PUERPERAL INFECTION

1. PUERPERAL INFECTION ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD

2. 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%.

3. PUERPERAL INFECTION Facts • IGNAZ SEMMELWEIS (1818–1865)initiated a mandatory hand washing policy for medical students and physicians using a chlorideof 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

4. 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).

5. 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.

6. 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.

7. 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

8. 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.

9. 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.

10. 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.

11. PUERPERAL INFECTION Pelvic peritonitis • Generally unwell patient, pyrexia, disproportionate tachycardia, vomiting and paralytic ileus, low abdominal pain and tenderness, tenderness in the vaginalfornices, 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.

12. 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.

13. PUERPERAL INFECTION Septicemia • virulent organisms (group A hemolitic streptococci) + lowresistance • 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.

14. 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.

15. PUERPERAL INFECTION Treatment • Antibiotic therapy • The type of antibiotic, combination of antibioticsdepend 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.