Puerprium ,peurpral fever and peurpral sepsis (1)

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Undergraduate course lectures in Obstetrics&Gynecology,Faculty of medicine,Zagazig University,Egypt, Prepared by DR Manal Behery

Undergraduate course lectures in Obstetrics&Gynecology,Faculty of medicine,Zagazig University,Egypt, Prepared by DR Manal Behery

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  • 1. Normalpuerperium.
  • 2. Definition of Normal Puerperium It is the period following delivery of the baby and placenta to 6 weeks postpartum. It is the period during it ,the reproductive organs & maternal physiology returns towards the pre pregnancy state .
  • 3. Divided into –First 24 hours –Early- up to 7 days –Remote- up to 6 weeks
  • 4. Objectives  To monitor physiological changes of puerperium  To diagnose and treats any postnatal complications  To establish infant feeding  To advise about contraception
  • 5. Physiological changes in NormalPuerperium  Changes in Genital Tract  Changes in breast and Lactation  Changes in other systems
  • 6. Changes in Genital Tract Involution of the Uterus Lochia Involution of Other Pelvic Organs Menstruation
  • 7. Uterine involutionA. Immediately after delivery:fundus palpable atlevel of umbilicusB. 10-14 days later,At level of thesymphysis pubis.C. 6 WKS post partun :non pregnant size
  • 8. Endometrium Cavity Decidua is cast off as a result of ischemia→ lochial flow Lochia= blood, leucocytes, shreds ofdecidua and organisms. Initially; dusky red3-4 days(rubra), fadesafter one-two week(serosa), clears within 4weeks of delivery(alba). New endometrium grows from basallayer of decidua.
  • 9. Cervix:  It has reformed within several hours of delivery it usually admits only one finger by 1 weeks the external os is fish-mouth-shaped it return to its normal state at 4 weeks after birth
  • 10. Ovarian functionReturn of menstruation * non-nursing mothers: menstruation returns by 6 – 8 weeks. * nursing mothers: may develop lactating amenorrhea. time of ovulation is 3 months in non- breast -feeding women
  • 11. Changes in Breast and Lactation Mamogenesis (Mammary duct- gland growth & dev.) Lactogenesis (Initiation Of milk secretion in alveoli) Galactopoiesis (Maintenance of Lactation)
  • 12. Changes in other systems  Pulse slow  Temp. subnormal  Shivering  Fever up to first 24 hours  Hb. Rises  TLC increases  Diuresis- 2nd to 5th day post delivery
  • 13. OTHER SYSTEMS: OTHER SYSTEMS: Bladder & Urethra - Within 2-3 weeks Hydroureter and calycial dilatation of pregnancy is much less evident. - Complete return to normal → 6-8 weeksCardiovascular system * cardiac output & plasma volume gradually returns to normal during the first 2 weeks. * marked weight loss occurs in the first week as a result of the decrease of plasma volume and the deuresis of the extracellular fluid.
  • 14. Daily round by physical staff shouldincluid: Uterus: palpate uterine funds to evaluate level and tone Abdomen: examine for distension especially postoperative Lochia :for quantity ,and unusual odors Perineum: inspected for hematoma formation ,signs of infections, or wound breakdown.
  • 15.  Bladder: function may be abnormal after traumatic delivery or epidural anethesia.(Catheter may be left in place for 24 hr if there is marked periurtheral edema or repair). Breasts :examined for engorgement or signs of infection Lungs :evaluated in all post CS patients. Extremities :because post partum pt are at increased risk of DVT especially post CS.
  • 16. Post partum immunization Adminster a booster dose in Rubella non immune wommen or MMR vacine. Adminster 300 ug of RhoGAM within first 72 hours after delivery to RH –ve mothers .
  • 17. Breast feeding should be Encouraged Help in rapid uterine involution, decreased risk of ovarian ,breast cancer,osteprosis.Women shouldnt breastfed if: Have infant with galactosemia Are infected with HIV. Have active untreated TB. Are being treated for breast cancer.
  • 18. Contraceptive advice Breast feeding women shouldn’t relay on lactation amenorrhea as a method of contraception (98% protection in first 6 months provided that feeding every 4 hours daily ,6 hours at nigth ,formula supply 10- 15%) Use a barrier method or hormonal contraception .POP 2-3 weeks postpartum DMPA 6 weeks postpartum
  • 19. Health& nutrition education Health & nutrition education Calorie need per day-2200+700 =2900 Care of MLE stitches if any Care of nipples and areola Sexual intercourse can be resumed after 6 weeks after delivery Immunization of child
  • 20. Puerperal fever
  • 21. DefinitionTemperatures reach 100.4F(38.0C) or higher on any two of the first 10 days postpartum, exclusive of the first 24 hours. 
  • 22. Benign single-day fevers followingvaginal delivery Fever in the first 24 hours after delivery often resolves spontaneously and cannot be explained by an identifiable infection.
  • 23. Significance Significance Fever is not an automatic indicator of puerperal infection. A new mother may have a fever owing to prior illness or an illness unconnected to childbirth. However, any fever within 10 days postpartum is aggressively investigated. Physical symptoms such as pain, malaise, loss of appetite, and others point to infection.
  • 24. CausesEndometritis (most common),Milk engorgment, Mastitis,breast abscessUrinary tract infectionpneumoniaatlectasis,CS ,perineal wound infection, fasiaties.Septic pelvic thrombophlebitis.
  • 25. Mastitis : = uncommon complication usually develops after 2 – 4 weeks. symptoms & signs low grade fever , chills , indurated ,red and painful segment of the breast. caused by Staphylococcus aureus bacteria from the infant’s oral pharynx.
  • 26. Mastitis
  • 27. Treatment Mother should start antibiotics immediately, such as dicloxacillin for 7-10 days. Breastfeeding may be discontinued so, breast pump can be used to maintain lactation . however , suppression of lactation is advisable. if a breast abscess develops , it should be surgically drained.
  • 28. Endometritis 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.
  • 29. Atelectasis Caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery
  • 30. Acute pyelonephritis AcuteHas a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting.
  • 31. Wound infections Incisional abscesses that develop following cesarean delivery usually cause persistent fever beginning about the fourth day Perinealinfection uncommon , caused by bacterial contamination during delivery Antimicrobials and surgical drainage, with careful inspection to ensure that the fascia is intact.
  • 32. Septic ThrombophlebitisA dignosis of exclusion .Thrombous spread by lymphatics to the iliac vessels or directly via the ovarian vessels. Suspected by intermittent spiky fever which fails to response to ordinary antibiotics and improved with heparin .
  • 33. Puerpral sepsis
  • 34. Incidence3%- 7% of all direct maternal deaths , excluding deaths after abortion.Etiology: Puerperal infection is usually poly microbial involves contaminants from the bowel that colonize the perineum and lower genital tract.
  • 35. Clinical course & severity of theisinfection is clinical course & severity of the infection determined bydetermined by 1. general health and resistance of the woman. 2. virulence of the causative organisms. 3. presence of predisposing factors as bl. Clots, hematoma or retained products of conception. 4. timing of antibiotic therapy.
  • 36. Risk factors  Prolonged PROM  Prolonged (more than 24 hours) labor  Frequent vaginal examinations  Retained products of conception  Hemorrhage  Anemia, poor nutrition during pregnancy.  Obesity.  Diabetes.
  • 37. Risk factors (CONT ..)  Cesarean birth (20-fold increase in risk for puerperal infection).  Genital or urinary tract infection prior to delivery.  Urinary catheter  Fetal scalp electrode, internal FHR during labor.
  • 38. Pathogenesisof puerperal sepsis
  • 39.  Puerperal infection following vaginal delivery primarily involves the placental implantation site, decidua and adjacent myometrium, or cervicovaginal lacerations. Uterine infection following cesarean delivery is that of an infected surgical incision Bacteria that colonize the cervix and vagina gain access to amnionic fluid during labor, and postpartum, they invade devitalized uterine tissue.
  • 40. UTERINE INFECTIONS Postpartum uterine infection has been called variously endometritis, endomyometritis, and endoparametritis. Because infection involves not only the decidua but also the myometrium and parametrial tissues, the inclusive term metritis with pelvic cellulitis.
  • 41. Predisposing factor The route of delivery is the single most significant risk factor for the development of uterine infection 1- to 6-% incidence of metritis after vaginal delivery. If there is intrapartum chorioamnionitis, the risk of persistent uterine infection increases to 13 %
  • 42. CESAREAN DELIVERYSingle-dose perioperative antimicrobial prophylaxis is given almost universally at CS10-50% incidence of metritis after CSWomen with CS after labor (risk factors factors) who were not given perioperative prophylaxis had a 90-percent serious pelvic infection rate
  • 43. DiagnosisA. Clinical Picture symptoms: • fever ,rigors, malaise, headache. • vomiting and diarrhoea. • abdominal discomfort. • offensive lochia. • 2ry PP Hge.
  • 44. SignsPyrexia and tachycardiaUterus is large and tenderParametrial tenderness (parametritis)or fullness in pelvis due to abscess is elicited on abdominal and bimanual examinationperitoneum and paralytic ileus (severe cases).
  • 45. Investigations 1. CBC anaemia, Leukocytosis may range from 15,000 to 30,000 cells/L, but recall that cesarean delivery itself increases the leukocyte count 2. Coagulation Profile DIC. 3 Arterial blood gas acidosis & hypoxia. ( septiceamic shock)
  • 46. Bacterial cultures4-Routine pretreatment genital tractcultures are of little clinical use andadd significant costs5-Similarly, routine blood culturesseldom modify care(25% +ve in septicPelvic thrombo phelbities.
  • 47. Investigations6.Urine analysis: white blood cell casts is diagnostic of pyelonephrities.7-Pelvic US : Retained products Adnexal mass in pelvic abscess.CT: Occult abscess or thrombous in tthrombophelbities.
  • 48. Management
  • 49. PreventionAwareness of general hygiene principles Good surgical technique with proper hemostasis. Prophylactic antibiotics especially in emergency CS.a single intra operative dose of cphalosporin+ metronidazole.
  • 50. Treatment Begins with I.V. infusion of broad spectrum antibiotics and is continued for 48 hours after fever is resolved. Surgery may be necessary to remove any remaining products of conception or to drain local lesions, such as an infected episiotomy .
  • 51. CLINDAMYCIN-GENTAMICIN REGIMEN had a 95-percent response rate still considered by most to be the standard by which others are measured Because enterococcal infections may persist despite this standard therapy, many add ampicillin to the clindamycin-gentamicin regimen, either initially or if there is no response by 48 to 72 hours.
  • 52. Patients with persistant fever despiteantibiotics TTT are assessed for  Ratained product of conception  Wound infection  Pelvic abcess  Ovarian vein thrombosis  Septic pelvic thrombophelbities.
  • 53. Complications
  • 54. 1- Metritis and parametitis.2. Pelvic abscess3 Pelvic Peritonitis4. Septic Thrombophlebitis
  • 55. * Necrotizing Fasciitis Fatal infection of skin ,fascia and muscle. It occurs in the perineal tears, episiotomy sites & CS wounds. caused by a variety of bacteria including anaerobes.*
  • 56.  Necrotizing fasciitis of the episiotomy site may involve any of the several superficial or deep perineal fascial layers, and thus may extend to the thighs, buttocks, and abdominal wall
  • 57.  in addition to signs of infection ,there is extensive necrosis managed by surgical removal of the necrotic tissue under general anesthesia and split-thickness skin grafts
  • 58. CASE SCENARIO
  • 59.  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.
  • 60.  A diagnosis of postpartum endometritis was made and the infection was treated with Mefoxine 1 g IV Q8H.
  • 61.  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 . On Abdominal exam : Soft, flat abdomen Tenderness on the right iliac fossa No rebound-tenderness, Mcburney’s point (+/-),Murphy’s sign(-), Kindey region percussion (-).
  • 62. investigation Urinalysis was unremarkable.
  • 63. On postpartum day four The patient’s condition showed no improvement after antibiotic treatment, An abdominal CT scan was obtained. A right ovarian vein thrombosis was noted on the imaging. Diagnosis : ovarian vein thrombophlebitis
  • 64.  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 After 6 weeks a CT scan was repeated. The right ovarian thrombosis was not present in the images and warfarin was discontinued
  • 65. How to prevent ? Avoid the risk factors Keep the episiotomy site clean Careful attention to antiseptic procedures during childbirth is the basic key of preventing infection. Administer prophylactic antibiotics with Cesarean section, PROM, cardiac ,diabetic patients and with any uterine manipulation.
  • 66. MCQ
  • 67. Which change can be seen in puerperium? A-maternal heart beat is increased 2 days after delivery B- endometrium repair is resumed three weeks after delivery C- Ureters will return to non pregnant state after 8 weeks D- Vaginal rugae appear after 3 months from delivery Ans:C
  • 68. Which is true about puerpural changes? A- total number of uterine muscular cells is not reduced B-vaginal rugae occur in the third month from delivery C-uterine connective tissue won’t change D-uterine is re-epithelialized totally in the first week of pregnancy Ans:A med-ed-online
  • 69. Which organism is the least responsible inpuerpural infection? A- peptostreptococcus B-enterococcus C- chlamydia trachomatis D-mycoplasma Ans:D
  • 70. A patient comes to the clinic because of fever 4days after C/S which persists 72 hours fromantibiotic administration. What is the most likelyreason of antibiotic failure? A- wound infection B- pelvic thrombophlebitis C- pyelonephritis D- adenexal infection Ans:A med-ed-online
  • 71. What is wrong about puerpural immunization? A- tetanus and diphtheria vaccine before discharge from hospital is advocated B-a woman already injected measles vaccine does not need a booster dose C- Rh negative women with an Rh positive newborn should take RhoGam D- women who have never taken rubella vaccine should be vaccinated Ans:B
  • 72. Which is wrong about fever afterdelivery?A-fever more than 39 c in the first 24 hours after delivery is a sign of severe infectionB-fever in bacterial mastitis usually is late and persistentC-pulmonary infection usually occurs in the first 24 hours mostly after C/SD-pyelonephritis is one of the most common reason of infection and is most often mistaken for pelvic infectionAns: D
  • 73. A woman has gone through C/S 7 days ago .Three days after the operation chills and fever(enigmatic fever) occured. She is givenantibiotic with no improvement in her condition.She doesn’t look ill. What is your diagnosis? A-pelvic abscess B-parametrial phlegmon C-pelvic septic thrombophlebitis D-adenexal infection Ans:C
  • 74. Who can lactate?A- mother of a galactosemic newbornB- mother with HBVC- mother with active untreated TBD-mother with breast herpetic lesionsAns:B
  • 75. An infection after C/S which is notresponsive to clinda+genta is because of: A-clostridium B-enterococcus C-bacteroid fargilis D-chlamydia trachomatis Ans:B
  • 76. What is true about lactation periodmastitis?A-It occurs in the last days of the first weekB- Most of the time it is bilateralC-nose and throat of the newborn is the source of infectionD-it is mostly a result of coagulase-negative staphAns:C
  • 77. THANK YOU Thank you