Welcome to the morning

session
Dr. Md. Maynur Hossain
Intern Doctor

Department of Obstetrics & Gynecology

Tairunnessa Memorial Medical College & Hospital

Or Sepsis
 Complication
Risk factors
Sites of infection Diagnosis
Definition
 If Diagnosis is Management
late of puerperal
or Infection of sepsis
long time Septicemia
Investigation Prevention
Investigation
Definition:
An infection of the genital tract which occurs as a complication of delivery
is termed Puerperal Sepsis.

Puerperal sepsis is commonly due to—(i) Endometritis, (ii) Endomyometritis,

or (iii) Endoparametritis or a combination of all these when it is called
Pelvic cellulitis.
Vaginal flora: The vaginal flora in late pregnancy and at the onset of labor
consists of the following organisms:

1) Doderlein’s bacillus (60-70%)

2) Candida albicans (25%)
3) Staphylococcus albus or aureus
4) Streptococcus – anaerobic common
5) Escherichia coli & Bacteroides groups
6) Clostridium welchii on occasion

Ref- D.C Dutta/9th

Microorganisms responsible for puerperal sepsis are :-

A)Aerobic
Streptococcus haemoyticus group A
E.Coli
Klebsiella
Pseudomonas
Staphylococcus aureus
B) Anaerobic
Anaerobic streptococcus
Cl. Welchii
Cl. Tetani

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Ante partum risk factors:
(1) Malnutrition and anemia,
(2) Preterm labor,
(3) Premature rupture of the membranes,
(4) Immuno-compromised (HIV),
(5) Prolonged rupture of membrane more than 18 hours,
(6) Diabetes.

Intra partum risk factors:

(1) Repeated vaginal examinations,
(2) Dehydration and ketoacidosis during labor,
(3) Traumatic vaginal delivery,
(4) Hemorrhage—ante partum or postpartum,
(5) Retained bits of placental tissue or membranes,
(6) Prolonged labor,
(7) Obstructed labor,
(8) Cesarean delivery.

Ref- D.C Dutta/9th

The primary sites of infection are:

(1) Perineum, (2) Vagina, (3) Cervix, (4) Uterus.

Fig: Necrotizing fasciiti s
involving the skin,
subcutaneous tissues, rectus
sheath and the muscles
(myofasciiti s) in a cesarean
section wound

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Complication of puerperal sepsis:
1) Pelvic cellulitis
2) Pelvic peritonitis
3) General peritonitis
4) Septic pelvic thrombophlebitis
5) Septicemia & Septic shock

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Diagnosis:
Symptoms:
1) Pyrexia
2) L\A Pain
3) Foul smelling discharge (excessive / scanty)

Sign:

General examination:
1) Temperature raised
2) Tachycardia
3) Anemia

P/A/E:
1) Height of uterus not correspond with day of puerperium
due to sub involution
2) Tense, Tender L/A

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 P/V/E:
1) Foul smelling discharge (fishy smell)
2) Amount- Scanty

Investigation:
(Depend upon the severity of infection)

1) High vaginal swab & endocervical swab for gram staining & culture/sensitivity
2) USG- to see retained bits of placenta
3) CBC
4) Blood culture
5) RBS
6) Urine R/M/E

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 If Diagnosis is late/ Infaction of long time:
Localized infaction :

Parametritis – Broad ligament to parametrum

Salphingitis – Uterus to Fallopian tube
Pelvic Peritonitis – Tube to pelvic peritoneum
Generalized Peritonitis – P. Peritoneum to G. Peritoneum
Septicemia – G. Peritoneum to Blood
[ Kidney, liver, lung- Vital organ
damage]
Septic Shock
Pelvic abscess – Main symptom of PA – Diarrhoea , Abdominal Pain

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Septicemia Investigation :
1) Renal function test – Blood urea, S. Creatinine
2) Liver function test – Bilirubin, SGPT
3) Chest X-ray
4) Serum Electrolyte
5) DIC – BT, CT, PC, APTT, Fibrinogen, Fibrin Product

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Management of puerperial sepsis:
A) General Management
1) Isolation of the patient
2) Dehydration & anemia correction
3) Anti-Pyretics
4) Protein rich diet
B) Specific:
1) I/V injection : BSA Cephalosporine (2nd and 3rd Generation)
2) Retained bit of placenta
>3 cm – Dilatation & curettage
<3 cm – Dissolution spontaneously
3) If culture report respond – Continue anti-biotic
If culture report not respond – then change the anti-biotic
4) If Pelvic abscess – should be drained by colpotomy under
ultrasound guidance.

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Anti-biotic (oral): Triple anti-biotic therapy
* Amoxycillin – (+ve)
*Gentamycin – (-ve)
* Metronidazol – (-ve)
or * Clindamycin – (-ve)
Treatment is continued until the infection is controlled for at least 7-10 days.

Antibiotic Regimens:
Severe sepsis. A combination of either piperacillin-tazobactam or
Carbapenem plus clindamycin has broadest range of antimicrobial coverage.

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Management of septic shock:
1) Fluid & electrolyte balance (to monitor CVP)
2) Respiratory support (to maintain arterial PO2 & PCO2)
3) Circulatory support (Nor-adrenaline)
4) Control of infection (intensive antibiotic therapy &/or surgical removal of the
sepsis foci)
5) Specific management (hemodialysis for ARF)

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Prevention of puerperal sepsis:
1) Antenatal Prophylaxis
1) Improvement of nutritional status (to raise Hb% level)
2) Eradication of any septic foci in the body
2) Intra-natal Prophylaxis
1) Full surgical prophylaxis during delivery
2) Screening for group B streptococcus
3) Prophylactic use of antibiotic at the time of C/S
3) Post-partum Prophylaxis
1) Aseptic precautions for at least 1 week following delivery until
wounds are healed up
2) Restriction of too many visitors
3) Sterilized sanitary pads are to be used
4) Infected mothers & babies should be in isolated room

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Thank
You