms of systemic toxicity are serious.
Treatment of late postpartum hemorrhage
Small or moderate vaginal bleeding, give broad-spectrum antibiotics, uterine contraction drugs and supportive therapy.
Suspected retained placenta, fetal membranes, etc., need prompt treatment of uterine evacuation and blood preparation.
Suspected uterine incision cracking, if bleeding is heavy need cesarean section or laparoscopy. If the incision pseudoaneurysm formation, uterine artery embolization is feasible. If tissue necrosis is extensive or active bleeding is severe, subtotal hysterectomy or total hysterectomy is chosen as appropriate.
Treatment of puerperal depression
For mild to moderate depression, psychotherapy is recommended for initial treatment. Antidepressant medication is also an option if psychotherapy is not available, psychotherapy is unsuccessful, refused, or previous antidepressant treatment has been effective. Compliance with medication and, if necessary, suspension of breastfeeding are required.
Patients with moderate to severe depression during the puerperium usually require a combination of medication, psychotherapy, or modified electroconvulsive therapy (MECT).
In addition, family relationships need to be regulated, and the mother needs to be instructed in good sleep habits to ensure adequate sleep.
Treatment of venous thromboembolism in the puerperium
Anticoagulation: A multidisciplinary team will formulate an anticoagulation plan based on the timing of thrombosis and risk factors, including the choice of drugs and dosage, and will closely monitor adverse reactions associated with anticoagulants.
If pulmonary embolism or intracranial venous system embolism is suspected, respiratory and neurological physicians should be asked to fully evaluate and guide the treatment, and percutaneous inferior vena cava filter and thrombolytic therapy should be performed if necessary.
Physical therapy: including foot dorsiflexion, gradient compression compression stockings, intermittent inflation compression devices or plantar vein pumps [8-17].
Prognosis.
For puerperal diseases, the prognosis is good in most cases with timely management, while severe conditions or delayed treatment may endanger the patient’s life.
Cure
The prognosis of puerperal infections is good after timely and effective antibiotic treatment, and early detection and early intervention is the key.
Late postpartum hemorrhage can be controlled by active treatment of the cause of the hemorrhage, uterine contraction drugs, antibiotics, and surgery if necessary.
Puerperal depression has a good prognosis, about 70% of patients can be cured within 1 year with active treatment, and very few patients last more than 1 year.
Puerperal venous thromboembolism has a good prognosis with prompt detection and treatment, while severe pulmonary embolism and intracranial venous system embolism may have a poor prognosis.
Prognostic factors
The severity of puerperal disease is the most critical factor affecting prognosis.
With early diagnosis and treatment, most patients have a favorable prognosis. Early recognition of potentially life-threatening diseases is important [1-3].
Daily
Patients with puerperal diseases should pay attention to nutrition, adequate rest, emotional adjustment, pay attention to the relief of their symptoms, and follow the doctor’s instructions for regular review.
Daily management
Postpartum health education
Understand the recovery process of normal puerperium and health care knowledge, and grasp what situations need to seek timely medical advice, including but not limited to:
Determination of postpartum bleeding, excessive such as soaking through a sanitary napkin within 1 hour.
Abnormal discharge, such as foul-smelling, purulent discharge.
Fever, especially over 38.5°C.
New or worsening perineal or lower abdominal pain.
Difficulty in breathing, chest pain, lower extremity pain or swelling.
Severe mood disorders, such as interference with relationships or normal activities.
Dietary management
Balanced nutrition with high quality protein.
Supplement more dietary fiber, pay attention to the intake of fresh fruits and vegetables, and drink sufficient amount of water to avoid constipation.
Appropriately increase calcium-rich foods such as milk, and reasonably supplement vitamins and iron.
Life management
Pay attention to rest after delivery and ensure sufficient sleep.
Perform appropriate activities under doctor’s guidance to maintain a healthy weight.
Pay attention to postpartum personal hygiene and keep the vulva clean and dry.
Avoid sexual intercourse during puerperium. Ovulation mostly resumes 6 weeks after delivery. Consult your doctor to choose a suitable contraceptive method to minimize unwanted pregnancy.
Psychological support
Family members should pay attention to the emotional changes of the mother, take the initiative to share the household chores and newborn feeding, and avoid overwork and exhaustion of the mother.
They should ease the worries about nursing the newborn and relieve the emotional depression caused by physical discomfort during puerperium.
Provide adequate spiritual care, encourage and comfort the mother, and help her regain self-confidence as soon as possible.
Condition monitoring
Those with complications during pregnancy or labor should take medication regularly as prescribed by the doctor, pay attention to the recovery of various symptoms, and follow up on time.
During the puerperium, monitor the body temperature, heart rate, respiration, etc., and pay attention to the changes in menstrual discharge and the recovery of wounds.
Follow up at the outpatient clinic on the 42nd day after delivery; special mothers should follow the doctor’s advice.
Prevention
Strengthen the publicity of puerperal health care and help mothers understand normal puerperal changes.
After delivery, carefully check whether the placenta and membranes are intact; choose the right incision for cesarean section to avoid prolonged fracture; strictly aseptic operation.
Keep the vulva clean and dry, and avoid sexual intercourse during puerperium.
People at high risk of venous thromboembolism can use compression stockings and anticoagulant drugs prophylactically under the guidance of doctors [4,16].