13.1. Non-infectious postpartum diseases
Non-infectious postpartum diseases are those unrelated to infection, but caused by impairment of the uterine contractile activity (UCA), in which lochia or placental remnants (lochiometra) are retained, or milk outflow in the mammary gland is disturbed (lactostasis). Timely diagnosis and treatment of these complications prevents infection of the uterus and breasts, and the woman quickly recovers.
Uterine subinvolution is a poor rate of return to the normal size of the uterus, a decrease in UCA, retention of postpartum secretions (lochia) in its cavity resulting from a spasm of the internal uterine os. Sometimes thick blood clots, fetal membranes, small pieces of the placenta are retained in the uterine cavity.
The puerpera complains of cramping pains in the lower abdomen, vaginal discharge diminishes or stops, there may be subfebrile temperature. When examining the puerpera, one notes the larger size of the uterus, which does not correspond to the rate of postpartum involution. In the normal course of the postpartum period, the uterine fundus descends by 2 cm a day, and by the 5th day, it is on the midline between the umbilicus and pubis. At subinvolution, the uterine fundus is palpated at the level of the umbilicus. On palpation, the density of the uterus is reduced, the consistency is soft.
Subinvolution of the postpartum uterus is often accompanied by lochio-metra - retention of postpartum secretions (lochia) in the uterine cavity. The puerpera has moderate cramping pains in the lower abdomen, vaginal discharge decreases significantly, becomes cloudy with an admixture of blood,
or stops completely. Epithelization of the inner surface of the uterus, reverse development of the placental site are delayed. There is a threat of superimposed infection and development of uterine inflammation, endomyometritis. This can develop fast, because after birth the inner surface of the uterus is in fact a wound surface. The presence of blood clots in combination with a temperature in the uterus of up to 40 °C provides thermostatic conditions. The open cervical canal provides a good access for microorganisms that pass from the vagina into the uterine cavity. Retained lochia in combination with reduced UCA are risk factors for endometritis and a further spread of the infection outside the uterus: peritonitis, sepsis. Treatment should aim to promote UCA, improve the outflow of lochia, remove retained blood clots, membranes, parts of the placenta, i.e. to empty the uterine cavity. The postpartum uterus has a good ability to constrict and limit the spread of infection, but only when cavity is absolutely clear. Presence of foreign tissue will certainly cause infection and bleeding (sometimes significant). To increase the contractile activity of the uterus in case of its subinvolution, uterotonics (oxytocin 5 U - 1.0 ml) together with antispasmodics (no-spa - 2.0 ml) are administered 2-3 times a day during breastfeeding. To remove the lochia and tissue that are retained in the uterus, vacuum aspiration, or light curettage (light so as not to damage the basal layer of the uterus) is performed under the guidance of a hysteroscope and ultrasound.