DR.

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 +
feverbacteremia 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.
SEVIARTY ANTIBIOTICS DOSE FREQUENCY ROUTE

MILD AMOXICILLIN/ 625MG + 12 HOURLY ORAL

INFECTION, CLAVULANIC
VAGINAL ACID +
ROUTE METRINIDAZO 400MG 8 HOURLY ORAL
LE
MODERATE- CLINDAMYCIN 900MG + 8 HOURLY IV
SEVERE, +
AFTER GENTAMYCYN 5MG/KG ONCE DAILY IV
CESAREAN
 Clinical response evident within 48 hours of initiation
of treatment.
 IV antibiotics must be continued for 24 hours after the
patients become afebrile.
 With positive blood culture parenteral antibiotics
should be continued for 2 weeks.
 If no response till 48-72 hours
 1. evaluate other cause sof fever
 2.drug resistance: change antibiotic
 3. pelvic cellulistis, abscess, and uterine wound
dehiscence imaging and surgery
 4. unusual organism treat according to blood
culture
 5.retained products USG and curettage
 Abdominal Incisional Infections:
 Wound infection is a common cause of
persistent fever in women treated for
metritis.
 Other wound infection risk factors include
obesity, diabetes, corticosteroid therapy,
immunosuppression, anemia,hypertension,
and inadequate hemostasis with hematoma
formation.
 Local wound care twice daily.
 Before each dressing change, procedural
 analgesia is tailored to wound size and location,
and oral, intramuscular, or intravenous dosage
routes are suitable. Topical lidocaine given.
 Necrotic tissue is removed, and the wound is
repacked with moist gauze. At 4 to 6 days,
healthy granulation tissue is typically present,
and secondary en bloc closure of the open layers
can usually be accomplished.
 Incisional abscesses that develop following cesarean delivery
usually cause persistent fever or fever beginning about the fourth
day.
 There is wound erythema and drainage.
 Organisms isolated from amnionic fluid at cesarean delivery,
hospital-acquired pathogens
 Treatment  antimicrobials, surgical drainage, and debridement
of devitalized tissue closure, a polypropylene or nylon suture of
appropriate gauge enters 3 cm from one wound edge.
 It crosses the wound to incorporate the full wound thickness and
emerges 3 cm from the other wound edge. These are placed in
series to close the opening.
 Sutures removed on postprocedural day 10.
 Wound vacuum device use is gaining popularity