3. DEFINITION
Is an infection of the genital tract which occurs
as a complication of delivery is termed as
Puerperal sepsis /Puerperal infection
D.C.DUTTA
6. INCIDENCE
• The Kerala Federation of Obstetrics and
Gynaecology (KFOG), which has been
conducting a confidential review of maternal
deaths in the State since 2004, has reported
that if in 2006 sepsis accounted for seven per
cent of all maternal deaths and was its fifth
leading cause, in 2009, it was the third
leading cause, responsible for 8 per cent of
all maternal deaths.
7. ORGANISMS IN VAGINAL
FLORA
Doderlein’s bacillus (60–70%)
Yeast like fungus with increased
prevalence of Candida albicans
(25%)
Staphylococcus albus or aureus
17. ENDOGENOUS
• where organisms are present in the genital
tract before delivery
• Anaerobic streptococcus is the predominant
pathogen.
18. AUTOGENOUS
• Organisms, present elsewhere (skin, throat)
in the body and migrate to the genital organs
by blood stream or by the patient herself
• Streptococcus b hemolyticus, E. Coli,
staphylococcus are important.
19. EXOGENOUS
• Where infection is contracted from sources
outside the patient (from hospital or
attendants)
• Streptococcus b haemolyticus, Staphylococcus
and E. coli are important.
20. PATHOGENESIS
Bacterial growth and multiplication.
Endometrium (placental implantation site),
cervical lacerated wound, vaginal wound or
perineal lacerated wound
25. UTERINE INFECTION
MILD
• There is rise in temperature and pulse rate
• Lochial discharge becomes offensive and
copious
• The uterus is subinvoluted and tender.
26. UTERINE INFECTION
SEVERE
• The onset is acute with high rise of
temperature, often with chills and rigor
• Pulse rate is rapid, out of proportion to
temperature
27. UTERINE INFECTION
SEVERE
• Lochia may be scanty and odorless
• Uterus may be subinvoluted, tender and softer
• There may be associated wound infection
(perineum, vagina or the cervix).
28. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
PARAMETRITIS
• The onset is usually about 7–10th day of
puerperium
• Constant pelvic pain
• Tenderness on either sides on the
hypogastrium
29. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
PARAMETRITIS
• Vaginal examination reveals an unilateral
tender indurated mass pushing the uterus to the
contralateral side
• Rectal examination confirms the induration
specially extending along the uterosacral
ligament
30. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
PARAMETRITIS
• Steady rise of spiky temperature with chills
and rigor
• Intense pain
• Gradual deterioration of the general condition
• Leucocytosis.
31. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
PELVIC PERITONITIS
• Pyrexia with increase in pulse rate
• Lower abdominal pain and tenderness
• Vaginal examination reveals tenderness on the
fornix and with the movement of the cervix
32. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
PELVIC PERITONITIS
• Muscle guard may be absent
• Collection of pus in the pouch of Douglas is
evidenced by swinging temperature, diarrhea
and a bulging fluctuant mass felt through the
posterior fornix.
34. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
GENERAL PERITONITIS
• Patient looks very ill and dehydrated
• Abdomen is tender and distended
• Rebound tenderness is often present.
35. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
THROMBOPHLEBITIS
• There may be swinging temperature continued
for a longer period with chills and rigor
• The features of pyemia are present according
to the organs involved.
36. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
SEPTICEMIA
• There is high rise of temperature usually
associated with rigor
• Pulse rate is usually rapid even after the
temperature settles down to normal
37. SPREADING INFECTION (EXTRA
UTERINE SPREAD)
SEPTICEMIA
• Blood culture is positive
• Symptoms and signs of metastatic infection in
the lungs, meninges or joints may appear.
38. INVESTIGATION
• History
• Clinical examination
• High vaginal and endocervical swabs for culture
• ‘Clean catch’ mid stream specimen of urine for
analysis and culture including sensitivity test
39. INVESTIGATION
• Blood for total and differential white cell count,
hemoglobin estimation.
• A low platelet count may indicate septicemia or
DIC.
• Thick blood film should be examined for malarial
parasites
41. PROPHYLAXIS
ANTENATAL
• Improvement of nutritional status (to raise
hemoglobin level) of the pregnant woman
• Eradication of any septic focus (skin, throat,
tonsils) in the body.
• Proper antenatal care and advise
42. PROPHYLAXIS
INTRANATAL
• Full surgical asepsis during delivery
• Screening for group B streptococcus in a high
risk patient
• Prophylactic use of antibiotic
• Avoid frequent vaginal examination
43. PROPHYLAXIS
POSTPARTUM
• Aseptic precautions for at least one week
following delivery until the open wounds in
the uterus, perineum, vagina are healed up
• Too many visitors are restricted
45. TREATMENT
GENERAL CARE
• Isolation of the patient
• Adequate fluid and calorie
• Anemia is corrected by oral iron or if needed
by blood transfusion
46. TREATMENT
GENERAL CARE
• An indwelling catheter
• Vitals
• Monitoring of lochia
• Antibiotics
• Management of bacteremic or septic shock
47. TREATMENT
• Antibiotic regime should depend on the culture
and sensitivity report.
• Gentamicin (2 mg/kg iv loading dose followed
by 1.5 mg/kg IV every eight hours)
• Ampicillin (1 g IV every 6 hours)
48. TREATMENT
• Clindamycin (900 mg IV every 8 hours)
• Intravenous administration of cefotaxime 1 g,
8 hourly
• Metronidazole 0.5 g, IV is given at 8 hours
49. MANAGEMENT OF
BACTEREMIC OR SEPTIC
SHOCK
• Fluid and electrolyte balance
• Monitor CVP
• Respiratory supports
50. MANAGEMENT OF
BACTEREMIC OR SEPTIC
SHOCK
• Circulatory support
• Infection control
• Specific management (as hemodialysis for
renal failure).
51. SURGICAL TREATMENT
PERINEAL WOUND
• stitches of the wound may have to be removed to
facilitate drainage of pus and relieve pain.
• The wound is to be cleaned with sitz bath and is
dressed with an antiseptic ointment or powder.
• After the infection is controlled secondary suturing
52. SURGICAL TREATMENT
RETAINED UTERINE PRODUCTS
• Surgical evacuation after antibiotic coverage
for 24 hours should be done to avoid the risk
of septicemia.
• Cases with septic pelvic thrombophlebitis are
treated with iv heparin for 7–10 days
53. SURGICAL TREATMENT
WOUND DEHISCENCE
• Scrubbing the wound twice daily
• Debridement of all necrotic tissue and then
closing the wound with secondary suture.
• Appropriate antimicrobials are used following
culture and sensitivity.
54. SURGICAL TREATMENT
• Pelvic abscess – Colpotomy
• Abscess should be incised and the pus is
drained.
• Laparotomy
• Hysterectomy
