Download puerperal infections - University of Yeditepe Faculty of Medicine, 2011

PUERPERAL
INFECTIONS
ASSOC. PROF. OLUŞ APİ,
Yeditepe University Hospital, Department of
Obstetrics & Gynecology
PUERPERIUM
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DEFINITION:
6 to 8 weeks following delivery of the placenta in which
the uterus returns to its normal state.
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Following delivery of the placenta, the uterus rapidly
contracts to half of its predelivery size.
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The involution that then occurs over the next several
weeks is most rapid in nursing women.
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Postpartum vaginal discharge is called LOCHIA.
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It contains blood, mucus and placental
tissue.
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Lochia changes as the uterus involutes.
TYPES OF LOCHIA
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1) LOCHIA RUBRA: Initially, the discharge is grossly bloody,
persisting for 3 to 4 days. It contains large amount of blood.
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2) LOCHIA SEROSA: It then decreases in volume and
changes to pale brown and becomes thinner, persisting for 10 to
12 days. It contains serous exudate, erythrocytes, leukocytes and
cervical mucus.
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3) LOCHI ALBA: Finally, the discharge becomes yellowish
white, occasionally tinged with blood, and may persist for several
weeks. It contains leukocytes, epithelial cells, cholesterol, fat and
mucus.
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After 1 week, the uterus is firm and nontender
and extends to about midway between the
symphysis and the umbilicus.
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By 2 weeks postpartum, the uterus is no longer
palpable abdominally.
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Puerperal complications include:
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Postpartum hemorrhage
 Postpartum
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infection
Postpartum depression
Puerperal fever
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Puerperal fever, also known as postpartum fever or
puerperal infection
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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.
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Abortion or miscarriage isn’t usually associated with
this infection and fever.
Benign fever following vaginal
delivery
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Benign single-day fevers:
Fever in the first 24 hours after delivery often
resolves spontaneously and cannot be explained
by an identifiable infection.
Puerperal fever
Causes ( listed in order of decreasing frequency )
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.
risk increases with
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❑ 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).
❑ genital or urinary tract infection prior to delivery.
❑ use of a fetal scalp electrode during labor.
❑ obesity.
❑ diabetes.
❑ urinary catheter
❑ nipple trauma from breastfeeding
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The associated symptoms depend on the site and
nature of the infection.
The most typical site of infection is the genital tract.
Endometritis, which affects the uterus, is the most
prominent of these infections.
Endometritis is much more common if a small part
of the placenta has been retained in the uterus.
(REST PLACENTA)
Physical examination
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.
Laboratory
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
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Treatment
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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, such as
An infected episiotomy (incision made during delivery)
may need to be opened and drained.
In the presence of thrombophlebitis, heparin therapy
will be needed to provide anticoagulation.
Prevention
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Avoid the risk factors
Keep the episiotomy site clean
Careful attention to antiseptic procedures during
childbirth is the basic underpinning of
preventing infection.
Infection
Endometritis
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Ascending polymicrobial infection
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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
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May receive prophylactic antibiotics
<2% develop life-threatening complications
ETIOLOGY
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Endometritis is an ascending polymicrobial infection
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The most common organisms are divided into 4 groups:
aerobic gram-negative bacilli
anaerobic gram-negative bacilli
aerobic streptococci
anaerobic gram-positive cocci.
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Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species
are the most frequently identified organisms.
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The infection is variously known
as endometritis;
endoparametritis; or simply,
metritis.
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Endometritis complicates 1-3%
of all vaginal deliveries and 515% 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.
Endometritis
Risk factors:
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C-section
Young age
Low SES
Prolonged labor
Prolonged rupture of
membranes
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Multiple vaginal exams
Placement of intrauterine
catheter
Preexisting infection
Twin delivery
Manual removal of the
placenta
Endometritis
Clinical presentation
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Fever
Chills
Lower abdominal pain
Malodorous lochia
Increased vaginal bleeding
Anorexia
Malaise
Exam findings
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Fever
Tachycardia
Fundal tenderness
Treatment
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Antibiotics
Urinary Tract Infection
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Bacterial inflammation of the bladder or urethra
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3-34% of patients
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Symptomatic infection in ~2%
Urinary Tract Infection
Risk factors
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C-section
Forceps delivery
Vacuum delivery
Tocolysis
Induction of labor
Maternal renal disease
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Preeclampsia
Eclampsia
Epidural anesthesia
Bladder catheterization
Length of hospital stay
Previous UTI during
pregnancy
Urinary Tract Infection
Clinical Presentation
Exam Findings
Urinary frequency/urgency
 Dysuria
 Hematuria
 Suprapubic or lower
abdominal pain
OR…
 No symptoms at all
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Stable vitals
Afebrile
Suprapubic tenderness
Treatment
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antibiotics
Mastitis
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Inflammation of the mammary gland
Milk stasis & cracked nipples contribute to the
influx of skin flora
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2.5-3% in the USA
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Neglected, resistant or recurrent infections can lead
to the development of an abscess (5-11%)
Mastitis
Clinical Presentation
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Fever
Chills
Myalgias
Warmth, swelling and breast
tenderness
Exam Findings
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Area of the breast that is warm,
red, and tender
Treatment
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Moist heat
stasis
Massage
Fluids
Rest
Proper positioning of the infant
during nursing
Nursing or manual expression
of milk
Analgesics
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Antibiotics
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Wound Infection
Perineum
Abdominal incision
(episiotomy or laceration)
 3-4 days postpartum
 rare
(C-section)
 Postoperative day 4
 3-15%
 prophylactic antibiotics
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2%
Wound Infection
Perineum
Abdominal incision
Risk Factors:
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Infected lochia
Fecal contamination
Poor hygiene
Risk factors:
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Diabetes
Hypertension
Obesity
Corticosteroid treatment
Immunosuppression
Anemia
Prolonged labor
Prolonged rupture of
membranes
Prolonged operating time
Abdominal twin delivery
Excessive blood loss
Wound Infection
Clinical Presentation
Diagnosis
Perineal Infection:
 Pain
 Malodorous discharge
 Vulvar edema
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Abdominal Infection
 Persistent fever
(despite antibiotics)
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Erythema
Induration
Warmth
Tenderness
Purulent drainage
With or without fever
POST-CESAREAN WOUND
INFECTION
Differential diagnosis
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Perineal infection
Hematoma
Hemorrhoids
Perineal cellulitis
Necrotizing fasciitis
Abdominal wound infection
Cellulitis
Wound dehiscence
TREATMENT: Perineal infections
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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
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These infections are treated with drainage and inspection of the fascia to
ensure that it is intact.
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Antibiotics may be used if the patient is afebrile.
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Most patients respond quickly to the antibiotic once the wound is
drained. Antibiotics are generally continued until the patient has been
afebrile for 24-48 hours.
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Patients do not require long-term antibiotics unless cellulitis has
developed.
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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
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In emergency cesarean deliveries, use of prophylactic cefazolin
has been shown to reduce the rate of postpartum endometritis
and wound infection.
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Other studies have demonstrated that ampicillin/sulbactam,
cefazolin, and cefotetan are all acceptable choices for singledose antibiotic prophylaxis.
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Controversy still exists with regard to the need for
prophylactic antibiotics during elective deliveries
Other Puerperal Infections
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Urinary tract infections (UTI’s)
Mastitis
Wound infection
Septic pelvic trombophlebitis
MASTITIS
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Mastitis is defined as inflammation of the mammary gland.
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Milk stasis and cracked nipples, which contribute to the influx of skin
flora, are the underlying factors associated with the development of
mastitis.
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Mastitis is also associated with primiparity, incomplete emptying of the
breast, and improper nursing technique.
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The most common causative organism, isolated in approximately half of
all cases, is Staphylococcus aureus.
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Other common pathogens include Staphylococcus epidermidis, S saprophyticus,
Streptococcus viridans, and E coli.
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Incidence
In the United States, the incidence of postpartum mastitis is
2.5-3%.
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Mastitis typically develops during the first 3 months
postpartum, with the highest incidence in the first few weeks
after delivery.
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Morbidity and mortality
Neglected, resistant, or recurrent infections can lead to the
development of an abscess, requiring parenteral antibiotics
and surgical drainage.
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Abscess development complicates 5-11% of the cases of
postpartum mastitis and should be suspected when antibiotic
therapy fails.
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History
Fever, chills, myalgias, erythema, warmth, swelling,
and breast tenderness characterize mastitis.
Physical
Typical findings include an area of the breast that is
warm, red, and tender.
When the exam reveals a tender, hard, possibly
fluctuant mass with overlying erythema, a breast
abscess should be considered.
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Differential diagnosis
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Mastitis
Breast abscess
Cellulitis
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Workup
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No laboratory tests are required.
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Expressed milk can be sent for analysis, but the accuracy and
reliability of these results are controversial and aid little in the
diagnosis and treatment of mastitis
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TREATMENT
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Milk stasis sets the stage for the development of mastitis, which can be
treated with moist heat, massage, fluids, rest, proper positioning of the
infant during nursing, nursing or manual expression of milk, and
analgesics.
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When mastitis develops, penicillinase-resistant penicillins and
cephalosporins.
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Erythromycin, clindamycin, and vancomycin may be used for infections
that are resistant to penicillin.
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Resolution usually occurs 48 hours after the onset of antimicrobial
therapy.
SEPTIC PELVIC
TROMBOPHLEBITIS
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Septic pelvic thrombophlebitis is defined as venous
inflammation with thrombus formation in association
with fevers unresponsive to antibiotic therapy.
CASE
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A 28-year-old primigravid underwent a cesarean
section secondary to having a breech
presentation and rupture of membranes at 36
weeks gestation. The cesarean section was
uncomplicated, but on postpartum day two the
patient was having fever (38.5C) and uterine
tenderness.
A diagnosis of postpartum endometritis was
made and the infection was treated with
Mefoxine 1 g IV Q8H.
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After 24 hours of antibiotics, the patient
presented pain in the right lower abdomen and
loin, and her WBC count was 12000/mm3. She
continued to spike fevers .
Abd:soft,flat, tenderness on the right
abdomen,no rebound-tenderness, Mcburney’s
point (+/-),Murphy’s sign(-), kindey region
percussion (-).
Urinalysis was unremarkable.
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On postpartum day four, the patient’s condition
was no improvement after antibiotic treatment,
and an abdominal CT scan was obtained. A right
ovarian vein thrombosis was noted on the
imaging.
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IMP: ovarian vein thrombophlebitis
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The patient started therapeutic
enoxaparin(clexane). After 48 hours of
anticoagulation, the patient was afebrile and
asymptomatic. The patient was discharged home
after being anticoagulated with warfarin and
after 6 weeks a CT scan was repeated. The right
ovarian thrombosis was not present in the
images and warfarin was discontinued
ETIOLOGY
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Bacterial infection of the endometrium seeds organisms into the
venous circulation, which damages the vascular endothelium and in
turn results in thrombus formation.
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The thrombus acts as a suitable medium for proliferation of anaerobic
bacteria.
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Ovarian veins are often involved because they drain the upper half of
the uterus.
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Risk factors include low socioeconomic status, cesarean birth,
prolonged rupture of membranes, and excessive blood loss.
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Incidence
Septic pelvic thrombophlebitis occurs in 1 of every 2000-3000
pregnancies and is 10 times more common after cesarean birth (1 per
800) than after vaginal delivery (1 per 9000).
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The condition affects less than 1% of patients with endometritis.
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Morbidity and mortality
Septic thrombophlebitis may result in the migration of small septic
thrombi into the pulmonary circulation, resulting in effusions,
infections, and abscesses.
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Only rarely is a thrombus large enough to cause death.
HISTORY
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Septic pelvic thrombophlebitis usually
accompanies endometritis.
Patients report initial improvement after an
intravenous antibiotic is initiated for treatment
of the endometritis.
The patient does not appear ill. Patients with
ovarian vein thrombosis may describe lower
abdominal pain, with or without radiation to the
flank, groin, or upper abdomen.
PHYSICAL SIGNS
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Vital signs demonstrate fever greater than 38°C and
resting tachycardia.
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If pulmonary involvement is significant, the patient
may be tachypneic.
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On abdominal examination, 50-70% of patients with
ovarian vein thrombosis have a tender, palpable,
ropelike mass extending cephalad beyond the uterine
cornu.
WORK-UP
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Urinalysis, urine culture, and CBC count with
differential.
Imaging: CT scan and MRI are the studies of
choice for the diagnosis of septic pelvic
thrombophlebitis.
MRI has 92% sensitivity and 100% specificity, and
CT imaging has a 100% sensitivity and specificity
for identifying ovarian vein thrombosis.
TREATMENT
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The standard therapy after diagnosis of septic pelvic thrombophlebitis
includes anticoagulation with intravenous heparin to an aPTT that is
twice normal and continued antibiotic therapy.
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A therapeutic aPTT is usually reached within 24 hours, and heparin is
continued for 7-10 days.
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Antibiotic therapy is most commonly with gentamicin and clindamycin.
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Other choices include a second- or third-generation cephalosporin,
imipenem, cilastin, or ampicillin and sulbactam.
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All of these antibiotics have a cure rate of greater than 90%.