PUERPERAL SEPSISFahad zakwan

PUERPERAL INFECTION

any bacterial infection of the genital tract

after delivery

PUERPERAL FEVER

• Most persistent fevers after childbirth are caused by genital tract infection

temperature – 38.0° C (100.4° F) or higher at any 2 of the first 10 days postpartum, exclusive of the first 24 hours and to be taken by mouth by a standard technique at least 4 times dailyhigh spiking fever within first 24 hours virulent infection with group A strep

Attributable fever rarely exceeds 39°C in the first few postpartum days and usually lasts less than 24 hours.Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting.Atelectasis is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery

UTERINE INFECTIONS

•Postpartum uterine infection has been called variously endometritis, endomyometritis, and endoparametritis.

• Because infection involves not only the decidua but also the myometrium and parametrial tissues, the inclusive term metritis with pelvic cellulitis.

•The route of delivery is the single most significant risk factor for the development of uterine infection •c/s more risky than SVD

PREDISPOSING FACTOR

VAGINAL DELIVERY

Women at high risk for infection because of membrane rupture, prolonged labor, and multiple cervical examinations have a 5- to 6-percent incidence of metritis after vaginal delivery.

If there is intrapartum chorioamnionitis, the risk of persistent uterine infection increases to 13 percent

CESAREAN DELIVERY

Single-dose perioperative antimicrobial prophylaxis is given almost universally at cesarean delivery

Important risk factors for infection following surgery ARE:

1. prolonged labor

2. membrane rupture, multiple cervical examinations,

3. internal fetal monitoring

Women with all of these factors who were not given perioperative prophylaxis had a 90-percent serious pelvic infection rate

OTHER RISK FACTORS

• Lower socioeconomic status

• Group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, and Gardnerella vaginalis

•Cesarean delivery for multifetal gestation

• Young maternal age and nulliparity

• Prolonged labor induction

• Obesity

• Meconium-stained amnionic fluid

BACTERIOLOGY

group A -hemolytic streptococcus causing toxic shock-like syndrome and life-threatening infectionskin and soft-tissue infections due to community-acquired methicillin-resistant Staphylococcus aureus—CA-MRSA—have become common METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS-these strains are not a common agent of puerperal metritis, but

they are causative in incisional wound infections.

BACTERIAL CULTURES

Routine pretreatment genital tract cultures are of little clinical use and add significant costsSimilarly, routine blood cultures seldom modify care

PATHOGENESIS

Puerperal infection following vaginal delivery primarily involves the placental implantation site, decidua and adjacent myometrium, or cervicovaginal lacerations.

The pathogenesis of uterine infection following cesarean delivery is that of an infected surgical incision

Bacteria that colonize the cervix and vagina gain access to amnionic fluid during labor, and postpartum, they invade devitalized uterine tissue.

With early treatment, infection is contained within the paravaginal tissue but may extend deeply into the pelvis.

CLINICAL COURSE

Fever is the most important criterion for the diagnosis of postpartum metritis.Temperatures commonly are 38 to 39°C. Chills that accompany fever suggest bacteremia.Women usually complain of abdominal pain, and parametrial tenderness is elicited on abdominal and bimanual examinationAlthough an offensive odor may develop, many women have foul-smelling lochia without evidence for infection. Other infections, notably those due to group A -hemolytic streptococci, are frequently associated with scanty, odorless lochiaLeukocytosis may range from 15,000 to 30,000 cells/L, but recall that cesarean delivery itself increases the leukocyte count

TREATMENT

If mild metritis develops after a woman has been discharged following vaginal delivery, outpatient treatment with an oral antimicrobial agent is usually sufficient. For moderate to severe infections, however, intravenous therapy with a broad-spectrum antimicrobial regimen is indicated. Improvement follows in 48 to 72 hours in nearly 90 percent of women treated with one of several regimens.

TREATMENT

PARAMETRIAL PHLEGMON—an area of intense cellulitis; an abdominal incisional or pelvic abscess or infected hematoma; and septic pelvic thrombophlebitis. The woman may be discharged home after she has been afebrile for at least 24 hours. Further oral antimicrobial therapy is not needed

CHOICE OF ANTIMICROBIALS

CLINDAMYCIN-GENTAMICIN REGIMEN

• had a 95-percent response rate

• still considered by most to be the standard by which others are measured

•Because enterococcal infections may persist despite this standard therapy, many add ampicillin to the clindamycin-gentamicin regimen, either initially or if there is no response by 48 to 72 hours.

Because of potential nephrotoxicity and ototoxicitywith gentamicin in the event of diminished glomerular filtration, some have recommended a combination of clindamycin and a second-generation cephalosporin to treat such women. Others recommend a combination of clindamycin and aztreonam, a monobactam compound with activity similar to the aminoglycosides

LACTAM ANTIMICROBIALS

( cephalosporins such as cefoxitin, cefotetan, and cefotaxime, as well as extended-spectrum penicillinssuch as piperacillin, ticarcillin, and mezlocillin)

include activity against many anaerobic pathogens are inherently safe and except for allergic reactions, are free of major toxicity.

LACTAMASE INHIBITORS (CLAVULANIC ACID, SULBACTAM, AND TAZOBACTAM)

combined with ampicillin, amoxicillin, ticarcillin, piperacillin to extend their spectra.

METRONIDAZOLE superior in vitro activity against most

given with ampicillin and an aminoglycoside provides coverage against most organisms encountered in serious pelvic infections

CHOICE OF ANTIMICROBIALS

IMIPENEM a carbapenem that has broad-spectrum coverage against most organisms associated with metritis used in combination with cilastatin, which inhibits renal metabolism of imipenemit is effective in most cases of metritis

PERIOPERATIVE ANTIMICROBIAL PROPHYLAXIS

• Numerous studies have shown that prophylactic antimicrobials reduce the rate of pelvic infection by 70 to 80 percent

• Single-dose prophylaxis with ampicillin or a first-generation cephalosporin is ideal, and both are as effective as broad-spectrum agents or a multiple-dose regimen

• Recent report of extended-spectrum prophylaxis with azithromycin added to standard single-dose prophylaxis showed a significant reduction in postcesarean metritis

TREATMENT OF VAGINITIS

•Prenatal treatment of asymptomatic vaginal infections has not been shown to prevent postpartum pelvic infections

•No beneficial effects for women treated for asymptomatic bacterial vaginosis.

OPERATIVE TECHNIQUE TO PREVENT POSTPARTUM INFECTION

Allowing the placenta to separate spontaneously compared with removing it manually lowers the risk of infection, but changing gloves by the surgical team after placental delivery does not .

Exteriorizing the uterus to close the hysterotomy may decrease febrile morbidity

Similarly, infection rates are not appreciatively affected by closure versus nonclosure of the peritoneum

• Importantly, although closure of subcutaneous tissue in obese women does not lower the rate of wound infection, it does decrease the incidence of wound separation

COMPLICATIONS OF PELVIC INFECTIONS

•In more than 90 percent of women, metritis responds to treatment within 48 to 72 hours

Clinical Course

• If without treatment indolent course ultimate suppuration

• Fever after exclusion of other causes –most important criterion for the diagnosis of postpartum metritis

Treatment

• Mild Cases – Oral antibiotics

• Moderate to Severe – Parental therapy with broad spectrum antimicrobial regimen, improvement within 48-72 hours

Complications that cause persistent fever

• Parametrial incision and pelvic abscesses

• Surgical incisional and pelvic abscesses

• Infected hematoma

• Septic pelvic thrombophlebitis

WOUND INFECTIONS

•When prophylactic antimicrobials are given as described above, the incidence of abdominal incisional infections following cesarean delivery is less than 2 percent

• The incidence in some cases averaged 6 percent and ranged from 3 to 15 percent

• Wound infection is a common cause of persistent fever in women treated for metritis

WOUND INFECTIONS

Risk factors:obesitydiabetescorticosteroid therapyimmunosuppressionanemia poor hemostasis with hematoma formation

WOUND INFECTIONS

• Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for its persistence beginning about the fourth day.•Wound erythema and drainage usually accompany it.•Treatment includes antimicrobials and surgical drainage, with careful inspection to ensure that the fascia is intact.

WOUND INFECTIONS

With local wound care given two to three times daily, secondary en bloc closure at 4 to 6 days of tissue involved in superficial wound infection can usually be With this closure, a polypropylene or nylon suture of appropriate gauge enters 3 cm from one wound edge. It crosses the wound to incorporate the full wound thickness and emerges 3 cm from the other wound edge These are placed in series to close the opening. In most cases, sutures may be removed on postprocedural day 10

WOUND DEHISCENCE

refers to separation of the fascial layerserious complication and requires secondary closure of the incision in the operating roomdisruptions manifest about 5th post-op day with serosanguineous discharges

TREATMENTsecondary closure of the incision with adequate anesthesia

Necrotizing Fasciitis

uncommon, severe wound infection is associated with high mortality

may involve abdominal incisions, or it may complicate episiotomy or other perineal lacerations

RISK FACTORS:—diabetes, obesity, and hypertension—are relatively common in pregnant women

caused by a single virulent bacterial species such as group A -hemolytic streptococcus. Occasionally some are caused by rarely encountered pathogens

Necrotizing Fasciitis

TREATMENTTreatment consists of broad-spectrum antibiotics along with prompt wide fascial debridement until healthy bleeding tissue is encountered.With extensive resection, synthetic mesh may be required to close the fascial incision Clindamycin given with a beta-lactam antimicrobial -most effective regimen

PERITONITISunusual for peritonitis to develop following cesarean

delivery

It is almost invariably preceded by metritis and uterine incisional necrosis and dehiscence.

Other cases may be due to inadvertent bowel injury at cesarean delivery.

Yet another cause is peritonitis following rupture of a parametrial or adnexal abscess.

It may rarely be encountered after vaginal delivery.

Abdominal rigidity may not be prominent with puerperal peritonitis because of abdominal wall laxity from pregnancy

Pain may be severe, but frequently, the first symptoms of peritonitis are those of adynamic ileus.

Marked bowel distension may develop, and these findings are unusual after uncomplicated cesarean delivery

If the infection begins in an intact uterus and extends into the peritoneum, antimicrobial treatment alone usually suffices

Peritonitis caused by uterine incisional necrosis or bowel perforation must be treated surgically

ADNEXAL INFECTIONS

Ovarian abscess bacterial invasion through a vent in the ovarian capsule

usually unilateral and present 1-2 weeks after delivery

Rupture is common and peritonitis may be severe

TREATMENT

drain and give antibiotics

Parametrial Phlegmon

In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of induration, or phlegmon, within the leaves of the broad ligament These infections should be considered when fever persists longer than 72 hours despite intravenous antimicrobial therapy

Parametrial Phlegmon

Phlegmons are usually unilateral, and they frequently are limited to the parametrial area at the base of the broad ligamentThe most common form of extension is laterally along the broad ligament, with a tendency to extend to the pelvic sidewall.Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass posterior to the cervix

Parametrial Phlegmon

Because puerperal metritis with cellulitis is typically a retroperitoneal infection, evidence of peritonitis suggests the possibility of uterine incisional necrosis, or less commonly, a bowel injury

Parametrial Phlegmon Treatment

In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen. Typically, fever resolves in 5 to 7 days, but in some cases, it is longer.Absorption of the induration may require several

days to weeks.

Parametrial Phlegmon Treatment

Surgery is reserved for women in whom uterine incisional necrosis is suspected In rare cases, uterine debridement and resuturing of the incision are feasible. For most, hysterectomy and surgical debridement are needed and are predictably difficultFrequently, the cervix and lower uterine segment are involved with an intensive inflammatory process that extends to the pelvic sidewall to encompass one or both ureters. The adnexa are seldom involved, and one or both ovaries usually can be conserved

PARAMETRIAL PHLEGMONOn bimanual pelvic examination, a phlegmon is palpable as a firm, three-dimensional mass

IMAGING TECHNIQUE

A.Pelvic computed tomography scan of dehiscence caused by infection of a vertical cesarean incision. Endometrial fluid (small black arrows) communicates with parametrial fluid (curved white arrows) through the uterine defect (large black arrow). A dilated bowel loop (b) is adjacent to the uterus on the left. B. Supracervical hysterectomy specimen with instrument through uterine dehiscence.

PELVIC ABSCESS

• parametrial phlegmon suppurates, forming a fluctuant broad ligament mass that may point above the inguinal ligament

• Psoas abscess may rarely follow delivery

TREATMENT

• antimicrobial therapy

• percutaneous drainage

SEPTIC PELVIC THROMBOPHLEBITIS

• common complication in the preantibotic era

• With the advent of antimicrobial therapy, the mortality rate and need for surgical therapy for these infections diminished

• Although there occasionally is pain in one or both lower quadrants, patients are usually asymptomatic except for chills.

• Diagnosis can be confirmed by either pelvic CT or MR imaging

PATHOGENESIS OF SEPTIC PELVIC THROMBOPHLEBITIS

Routes of extension of septic pelvic thrombophlebitis. Any pelvic vessel and the inferior vena cava may be involved as shown on the left. The clot in the right common iliac vein extends from the uterine and internal iliac veins and into the inferior vena cava.

TREATMENT OF SEPTIC PELVIC THROMBOPHLEBITIS• The addition of heparin to antimicrobial therapy for septic pelvic

thrombophlebitis did not hasten recovery or improve outcome.

• Certainly, there is no evidence for long-term anticoagulation as given for "bland" venous thromboembolism.

Infections of the Perineum, Vagina, and Cervix

Episiotomy infections are not common because the operation is performed much less frequently now than in the past.

Infection of a fourth-degree laceration is likely to be more serious

Infections of the Perineum, Vagina, and Cervix

Local pain and dysuria, with or without urinary retention, are common symptoms

most common findings were painin 65 percent, purulent discharge in 65 percent, and feverin 44 percent

Vaginal lacerations may become

infected directly or by extension from the perineum. The mucosa becomes red and swollen and may then

become necrotic and slough. Parametrial

extension may result in

lymphangitis

• Cervical lacerations are common but seldom are noticeably infected and may manifest as metritis.

TREATMENT

Infected episiotomies are managed like other infected surgical wounds. Drainage is established, and in most cases, sutures are removed and the infected wound debrided.

Cellulitis but no purulence, broad-spectrum antimicrobial therapy with close observation may be appropriate. With dehiscence, local wound care is continued along with intravenous antimicrobials

Technique for Early Repair

• Most important is that the surgical wound must be properly cleaned and free of infection

• once the surface of the episiotomy wound is free of infection and exudate and covered by pink granulation tissue, secondary repair can be accomplished

• Postoperative care includes local wound care, low-residue diet, stool softeners, and nothing per vagina or rectum until healed

Dehiscence of fourth-degree episiotomy. Secondary repair is done when the wound surface is free of exudate and covered by pink granulation tissue

Necrotizing Fasciitis

• rare but frequently fatal complication of perineal and vaginal wound infections is deep soft-tissue infection involving muscle and fascia

•Although women with diabetes or women who are immunocompromised are more vulnerable, these serious infections may develop in otherwise healthy women

• Necrotizing fasciitis of the episiotomy site may involve any of the several superficial or deep perineal fascial layers, and thus may extend to the thighs, buttocks, and abdominal wall

Necrotizing Fasciitis

Although some virulent infections, for example, from group A -hemolytic streptococci, develop early postpartum, these infections typically do not cause symptoms until 3 to 5 days after delivery.Clinical findings vary, and it is frequently difficult to differentiate more innocuous superficial perineal infections from an ominous deep fascial one. A high index of suspicion, with surgical exploration if the diagnosis is uncertain, may be lifesaving

TREATMENT

Early diagnosis, surgical debridement, antimicrobials, and intensive care are of paramount importance in the successful treatment of necrotizing soft-tissue infections

Surgery includes extensive debridement of all infected tissue, leaving wide margins of healthy tissue.

Mortality is virtually universal without surgical treatment, and rates approach 50 percent even if extensive debridement is performed.

TOXIC SHOCK SYNDROME

• acute febrile illness with severe multisystem derangement

• fever, headache, mental confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, watery diarrhea, marked hemoconcentration

• renal failure hepatic failure, DIC circulatory collapse

TOXIC SHOCK SYNDROME

• Staphylococcus aureus – toxic shock syndrome toxin – 1– first associated with young menstruating women who used tampons

• Therapy : SUPPORTIVE, similar treatment with septic shock, anti-staphylococcal antimicrobials, massive fluid replacement, mechanical ventilation with PEEP, renal dialysis