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Abnormal Pueperium
Abnormal Pueperium
ASHWINI MUNDAWANE
One cannot fail to be impressed with the very
large proportion of patients whose troubles
have originated from febrile a ections
during the puerperium, which in many cases
were clearly due to the neglect of aseptic
precautions on the part of the obstetrician or
midwife.
—J. Whitridge Williams (1903)
Although the woman who recently gave birth is
susceptible to several potentially serious
complications, pelvic infection continues to be the
most important source
of maternal morbidity and mortality.
Other infections include mastitis and breast
abscesses.
That said, puerperal complications include many of
those encountered during pregnancy. For example, as
discussed in venous thromboembolism during the
short 6-week puerperium is as frequent as
during all 40 antepartum weeks.
Secondory postpartum haemorrhage
Pueperal pyrexia
Thromboembolism
Postpartum neuropathy
Musculoskeletal pain
Maternal health issue
Any bacterial infection of the genital tract
afterer delivery.
Lethal triad of maternal death
Infections +Preeclampsia + obstetrical
haemorrhage
Because of effective antimicrobials, maternal
mortality from infection has become
uncommon.
DEFINITION
An oral temperature of 38.0°C (100.4°F) or
higher ,
on any 2 of the first 10 days postpartum,
exclusive of 1st 24 hours.
Several infective and noninfective factors can
cause puerperal fever.
Most persistent fevers after childbirth are
caused by genital tract infection.
Genital tract infection—>
1. Uterine infections
2. Pelvic cellulitis
3. Peritonitis
4. Septicemia
5. Septic pelvic thrombophlebitis
Wound infections
Urinary tract infections
Mastitis/ breast abscess
Respiratory tract infections
Postpartum uterine infection or puerperal
sepsis has been called variously endometritis,
endomyometritis, and endoparametritis.
Because infection involves not only the
decidua but also the myometrium and
parametrial tissues, we prefer the inclusive
term metritis with pelvic cellulitis
The route of delivery is the single most
significant risk factor
25-fold increased infection-related mortality
rate with cesarean versus vaginal delivery.
Rehospitalization rates for wound
complications and metritis were increased
planned primary cesarean delivery than a
planned vaginal birth
Cesarean section: most important
Prolonged labour
Prolonged rupture of membrane
Multiple vaginal examination
Internal fetal monitoring
Meconium stained amniotic fluid
Vaginal colonisation with
Group B streptococcus
Mycoplasma hominis
Ureoplasma urealyticum
Gardenella vaginalis
Chlamydia tracomatis
Low socioeconomic status
Operative vaginal deliveries
Intrapartum chorioamnionitis
Maternal anemia Diabetes
Manual removal of placenta
Younger age and nulliparity
HIV infections
POLYMICROBIAL
Bacteria Commonly Responsible for Female Genital Infections
AEROBES:
1.Gram-positive cocci—group A, B, and D streptococci,
2. enterococcus,
3.Staphylococcus aureus,
4.Staphylococcus epidermidis
Gram-negative bacteria—Escherichia coli, Klebsiella, Proteus
Gram-variable—Gardnerella vaginalis
Others:
Mycoplasma and Chlamydia, Neisseria gonorrhoeae
ANANEROBES:
1.Cocci—Peptostreptococcus and Peptococcus species
2.Others—Clostridium, Bacteroides, Fusobacterium, Mobiluncus
Following vaginal delivery the placental
implantation site,
the decidua and
the adjacent myometrium
cervicovaginal lacerations
Following cesarean delivery infected
surgical incision
Bacteria that colonize the cervix and vagina
Access to amnionic fluid during labor (multiple
PV examinations, PROM, prolonged labour, and
cesarean section)
invades
Placental site and devitalized uterine tissue
1. Myometrium
2. Parametrium
3.Pelvic/ general peritonitis
4.Blood stream
Fever is the most important criterion for the diagnosis
of postpartum metritis
Degree of fever α Extent of infection and
Sepsis syndrome.
Temperatures commonly are 38 to 39°C. Chills +
feverbacteremia or endotoxemia.
abdominalpain, excessive vaginal bleding , headache,
malaise.
SIGNS: Tachycardia, uterine tenderness,
subinvolution of uterus, purulent lochia, parametrial
tenderness.
Leukocytosis may range from 15,000 to 30,000
cells/μL.
group A β-hemolytic streptococci, may be associated
with scant, odorless lochia
Bacterial Cultures: usually not
recommended
Routine genital tract cultures obtained before
treatment
Blood culture when women actually ill with
sepsis syndrome or fever does not respond to
any treatmet or immunocompromised
women.
Antibiotic prophylaxix at cesarean section
Before skin incision
a singele dose Ampicillin 2g IV or
1st generation cephalosporins ( Cefazolin)
1-2g IV
Spontaneous delivery of placenta at cesarean
section.
Cleaning vagina with chlorehexidine or
povidone iodine before vaginal delivery.
Antimicrobial Regimens for Pelvic Infections Following Cesarean Delivery
REGIMEN COMMENTS
Clindamycin + gentamicin “Gold standard,” 90–97%
efficiency once-daily gentamicin
PLUS
Ampicillin ( if sepsis syndrome
or suspected enterococcal infection)
Clindamycin + aztreonam Gentamicin substitute for renal
insufficiency
Extended-spectrum penicillins Piperacillin, piperacillin tazobactam,
ampicillin/sulbactam,
ticarcillin/clavulanate
Cephalosporins Cefotetan, cefoxitin, cefotaxime
Vancomycin Added to other regimens for
suspected Staphylococcus aureus
Metronidazole + ampicillin + gentamicin Metronidazole has excellent
anaerobic coverage
Carbapenems Imipenem/cilastatin, meropenem,
ertapenem reserved for special.
value of prenatal cervicovaginal cultures.
These are obtained in the hope of identifying
pathogens that might be eradicated to
decrease incidences of preterm labor,
chorioamnionitis, and puerperal infections.
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