POSTPARTUM & PUERPERAL INFECTIONS(Current Diagnosis & Treatment Obstetrics & Gynecology, Tenth Edition 2007)

G.M. Punarbawa

Infections: most prominent puerperal complications. An improved understanding of the natural history of female genital infections and the availability of powerful antibioticsCost>>: patients & society, serious disability & deathPuerperal morbidity: temperature > 38 C on 2 separate occasions at least 24 hours apart following the first 24 hours after delivery Fever: patient with fever assumed: have a genital infection until proved otherwise

IncidencePuerperal infectious: 28% of pregnant women (>> low socioeconomic status, operative delivery, PROM, long labors, multiple pelvic exam)Morbidity & MortalityPostpartum infections: Death (8% of all pregnant women who die each year) The costs: additional hospitalization, medications, time lost from workSterility: (periadnexal adhesions)Hysterectomy (serious postpartum/ postoperative infection)

PathogenesisBirth canal flora: pregnant = nonpregnant Vaginal flora: pathogenic aerobic & anaerobic organisms (Table 311).Mechanisms to prevent overt genital tract infection: acidity (normal vagina)thick, tenacious cervical mucusmaternal antibodies to most vaginal flora

During labor & rupture of the membranes: some protective mechanisms (-)Examinations & invasive monitoring apparatus vaginal bacteria uterine cavity Contractions during labor: spread amniotic cavity bacteria adjacent uterine lymphatics bloodstreamPostpartum uterus (devoid of mechanisms keep it sterile), & bacteria recovered from uterus (nearly all women) in the postpartum period.

Disease? clinically expressed?:Depends on: predisposing factors, duration of uterine contamination, type & amount of microorganisms involvedDecidua necrosis & intrauterine contents (lochia) anaerobic bacteria>>, heretofore limited by lack of suitable nutrients and other factors necessary for growth.Endometrial cavity sterility: returns by 3rd 4th postpartum weekPrevent infection by: Granulocytes (penetrate endometrial cavity) & drainage of lochia

EtiologyAlmost by normal genitalia bacteria of pregnant women. Lochia: excellent culture medium (ascending vagina organisms)Cesarean section: >>devitalized tissue, foreign bodies (sutures) additional fertile ground contamination & subsequent infection+70% puerperal soft-tissue infections: mixed infections (aerobic & anaerobic organisms)

General EvaluationSource of infection should be identified, the likely cause determined, and the severity assessed. Postpartum period fever: >> endometritis. Urinary tract infection (UTI): next most commonNeglected / virulent endomyometritis serious infection (sepsis, septic pelvic thrombophlebitis, pelvic abscess)

EndometritisEtiologyRisk factors: prolonged rupture of the membranes (> 24 hours), chorioamnionitis, >>VT, prolonged labor (> 12 hours), toxemia, intrauterine pressure catheters (> 8 hours), fetal scalp electrode monitoring, preexisting vaginitis or cervicitis, operative vaginal deliveries, CS, intra/postpartum anemia, poor nutrition, obesity, low socioeconomic status, coitus near termCS & low socioeconomic class >>puerperal infectionSeries report: 4080% infection rate following CS Postpartum infection: > serious CS vs vaginal deliveryBacterial vaginosis history: higher risk post-CS endometritis

Clinical FindingsSYMPTOMS AND SIGNSEndometritis: fever, soft, tender uterusLochia: foul odor? (+/-)Leukocytosis (>10,000/ L) Severe disease: high fever, malaise, abdominal tenderness, ileus, hypotension, & sepsis. Uterus movement pain

FeverPuerperium: high metabolic activity (should not raise > 37.2 C & only briefly in 1st 24 hours postpartumFever > 38 C at any time (puerperium) be evaluated.Endometritis: 38 C - 40 C; depend on patient, microorganism, extent of infectionUsually develops on 2nd or 3rd postpartum

Uterine TendernessUterus: soft & tenderCervix & uterus motion painAbdominal tenderness: lower abdomen Adnexal masses (tubo-ovarian abscess)Bowel sounds, abdomen distended & tympaniticPelvic examination confirms the findings disclosed by abdominal examination.

LABORATORY FINDINGSHematologic FindingsLeukocytosis: > 20,000/ L Bacteremia: 510% of women with uncomplicated endometritis Mycoplasma :>> blood of patients with postpartum feverBacteroides: >> positive blood cultures

UrinalysisRoutinely performed (thought have endometritis)Urinary tract infections (UTI) clinical picture similar to mild endometritis. If pyuria & bacteria (+): antibiotic & culture

Lochia Cultureslochia cultures: Bacteria colonizing cervical canal & ectocervix (may not causing endometritis)Accurate cultures: transcervically (vaginal contamination -)Transabdominal aspiration uterine contents (not routine)

Bacteriologic FindingsMost puerperal infections: anaerobic streptococci, gram (-) coliforms, Bacteroides spp., & aerobic streptococci. Chlamydia & Mycoplasma: clinical isolates are rare (difficult to culture). The percentage of microorganisms recovered from women with endometritis is given in Table 312Patterns of bacterial isolates in puerperal infections (patient's hospital): important selection antibiotics

AEROBIC BACTERIAGroup A streptococci (not major cause of postpartum infection), but still occurs. Penicillin is highly effective.In 30% clinically recognized endometritis group B streptococci Signs: high fever & hypotension shortly after delivery. Group D streptococci (Streptococcus faecalis), :common isolates in endometritis R/ high doses Ampicillin & Aminoglycosides.Staphylococcus aureus postpartum infections (PPI); R/:nafcillin, cloxacillin, or cephalosporins

Gram (-) aerobic organisms recovered in PPI: E coli (most common) In PPI: E coli >> (seriously ill patients), In UTI: >> isolated organism (not in sickest patients). Hospital-acquired E coli : susceptible to aminoglycosides & cephalosporins.Incidence Neisseria gonorrhoeae: 28% in pregnant women antepartum. Incidence of asymptomatic endocervical gonorrhea at delivery: slightly less Gardnerella vaginalis cause of vaginitis: (+) in PPI, usually with a polymicrobial cause, although pure isolates have been reported.Other gram-negative (Klebsiella pneumoniae, Enterobacter, Proteus, and Pseudomonas spp.) >> medical & surgical wards (uncommon causes of endometritis).

ANAEROBIC BACTERIAAnaerobic bacteria: involved in 50%-95% PPI of uterus. > PPI, particularly with other anaerobic species: R/: Clindamycin, chloramphenicol, newer cephalosporins.Bacteroides spp., (Bacteroides fragilis), >> in mixed PPI. >>:serious infections (puerperal pelvic abscess, CS wound infections, septic pelvic thrombophlebitis). R/: clindamycin, chloramphenicol, 3rd generation cephalosporins.Gram (+) anaerobic organisms (only by Clostridium perfringens): rare cause of PPI.

OTHER ORGANISMSMycoplasma & Ureaplasma spp.: common genital pathogens (isolated from genital tract & blood of postpartum women): with & without overt infection. The role of these organisms in PPI is unknown.Chlamydia trachomatis (thought leading cause of PID) involved PPI, > (mild late-onset endometritis), cultures should be obtained from endometritis patients (Dx: several days after delivery). Chlamydia: difficult to culture

Differential DiagnosisIn the immediate postpartum period, involuntary chills are common and are not necessarily an indication of overt infection. Lower abdominal pain is common (uterus involution & contractions)Extragenital infections: less common vs endometritis & UTI. Most infections can ruled out by history & examination. Asked patients: coughing, chest pain, pain at the insertion site of iv catheters, breast tenderness, & leg pain.Examination: breasts, chest, iv catheter insertion site, leg veins.Chest x-ray (pulmonary cause of the fever)

TreatmentAntibiotics: (R/ endometritis) depends on organisms & disease severity. Initial therapy: iv antibiotics (high doses): because: large uterus volume, expanded maternal blood volume, brisk diuresis (puerperium), & difficulty in achieving adequate tissue concentrations distal to the thrombosed myometrial blood vessels. Clindamycin + aminoglycoside: standard 1st line regimen. Good evidence: once-a-day dosing as effective as thrice-daily regimen. Single-agent therapy with 2nd atau 3rd generation cephalosporins: acceptable alternative.Response: monitored for 2448 hours. Deterioration or failure to respond (clinically & laboratory) re-evaluation.

Ampicillin: added (inadequate response to usual regimen, particularly if Enterococcus spp. are suspected).Iv antibiotics: continued until afebrile for 2448 hours. Randomized & prospective trials: additional treatment with oral antibiotics after intravenous therapy is unnecessary. Remains febrile (standard regimens) evaluation: abscess, hematomas, wound infection, septic pelvic thrombophlebitis?Patients known infected, high risk infection (delivery), initial therapy: 2- or 3-drug regimens (1 agent is clindamycin is prudent). Single-agent iv infusion (broad-spectrum agents): piperacillin or cefoxitin equally effective.

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