Transcript 16. Puerperal infection

PUERPERAL INFECTION
ASSOCIATE PROFESSOR
IOLANDA ELENA BLIDARU
MD, PhD
PUERPERAL INFECTION
Definition
A rise in temperature to 38° C (100,4°F) or
over, maintained for 24 hours occurring in
the puerperium
infection without pyrexia
Extragenital causes: respiratory complications,
pyelonephritis, breast engorgement, bacterial mastitis,
thrombophlebitis, incisional wound abscess.
Incidence
1 to 3%.
PUERPERAL INFECTION
Facts
• IGNAZ SEMMELWEIS (1818–1865)
initiated a mandatory hand washing policy
for medical students and physicians using a
chloride of lime solution
• LOUIS PASTEUR (1822–1895) - the germ
theory of disease, reduced mortality from
puerperal fever, and created the first
vaccines for rabies and anthrax
• JOSEPH LISTER, 1st Baron Lister (1827–
1912) - a pioneer of antiseptic surgery
PUERPERAL INFECTION
Diagnosis
History: antepartum infection, the obstetric record
Physical examination: throat, heart, breasts,
abdomen, legs (to exclude venous thrombosis)
Local investigations (vaginal speculum
examination + vaginal smear, bimanual
examination)
Laboratory investigations (swabs to determine
the predominant bacteria and sensitivity to
antibiotics, urine for microscopic examination and
culture, hemoglobin, leukocyte count).
PUERPERAL INFECTION
Bacteriology
aerobes: Group A, B and D streptococci,
Enterococus, staphylococcus aureus,
Escherichia coli, Klebsiella, Proteus;
anaerobes: peptococcus, Peptostreptococous,
B.fragilis, Clostridium, Fusobacterium;
other: Mycoplasma hominis, Chlamydia
trachomatis.
PUERPERAL INFECTION
Mode of infection
bacteria, particularly anaerobes (60%), normal
inhabitant of the vagina become pathogenic when
 reduced maternal resistance
 damaged vaginal tissues (proteolytic action on
devitalized tissue)
 placental remnants in the uterus
staphylococcal infections (40%), introduced by the
patient → autogenous transmission, by the
attendants, or the environment → exogenous
transmission.
PUERPERAL INFECTION
Site and spread of infection
depend upon their virulence and the
resistance of the patient to invasion
(anemia, PE, diabetes, malnutrition,
dehydration, shock, instrumental or
operative deliveries)
the placental site → a large wound
PUERPERAL INFECTION
Infection of vulva, vagina and cervix
Infection of an episiotomy wound → perineal
pain, discharge, the wound edges are swollen
and red.
Treatment:
antibiotics
the sutures have to be removed, secondary
repair.
PUERPERAL INFECTION
Endometritis and myometritis
the most frequent puerperal infection.
In most cases, the infection is limited to the
endometrium (protective mechanisms).
onset – day 3-6 after delivery,
the clinical evolution depends upon the virulence of
the organisms.
the lochia becomes darker, increases in quantity and
has a bad smell;
pyrexia, shivering, headaches, malaise, tachycardia.
physical examinations - tender and large painful
uterus.
Treatment:
good drainage from the uterus (utero-tonics)
antibiotics.
PUERPERAL INFECTION
Salpingitis - the uterine tube becomes swollen
and tender.
Pelvic cellulitis - Spread may be lateral to
involve the connective tissues of the cardinal
ligaments.
in the 2 nd week of the puerperium - lower
abdominal pain, tender abdomen
vaginal examination → tenderness in the vaginal
fornix, with relative fixation of the cervix.
PUERPERAL INFECTION
Pelvic peritonitis
Generally unwell patient, pyrexia, disproportionate
tachycardia, vomiting and paralytic ileus, low abdominal
pain and tenderness, tenderness in the vaginal fornices,
pain on manipulating the uterus.
Suppuration → local abcess, in Douglas pouch (vaginal /
rectal examination).
Diarrhea - inflammation and irritation of the adjacent
rectum.
A pelvic abscess may burst spontaneously into the rectum
or posterior vaginal fornix, or can be drained by posterior
colpotomy.
PUERPERAL INFECTION
Generalized peritonitis
after abdominal delivery (unrecognized uterine
rupture, bowel trauma), or as continuation of
localized infection.
absent classic signs of pain, tenderness and
rigidity,
clear illness, toxic, often dehydrated, high fever,
rapid pulse, vomiting, ileus.
Treatment
Intravenous fluid and electrolytis, gastric aspiration
laparotomy (unless rapid improvement) for
diagnostic, drainage and repair or removal of
damaged organs.
PUERPERAL INFECTION
Septicemia
virulent organisms (group A hemolitic
streptococci) + low resistance
acute illness, swinging pyrexia, rapid
pulse, mental confusion
thrombophlebitis of the uterine veins →
infected clots may be carried to distant
organs, particularly the lungs to produce
further symptoms.
PUERPERAL INFECTION
Prophylaxis
General measures:
septic foci → treated in antenatal period;
surgical asepsis during labor;
vaginal examinations in labor must only be
performed after the hands have been
scrubbed and sterile gloves worn.
PUERPERAL INFECTION
Treatment
Antibiotic therapy
 The type of antibiotic, combination of antibiotics
depend on the severity of the infection.
 In early severe sepsis → intravenous administration of
Penicillins 4-6g/24 hours every 12 hours intravenously) or
cefotaxim (2 g every 12 hours) + Gentamycin (80 mg
per dose, in 3 divided doses; 240 mg/day + Metronidazole
(500 mg every 8 hours).
Surgical treatment – in generalized peritonitis
→ laparotomy and large drainage with or without
hysterectomy and adnexectomy.