PUERPERAL

INFECTIONS
DANAE KRISTINA NATASIA
SUPERVISOR : DR. H. SIGIT NURFIANTO, SP.OG (K)
PUERPERIUM
6 to 8 weeks following delivery of the placenta in which the uterus
returns to its normal state.
Following delivery of the placenta, the uterus rapidly
contracts to half of its predelivery size.
The involution that then occurs over the next several
weeks is most rapid in nursing women.
Puerperal complications include:
Postpartum hemorrhage
Postpartum infection
Postpartum depression

PUERPERAL INFECTION:
a general term used to describe any bacterial
infection of the genital tract after delivery
PAST: constitutes the LETHAL TRIAD of maternal death,
along with preeclampsia and obstetrical hemorrhage
PRESENT: maternal deaths from infection have become
uncommon due to effective antimicrobials (13% of
maternal deaths)
Consist of :
Puerpural fever
Uterine Infection
PUERPERAL FEVER
Puerperal fever, also known as postpartum fever or
puerperal infection

Definition: temperatures in the postpartum fever reach
100.4F(38.0C) or higher. The fevers occur on any two of the
first 10 days postpartum, exclusive of the first 24 hours.

Abortion or miscarriage isnt usually associated with this
infection and fever.
Causes :
endometritis (most common)
urinary tract infection
pneumonia\atelectasis
wound infection
septic pelvic thrombophlebitis.

Septic risk factors for each etiologic condition are
listed in order of the postpartum day(PPD) on which
the condition generally occurs.
PUERPERAL FEVER
Prolonged and premature
rupture of the membranes
Prolonged (more than 24
hours) labor
Frequent or unsanitary
vaginal examinations or
unsanitary delivery
Retained products of
conception
Hemorrhage
Maternal conditions, such as
anemia, poor nutrition
during pregnancy.
Cesarean birth (20-fold
increase in risk for puerperal
infection).
Cenital or urinary tract
infection prior to delivery.
Use of a fetal scalp electrode
during labor.
Obesity.
Diabetes.
Urinary catheter
Nipple trauma from
breastfeeding
PUERPERAL FEVER
Risk factors :
Diagnose :
Physical examination & Laboratory
A pelvic examination is done and samples are taken from the genital
tract to identify the bacteria involved in the infection.
The pelvic examination can reveal the extent of infection and possibly
the cause.
Blood samples may also be taken for blood counts , CRP, or blood culture.
A urinalysis may also be ordered, especially if the symptoms are
indicative of a urinary tract infection.
Chest x-ray
Wound culture
TREATMENT
Treatment of puerperal infection usually begins with I.V.
infusion of broadspectrum antibiotics and is continued for
48 hours after fever is resolved.
Supportive care
Symptomatic treatment
Surgery may be necessary to remove any remaining
products of conception or to drain local lesions
In the presence of thrombophlebitis, heparin therapy will
be needed to provide anticoagulation.
INFECTION
ENDOMETRITIS
Ascending polymicrobial infection
Usually normal vaginal flora or enteric bacteria

Primary cause of postpartum infection
1-3% vaginal births
5-15% scheduled C-sections
30-35% C-section after extended period of labor
May receive prophylactic antibiotics
<2% develop life-threatening complications
ETIOLOGY
Endometritis is an ascending polymicrobial infection

The most common organisms are divided into 4 groups:
aerobic gram-negative bacilli
anaerobic gram-negative bacilli
aerobic streptococci
anaerobic gram-positive cocci.

Specifically, Escherichia coli, Klebsiella pneumoniae, and
Proteus species are the most frequently identified
organisms.
The infection is variously known as
endometritis; endoparametritis; or
simply, metritis.

Endometritis complicates 1-3% of
all vaginal deliveries and 5-15% of
scheduled cesarean deliveries.

The incidence of endometritis in patients who undergo cesarean delivery after an
extended period of labor is 30-35% and falls to 15-20% if the patient receives
prophylactic antibiotics.
ENDOMETRITIS
Risk factors:
C-section
Young age
Low SES
Prolonged labor
Prolonged rupture of
membranes

Multiple vaginal exams
Placement of intrauterine
catheter
Preexisting infection
Twin delivery
Manual removal of the
placenta
Pathogenesis
Normal flora
cervicovaginal
bacteria
Innoculation of
Uterine Incision
Cervical Examination,
Internal monitoring,
Prolonged labor,
Uterina incision
Anaerobic
Condition
Clinical Infection
Bacterial
Proliferation
Surgical Trauma,
Sutures,
Devitalized tissue,
Blood and serum
ENDOMETRITIS
Clinical presentation
Fever
Chills
Lower abdominal pain
Malodorous lochia
Increased vaginal
bleeding
Anorexia
Malaise

Exam findings
Fever
Tachycardia
Fundal tenderness

Treatment
Antibiotics

OTHER PUERPERAL INFECTONS
Urinary tract infections (UTIs)
Mastitis
Wound infection
Septic pelvic trombophlebitis
Urinary Tract Infection
Bacterial inflammation of the bladder or urethra

3-34% of patients
Symptomatic infection in ~2%


Urinary Tract Infection
Risk factors
C-section
Forceps delivery
Vacuum delivery
Tocolysis
Induction of labor
Maternal renal disease

Preeclampsia
Eclampsia
Epidural anesthesia
Bladder catheterization
Length of hospital stay
Previous UTI during
pregnancy

Urinary Tract Infection
Clinical Presentation
Urinary
frequency/urgency
Dysuria
Hematuria
Suprapubic or lower
abdominal pain
OR
No symptoms at all
Exam Findings
Stable vitals
Afebrile
Suprapubic tenderness

Treatment
antibiotics

MASTITIS:
Inflammation of the mammary gland
Milk stasis & cracked nipples contribute to the influx of skin flora
Clinical Presentation
Fever
Chills
Myalgias
Warmth, swelling and breast
tenderness

Exam Findings
Area of the breast that is warm,
red, and tender

Treatment
Moist heat
Massage
Fluids
Rest
Proper positioning of the infant
during nursing
Nursing or manual expression of
milk
Analgesics
Antibiotics

WOUND INFECTION
Perineum
(episiotomy or laceration)
3-4 days postpartum
rare

Abdominal incision
(C-section)
Postoperative day 4
3-15%
prophylactic antibiotics
2%
Wound Infection

Perineum
Risk Factors:
Infected lochia
Fecal contamination
Poor hygiene



Abdominal incision
Risk factors:
Diabetes
Hypertension
Obesity
Corticosteroid treatment
Immunosuppression
Anemia
Prolonged labor
Prolonged rupture of membranes
Prolonged operating time
Abdominal twin delivery
Excessive blood loss
WOUND INFECTION
Clinical Presentation

Perineal Infection:
Pain
Malodorous discharge
Vulvar edema

Abdominal Infection
Persistent fever
(despite antibiotics)
Diagnosis
Erythema
Induration
Warmth
Tenderness
Purulent drainage
With or without fever
POST-CESAREAN WOUND INFECTION
DFFERENTAL DAGNOSS

Perineal infection
Hematoma
Hemorrhoids
Perineal cellulitis
Necrotizing fasciitis
Abdominal wound infection
Cellulitis
Wound dehiscence

TREATMENT:
Perineal infections
Treatment of perineal infections includes
symptomatic relief with NSAIDs, local
anesthetic spray, and sitz baths. Identified
abscesses must be drained, and broad-
spectrum antibiotics may be initiated.
TREATMENT:
Abdominal wound infections
These infections are treated with drainage and inspection of the
fascia to ensure that it is intact.
Antibiotics may be used if the patient is afebrile.
Most patients respond quickly to the antibiotic once the wound is
drained.
Patients do not require long-term antibiotics unless cellulitis has
developed.
Studies have shown that closed suction drainage or suturing of the
subcutaneous fat decreases the incidence of wound infection when
the subcutaneous tissue is greater than 2 cm in depth

In emergency cesarean deliveries, use of prophylactic
cefazolin has been shown to reduce the rate of
postpartum endometritis and wound infection.

Other studies have demonstrated that
ampicillin/sulbactam, cefazolin, and cefotetan are all
acceptable choices for single-dose antibiotic
prophylaxis

Controversy still exists with regard to the need for
prophylactic antibiotics during elective deliveries
SEPTIC PELVIC TROMBOPHLEBITIS
Septic pelvic thrombophlebitis is defined as
venous inflammation with thrombus formation in
association with fevers unresponsive to
antibiotic therapy.