PUERPERAL INFECTIONS

1. PUERPERAL INFECTIONS ASSOC. PROF. OLUŞ APİ, Yeditepe University Hospital, Department of Obstetrics & Gynecology

2. PUERPERIUM • DEFINITION: 6 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.

3. Postpartum vaginal discharge is called LOCHIA. • It contains blood, mucus and placental tissue. • Lochia changes as the uterus involutes.

4. TYPES OF LOCHIA • 1) LOCHIA RUBRA: Initially, the discharge is grossly bloody, persisting for 3 to 4 days. It contains large amount of blood. • 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. • 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.

5. After 1 week, the uterus is firm and nontender and extends to about midway between the symphysis and the umbilicus. • By 2 weeks postpartum, the uterus is no longer palpable abdominally.

6. Puerperal complications include: • Postpartum hemorrhage • Postpartum infection • Postpartum depression

7. 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.

8. Benign fever following vaginal delivery • Benign single-day fevers: Fever in the first 24 hours after delivery often resolves spontaneously and cannot be explained by an identifiable infection.

9. 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.

10. risk increases with • ❑ 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

11. 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)

13. 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.

14. 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

15. 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, 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.

16. Prevention • Avoid the risk factors • Keep the episiotomy site clean • Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection.

17. Infection

18. 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

19. 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.

20. 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.

21. Risk 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 Endometritis

22. Clinical presentation Fever Chills Lower abdominal pain Malodorous lochia Increased vaginal bleeding Anorexia Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics Endometritis

23. Urinary Tract Infection • Bacterial inflammation of the bladder or urethra • 3-34% of patients • Symptomatic infection in ~2%

24. 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

25. Clinical Presentation Urinary frequency/urgency Dysuria Hematuria Suprapubic or lower abdominal pain OR… No symptoms at all Exam Findings Stable vitals Afebrile Suprapubic tenderness Treatment antibiotics Urinary Tract Infection

26. Mastitis • Inflammation of the mammary gland • Milk stasis & cracked nipples contribute to the influx of skin flora • 2.5-3% in the USA • Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

27. Clinical 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 Mastitis stasis

28. Perineum (episiotomy or laceration) 3-4 days postpartum rare Abdominal incision (C-section) Postoperative day 4 3-15% prophylactic antibiotics 2% Wound Infection

29. 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 Infection

30. Clinical Presentation Perineal Infection: Pain Malodorous discharge Vulvar edema Abdominal Infection Persistent fever (despite antibiotics) Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever Wound Infection

31. POST-CESAREAN WOUND INFECTION

32. Differential diagnosis • Perineal infection • Hematoma • Hemorrhoids • Perineal cellulitis • Necrotizing fasciitis • Abdominal wound infection • Cellulitis • Wound dehiscence

33. 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.

34. 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. Antibiotics are generally continued until the patient has been afebrile for 24-48 hours. • 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

35. 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

36. Other Puerperal Infections • Urinary tract infections (UTI’s) • Mastitis • Wound infection • Septic pelvic trombophlebitis

37. MASTITIS • Mastitis is defined as inflammation of the mammary gland. • Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. • Mastitis is also associated with primiparity, incomplete emptying of the breast, and improper nursing technique. • The most common causative organism, isolated in approximately half of all cases, is Staphylococcus aureus. • Other common pathogens include Staphylococcus epidermidis, S saprophyticus, Streptococcus viridans, and E coli.

39. Incidence • In the United States, the incidence of postpartum mastitis is 2.5-3%. • Mastitis typically develops during the first 3 months postpartum, with the highest incidence in the first few weeks after delivery. • Morbidity and mortality • Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. • Abscess development complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails.

40. 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.

41. Differential diagnosis • Mastitis • Breast abscess • Cellulitis • Workup • No laboratory tests are required. • 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

42. TREATMENT • 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. • When mastitis develops, penicillinase-resistant penicillins and cephalosporins. • Erythromycin, clindamycin, and vancomycin may be used for infections that are resistant to penicillin. • Resolution usually occurs 48 hours after the onset of antimicrobial therapy.

43. SEPTIC PELVIC TROMBOPHLEBITIS • Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.

44. CASE • 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.

45. 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.

46. 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. • IMP: ovarian vein thrombophlebitis

47. 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

48. ETIOLOGY • Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. • The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. • Ovarian veins are often involved because they drain the upper half of the uterus. • Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss.

49. 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). • The condition affects less than 1% of patients with endometritis. • Morbidity and mortality • Septic thrombophlebitis may result in the migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. • Only rarely is a thrombus large enough to cause death.

50. HISTORY • 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.