Raheegeh Awni RN, SMW, MSMCH, An-Najah National University Faculty of Medicine & Health Sciences

1. Raheegeh Awni RN, SMW, MSMCH, An-Najah National University Faculty of Medicine & Health Sciences Head of Midwifery Department

2. Puerperal infection • any bacterial infection of the genital tract after delivery. • The earliest reference to puerperal infection is found in the works of Hippocrates from the 5th century BC. • he described the condition and attributed it to retention of bowel contents. • Along with preeclampsia and obstetrical hemorrhage, puerperal infection formed the lethal triad of causes of maternal deaths for many decades of the 20th century

3. Introduction • It still accounts for significant postpartum maternal morbidity and mortality. • Patients with a puerperal genital tract infection are susceptible to the development of septic shock, pelvic thrombophlebitis, and pelvic abscess.

4. Following a vaginal delivery, approximately7% of women demonstrate febrile morbidity, defined as a temperature of 100.4°F (38°C) or higher that occurs for more than 2 consecutive days (exclusive of the first postpartum day) during the first 10 postpartum days. • Following primary cesarean section, the incidence of febrile morbidity is about twice that following vaginal delivery. • The majority of these fevers are caused by endometritis

5. Puerperal Fever • Puerperal morbidity is defined as follows: a temperature of 38.0°C (100.4°F) or higher, which occurs on any 2 of the first 10 days postpartum, exclusive of the first 24 hours, and which is taken orally by a standard technique at least four times daily. • This definition developed from one proposed by the Joint Committee on Maternal Welfare, which was originally convened in 1919 • (Mussey and colleagues, 1935).

6. Differential Diagnosis • Most persistent fevers after childbirth are caused by genital tract infection. • 20 percent of women febrile within the first 24 hours after giving birth vaginally were subsequently diagnosed with pelvic infection. • This was in contrast to 70 percent of those undergoing cesarean delivery. • pelvic infection caused by either group A or group B streptococcus.

7. breast engorgement; • respiratory complications such as atelectasis, aspiration pneumonia, • and bacterial pneumonia; acute pyelonephritis; • and thrombophlebitis. • About 15 percent of all women develop postpartum fever from breast engorgement.

8. Pathophysiology • The pathophysiology of puerperal sepsis is closely related to the various microbial inhabitants of the vagina and cervix. • The vaginal flora during gestation resembles that in the nonpregnant state, although there is a trend toward isolating more Mycoplasma genitalis and anaerobic streptococci in the last trimester. • Potentially pathogenic organisms can be cultured from the vagina in approximately 80% of pregnant women.

9. These organisms include enterococci, hemolytic and nonhemolytic streptococci, anaerobic streptococci, enteric bacilli, pseudodiphtheria bacteria, and Neisseria species other than N. gonorrhoeae. • Excessive overgrowth of these organisms during pregnancy is inhibited by the acidity of the vagina (pH 4 to 5), primarily as a result of the production of lactic acid by the lactobacilli.

10. The uterine cavity is normally free of bacteria during pregnancy. • After parturition, the pH of the vagina changes from acidic to alkaline because of the neutralizing effect of the alkaline amniotic fluid, blood, and lochia, as well as the decreased population of lactobacilli.

11. This change in pH favors an increased growth of aerobic organisms. • Approximately 48 hours postpartum, progressive necrosis of the endometrial and placental remnants produces a favorable intrauterine environment for the multiplication of anaerobic bacteria.

12. Causes • About 70% of puerperal infections are caused by: • 1- Anaerobic organisms.Most of these are anaerobic cocci (Streptococcus). • 2-Aerobic organisms, Escherichia coli is the most common pathogen, followed by enterococci.

13. Intrauterine staphylococcal infection is rare. This organism is responsible for infection of perineal wounds and abdominal incisions. • 3- Trichomonas vaginalis and Candida albicans are frequent inhabitants of the vagina, but no connection with puerperal sepsis has been established. • 4-Mycoplasmaorganisms have been shown to contribute to puerperal endometritis

14. Antepartum factors • History of prvious venous thrombosis • UTI, MASTITIS • DM • DRUG ABUSE • ALCOHOLDRUG ABUSE • IMMUNSUPRESSION • ANEMIA • MALNUTRITION

15. PREDISPOSING FACTORS Factors predisposing to the development of puerperal genital tract infection are: • Poor nutrition and hygiene • Anemia • Premature rupture of the membranes (PROM) • Prolonged rupture of the membranes • Prolonged labor

16. Frequent vaginal examinations during labor • Cesarean delivery • Forceps or vacuum delivery • Cervical/vaginal lacerations • Manual removal of the placenta • Retained placental fragments or fetal membranes

17. After delivery, the placental site vessels are clotted off, and there is an exudation of lymph-like fluid along with massive numbers of neutrophils and other white cells to form the lochia. • Vaginal microorganisms readily enter the uterine cavity and may become pathogenic at the placental site, depending on such variables as the size of the inoculum (process of induction of immunity against various infectious diseases), the local Ph.

18. The normal body defense mechanisms usually prevent any progressive infection, but a breakdown of these defenses allows the bacteria to invade the myometrium. • Further invasion into the lymphatics of the parametrium can cause lymphangitis, pelvic cellulitis, and the possibility of widespread infection from septic emboli. Endomyoparametritis is a potentially life-threatening condition.

19. It commonly begins with retention of secundines (placental and amniochorionic membrane fragments) that block the normal lochial flow, allowing accumulation of intrauterine lochia, which in turn changes the local pH and acts as a culture medium for bacterial growth. • Unless normal lochial flow is established, bacterial invasion progresses

20. CLINICAL FEATURES • rising fever • increasing uterine tenderness on postpartum day 2 or 3. • development of parametritis (pelvic cellulitis), • temperature elevation will be sustained and signs of pelvic peritonitis may develop. • Erratic temperature fluctuations and severe chills suggest bacteremia and dissemination of septic emboli • likelihood of spread to the lungs.

22. a pelvic vein thrombophlebitis is likely to develop, usually on the right side of the pelvis. • pelvic thrombophlebitis is characterized by a persistent spiking fever for 7 to 10 days after delivery, despite antibiotic therapy

23. DIAGNOSIS • a careful history and physical examination. • palpation of tender, thrombosed, and edematous ovarian, parauterine, or iliac veins. • An abdominal pelvic computed tomographic scan or ultrasonographic

24. Looking for extrapelvic causes of fever as: • breast engorgement, • mastitis, • aspiration pneumonia, • Atelectasis cued by hypoventiltion • pyelonephritis, • thrombophlebitis, • or wound infection,

25. Risk factors • cesarean delivery for multifetal gestation • young maternal age and nulliparity • prolonged labor induction • meconium-stained amnionic fluid

26. MANAGEMENT • A febrile puerperal patient with cessation of lochial flow should undergo a pelvic examination and removal of any secundines that may be occluding the cervical os. • The antibiotic treatment of puerperal infection usually follows two major principles. • First, early antibiotic treatment should be instituted to confine then eliminate the infectious process. • Second, the antibiotics should provide anaerobic coverage because these organisms are involved in 70% of puerperal infections. • Antibiotics should be continued for at least 48 hours after the patient becomes afebrile. • Anaerobic organisms especially require prolonged chemotherapy for elimination.

27. Broad-spectrum antibiotics, such as ampicillin and the cephalosporins ( gentmycine), are effective first-linedrugs for mild and moderate cases of puerperal infection. • When the infection is moderate to severe, a penicillin-aminoglycoside combination has traditionally been used as first-line therapy. The major pelvic pathogen resistant to this combination.

28. When pelvic thrombophlebitis or thromboembolism is suspected, heparin therapy should be instituted • Only 2 to 3 weeks of anticoagulant therapy are needed for uncomplicated pelvic thrombophlebitis. • Patients with femoral thrombophlebitis require 4 to 6 weeks of heparin therapy followed by the administration of oral anticoagulants for a few months. • The presence of a pelvic abscess demands surgical drainage.

29. and as many as 90 percent of these infections respond to regimens such as ampicillin plus gentamicin. • In contrast, anaerobic coverage must be included for infections following cesarean delivery

30. CARE AND MANAGEMENT • Deficit knowledge related to transmission and Prevention of infection • Impaired tissue integrity related to effect of infection process • Acute pain related to mastitis • Risk of impaired parenting related to fear of spread of infection

31. Prevention is the least expensive and effective treatment • Good nutrition • Perineal hygiene • Aseptic techniques and hand washing • Hydration • Rest • Pain relief

32. Thank you