PUERPERAL INFECTIONS

DANAE KRISTINA NATASIASUPERVISOR : DR. H. SIGIT NURFIANTO, SP.OG (K)

PUERPERIUM6 to 8 weeks following delivery of the placenta in which the uterus returns to its normal state.

Following delivery of the placenta, the uterus rapidly contracts to half of its predelivery size.

The involution that then occurs over the next several weeks is most rapid in nursing women.

Puerperal complications include:Postpartum hemorrhagePostpartum infectionPostpartum depression

PUERPERAL INFECTION:a general term used to describe any bacterial infection of the genital tract after delivery

PAST: constitutes the LETHAL TRIAD of maternal death, along with preeclampsia and obstetrical hemorrhage

PRESENT: maternal deaths from infection have become uncommon due to effective antimicrobials (13% of maternal deaths)

Consist of : Puerpural fever Uterine Infection

PUERPERAL FEVER Puerperal fever, also known as postpartum fever or

puerperal infection

Definition: temperatures in the postpartum fever reach 100.4F(38.0C) or higher. The fevers occur on any two of the first 10 days postpartum, exclusive of the first 24 hours.

Abortion or miscarriage isn’t usually associated with this infection and fever. 

Causes : endometritis (most common) urinary tract infection pneumonia\atelectasis wound infection septic pelvic thrombophlebitis.

Septic risk factors for each etiologic condition are listed in order of the postpartum day(PPD) on which the condition generally occurs.

PUERPERAL FEVER

Prolonged and premature rupture of the membranes

Prolonged (more than 24 hours) labor

Frequent or unsanitary vaginal examinations or unsanitary delivery

Retained products of conception

Hemorrhage Maternal conditions, such

as anemia, poor nutrition during pregnancy.

Cesarean birth (20-fold increase in risk for puerperal infection).

Cenital or urinary tract infection prior to delivery.

Use of a fetal scalp electrode during labor.

Obesity. Diabetes. Urinary catheter Nipple trauma from

breastfeeding

PUERPERAL FEVERRisk factors :

Diagnose :Physical examination & Laboratory A pelvic examination is done and samples are taken from the genital

tract to identify the bacteria involved in the infection. The pelvic examination can reveal the extent of infection and possibly

the cause. Blood samples may also be taken for blood counts , CRP, or blood

culture. A urinalysis may also be ordered, especially if the symptoms are

indicative of a urinary tract infection. Chest x-ray Wound culture

TREATMENT Treatment of puerperal infection usually begins with I.V.

infusion of broadspectrum antibiotics and is continued for 48 hours after fever is resolved.

Supportive care Symptomatic treatment Surgery may be necessary to remove any remaining

products of conception or to drain local lesions In the presence of thrombophlebitis, heparin therapy

will be needed to provide anticoagulation.

INFECTION

ENDOMETRITIS Ascending polymicrobial infection

Usually normal vaginal flora or enteric bacteria

Primary cause of postpartum infection 1-3% vaginal births 5-15% scheduled C-sections 30-35% C-section after extended period of labor

May receive prophylactic antibiotics <2% develop life-threatening complications

ETIOLOGY Endometritis is an ascending polymicrobial

infection

The most common organisms are divided into 4 groups: aerobic gram-negative bacilli anaerobic gram-negative bacilli aerobic streptococci anaerobic gram-positive cocci.

Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species are the most frequently identified organisms.

The infection is variously known as endometritis; endoparametritis; or simply, metritis.

Endometritis complicates 1-3% of all vaginal deliveries and 5-15% of scheduled cesarean deliveries.

The incidence of endometritis in patients who undergo cesarean delivery after an extended period of labor is 30-35% and falls to 15-20% if the patient receives prophylactic antibiotics.

ENDOMETRITISRisk factors: C-section Young age Low SES Prolonged labor Prolonged rupture of

membranes

Multiple vaginal exams Placement of intrauterine

catheter Preexisting infection Twin delivery Manual removal of the

placenta

Pathogenesis Normal flora cervicovaginal

bacteria

Innoculation of Uterine Incision

Cervical Examination, Internal

monitoring, Prolonged labor, Uterina incision

Anaerobic Condition

Clinical Infection Bacterial

Proliferation

Surgical Trauma, Sutures,

Devitalized tissue, Blood and

serum

ENDOMETRITISClinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal

bleeding Anorexia Malaise

Exam findings Fever Tachycardia Fundal tenderness

Treatment Antibiotics

OTHER PUERPERAL INFECTİONS

Urinary tract infections (UTI’s)MastitisWound infectionSeptic pelvic trombophlebitis

Urinary Tract Infection

Bacterial inflammation of the bladder or urethra

3-34% of patients Symptomatic infection in ~2%

Urinary Tract Infection

Risk factors C-section Forceps delivery Vacuum delivery Tocolysis Induction of labor Maternal renal disease

Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during

pregnancy

Urinary Tract Infection

Clinical Presentation Urinary

frequency/urgency Dysuria Hematuria Suprapubic or lower

abdominal painOR… No symptoms at all

Exam Findings Stable vitals Afebrile Suprapubic tenderness

Treatment antibiotics

MASTITIS:Inflammation of the mammary glandMilk stasis & cracked nipples contribute to the influx of skin floraClinical Presentation Fever Chills Myalgias Warmth, swelling and breast

tenderness

Exam Findings Area of the breast that is

warm, red, and tender

Treatment Moist heat Massage Fluids Rest Proper positioning of the infant

during nursing Nursing or manual expression of

milk Analgesics Antibiotics

WOUND INFECTION

Perineum (episiotomy or

laceration) 3-4 days postpartum rare

Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics

2%

Wound Infection

Perineum Risk Factors:

Infected lochia Fecal contamination Poor hygiene

Abdominal incision Risk factors:

Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of membranes Prolonged operating time Abdominal twin delivery Excessive blood loss

WOUND INFECTIONClinical PresentationPerineal Infection: Pain Malodorous discharge Vulvar edema

Abdominal Infection Persistent fever

(despite antibiotics)

Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever

POST-CESAREAN WOUND INFECTION

DİFFERENTİAL DİAGNOSİS Perineal infection Hematoma Hemorrhoids Perineal cellulitis Necrotizing fasciitis Abdominal wound infection Cellulitis Wound dehiscence

TREATMENT: Perineal infections

Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated.

TREATMENT: Abdominal wound infections These infections are treated with drainage and inspection of the

fascia to ensure that it is intact. Antibiotics may be used if the patient is afebrile. Most patients respond quickly to the antibiotic once the wound is

drained. Patients do not require long-term antibiotics unless cellulitis has

developed. Studies have shown that closed suction drainage or suturing of the

subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth

In emergency cesarean deliveries, use of prophylactic cefazolin has been shown to reduce the rate of postpartum endometritis and wound infection.

Other studies have demonstrated that ampicillin/sulbactam, cefazolin, and cefotetan are all acceptable choices for single-dose antibiotic prophylaxis

Controversy still exists with regard to the need for prophylactic antibiotics during elective deliveries

SEPTIC PELVIC TROMBOPHLEBITIS

Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.