Puerperal Infections and Disorders of the Puerperium PDF Module 3

OB2 OBSTETRICS 2 Puerperal Infections and Disorders of the Puerperium TRANS 8...

OB2 OBSTETRICS 2 Puerperal Infections and Disorders of the Puerperium TRANS 8 MODULE 3 Jasmin S. Tamon, MD, FPOGS, FPIDSOG August 9, 2024 LECTURE OUTLINE CASE 30 year old, G1P0 I Introduction 1 Uncontrolled GDM, obese PROM x 12 hours II Puerperal Fever Labored for 10 hours Delivered by primary CS due to prolonged deceleration III Puerperal Infection phase A. Predisposing Factors Live baby girl, 3.8 kgs B. Microbiology Developed postpartum fever C. Clinical Features D. Treatment What is the cause of her puerperal fever? 1. Perioperative Prophylaxis How should this patient be managed? E. Complications of Uterine Infection 1. Abdominal Incisional Infections 2. Abdominal Wound Dehiscence II. PUERPERAL FEVER 3. Necrotizing Fasciitis Temperature of ≥ 38°C 4. Ovarian Abscess/Adnexal Infection Caused by infective and non infective factors 5. Parametrial Phlegmon/Pelvic Abscess 6. Peritonitis III. PUERPERAL INFECTION 7. Septic Pelvic Thrombophlebitis Most common cause of fever in the puerperium IV Infections of the Perineum, Vagina, and Cervix Can be caused by any bacterial infection of the genital tract after A. Episiotomy Wound Dehiscence delivery 1. Pathogenesis Puerperal uterine infections have also been called endometritis, 2. Treatment metritis, and endomyometritis Following vaginal delivery, if the infection involves not only the V Toxic Shock Syndrome decidua and the myometrium but also the parametrial tissue, it is A. Clinical Presentation termed as endomyoparametritis or metritis with pelvic cellulitis B. Treatment Table 1. Onset of Fever in relation to the timing of delivery VI Extragenital Causes of Puerperal Fever A. Pulmonary Atelectasis Number of Hours Post-op Infection Involved B. Pyelonephritis C. Superficial Thrombophlebitis 24 hrs Atelectasis D. Breast Engorgement 3rd - 5th Day Breast engorgement VII Other Disorders of the Puerperium 4th Day Abdominal Incision Infection A. Thromboembolic Diseases 1. Superficial Venous Thrombosis 5th Necrotizing Fasciitis 2. Deep Venous Thrombosis 7th - 10th Abdominal Wound Dehiscence 3. Pelvic Venous Thrombosis B. Disease and Abnormalities of the Uterus 1-2 Weeks Ovarian Abscess/Adnexal Infections 1. Uterine Subinvolution 1st Week Postpartum Psychosis C. Disorders of the Urinary Tract 1. Urinary Tract Infection 3rd - 4th Week Mastitis/Breast Abscess D. Disorders of the Breast 1. Breast Engorgement 2. Mastitis/Breast Abscess A. PREDISPOSING FACTORS E. Postpartum Psychosis Route of delivery ○ Single most significant risk factor for the development of VIII Summary uterine infection ○ Higher infection mortality rate with cesarean section (CS) as LECTURE OBJECTIVES compared with vaginal delivery, especially if the CS was done 1. Diagnose puerperal infection and other disorders of the as non elective or emergency case as compared to elective or puerperium: risk factors, clinical manifestations, and differential scheduled CS diagnosis CS > VSD 2. Provide comprehensive management by providing the Emergency CS > Elective CS appropriate diagnostic workup and treatment for the patient Ruptured membranes Prolonged labor 🧠 Must Know 📖 Book 📝 Previous Trans Multiple cervical examinations Internal fetal monitoring Vaginal and/or Cervical lacerations I. INTRODUCTION Retained placental fragments Infection, preeclampsia, and obstetrical hemorrhage form the Manual extraction of the placenta — failure for Placenta to be lethal triad or the top three leading causes of maternal death, but delivered within 30 minutes because of the availability of effective antibiotics, maternal General anesthesia — Rarely given unless indicated (Patients mortality from puerperal infection is now becoming uncommon. tend to be lying still for a long time, hence ambulation is delayed, Aside from puerperal infections, there are other disorders making them more prone to infection) encountered by a woman after giving birth. Meconium stained amniotic fluid CS for Multifetal gestation Young maternal age Nulliparity Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 1 of 8  Obesity D. CLINICAL PRESENTATION Low socioeconomic status Fever Anemia, poor nutrition ○ Most common or the most important criterion for the diagnosis of postpartum uterine infection and sepsis syndrome B. PATHOPHYSIOLOGY ○ Involvement of any of the endometrium and the superficial Ascending infection from normal vaginal flora myometrium will cause mild infection and may present with Polymicrobial low-grade fever Clinical presentation varies ○ Chills with accompanied fever suggest the presence of Treatment bacteremia or endotoxemia ○ Oral antimicrobials Abdominal pain and parametrial tenderness ○ IV antibiotics ○ On abdominal bimanual palpation ○ Surgical +/- Foul smelling lochia ○ “Gold Standard” – Clindamycin + Gentamycin ○ Many women with foul smelling lochia may not have an 90-97% efficacy infection and vice versa Plus Ampicillin – for Enterococcal Coverage ○ Some other infections especially those caused by Group A Beta-Hemolytic Streptococci (GAS) may be associated with C. MICROBIOLOGY scant odorless lochia Pathogens that cause pelvic infections are usually caused by Leukocytosis: 15,000 - 30,000 cells/mL bacteria that are indigenous to the normal genital tract ○ However, it is important to remember that delivery itself causes Most of these infections are polymicrobial which are of low a normal increase in the leukocyte count virulence becoming pathogenic due to the presence of hematomas and devitalized tissues. NOTE: The clinical presentation varies with severity of the disease. These polymicrobial consist of both aerobes and anaerobes ○ Although the cervix and vagina routinely harbor bacteria, the uterine cavity is usually sterile before the rupture of the E. TREATMENT amniotic membranes Mild Metritis after VSD Oral or IM / intramuscular antimicrobial ○ However, as a consequence of labor and delivery and because of multiple internal examinations, anaerobic and Moderate to Severe IV / intravenous broad spectrum aerobic bacteria contaminate the amniotic fluid in the uterus infections antibiotics Some women with Group A Beta Hemolytic Streptococcal infections (acquired either before or during delivery) can have as NOTE: Since majority of the causative organisms causing puerperal high as: infections are polymicrobial, treatment is directed against BOTH ○ 90% maternal mortality rate aerobes and anaerobes. ○ >50% fetal mortality rate Improvement after 48-78 hours in 90% of women after antimicrobial treatment Persistent fever beyond 48-72 hours mandates a careful search for possible causes of refractory pelvic infection including: ○ Parametrial phlegmon ○ Abdominal incision or pelvic abscess ○ Infected hematoma ○ Septic pelvic thrombophlebitis Table 2. Antimicrobials Regimens for Pelvic Infection Following A Cesarean Section Regimen Comments Figure 1. Bacteria Commonly Responsible for Female Genital Infections Puerperal Infections and Disorders of the Puerperium Part 1 Lecture Gold- standard; 90-70%efficacy, once daily gentamicin dosing acceptable CLINDAMYCIN + PLUS Ampicillin added to regimen GENTAMICIN sepsis syndrome or suspected enterococcal infection. CLINDAMYCIN + Gentamicin substitute for renal AZTREONAM insufficiency Piperacillin EXTENDED-SPECTRUM Piperacillin tazobactam PENICILLINS Ampicillin / Sulbactam Ticarcillin / Clavulanate Cefotetan CEPHALOSPORIN Cefoxitin Cefotaxime Added to other regimens for suspected VANCOMYCIN S. aureus infections Figure 2. Normal Flora and Cervicovaginal Bacteria METRONIDAZOLE + Metronidazole has excellent anaerobic Puerperal Infections and Disorders of the Puerperium Part 1 Lecture AMPICILLIN + coverage Favorable anaerobic bacterial conditions: GENTAMICIN ○ Presence of surgical trauma (e.g. in the case of CS) Imipenem / Cilastatin ○ Presence of devitalized tissue in the vagina and cervical Meropenem lacerations CARBAPENEMS Ertapenem ○ Presence of foreign body in the form of retained placental Reserved for special indications tissue and blood and serum All of these favor anaerobic bacterial proliferation with tissue Source: Puerperal Infections and Disorders of the Puerperium Part 1 Lecture invasion leading to metritis, parametrial cellulitis and abdominal wall infection NOTE: For infection following vaginal deliveries, 90% of women will respond well to Ampicillin + Gentamicin regimen. Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 2 of 8  BETA-LACTAM ANTIBIOTICS Obesity Bactericidal and interfere with cell wall synthesis Diabetes mellitus Activity against many anaerobic pathogens Corticosteroid treatment Includes the Cephalosporins, Penicillins, and the Immunosuppression extended-spectrum Penicillins or the Carbapenems 1 Risk Factors Prolonged rupture of membranes combined with the Beta-lactamase inhibitors (e.g. clavulanic Anemia acid, sulbactam, and tazobactam) to extend their spectrum Hypertension Hematoma formation from inadequate METRONIDAZOLE hemostasis Superior in vitro activity against most anaerobes Fever beginning 4th day post-op Given with ampicillin and an aminoglycoside to provide coverage Signs and Wound appears erythematous against most organisms seen in serious pelvic infections 2 Symptoms Pus drainage Pain on the incisional wound VANCOMYCIN A glycopeptide active against gram positive bacteria Pathogenic organisms generally the same as 3 Microbiology Used for patients with allergic reaction to B-lactam therapy those isolated from amniotic fluid Also for those with suspected infections due to S.aureus and C. Antimicrobials difficile colitis 4 Treatment Surgical drainage Wound debridement 1. PERIOPERATIVE PROPHYLAXIS Table 3. Perioperative Measures To Reduce Incidence Of Puerperal 2. ABDOMINAL WOUND DEHISCENCE Infections Abdominal wound may not only be infected but may even dehisce leading to wound disrupture Prophylactic antibiotics Commonly seen among obese and immunocompromised patients 1 VSD: Single antibiotic dose for 3rd and 4th degree perineal Serious complication where there is separation of fascial layer lacerations (7th-10th post op day) Single dose prophylaxis using a 2g of a 1st generation Superficial disruption of the subcutaneous layer and extensive Cephalosporin is ideal for women undergoing vaginal delivery leakage of peritoneal fluid/purulent drainage with 3rd and 4th degree perineal laceration. With or without bowel evisceration However, data are limited to support the use of prophylactic Require secondary closure of the wound dehiscence antibiotics against vaginal delivery, with first and second degree perineal laceration, or those who underwent manual Risk Wound infection 1 removal of the placenta. Factors Obesity 2 CS: Single dose first generation Cephalosporin Serosanguinous discharge For CS a single dose of first generation cephalosporin may Signs and Fascial infection 2 also be sufficient to prevent postpartum infection; it has been Symptoms Tissue necrosis (on the 7th-10th postoperative known to reduce infection by 70-80%. day) Timing of administration Broad spectrum antimicrobials ○ There are questions regarding the timing of giving 3 Treatment Surgical drainage antibiotics: whether it is better to give it before skin Secondary surgical closure of incision incision or after umbilical cord clamping. Preoperative skin preparation 1 Further decreases the incidence of puerperal infections. However, there are several controversies regarding the use of these prophylaxis. ○ Chlorhexidine-alcohol vs Iodine-alcohol for abdominal skin preparation ○ Staples vs sutures for (abdominal) skin closure Prenatal Preoperative vaginal cervicovaginal cultures cleansing with Povidone-iodine Figure 2. Abdominal wound dehiscence Dr. Tamon’s Video Lecture on Puerperal Infection, Part 1 Done to prevent puerperal infections Source: Puerperal Infections and Disorders of the Puerperium Part 1 Lecture 3. NECROTIZING FASCIITIS Rare but fatal complication of infection affecting the abdominal incision, episiotomy, or perineal laceration in vaginal deliveries MANEUVERS THAT ALTER THE POST-CESAREAN INFECTION Separation of fascial layer on the 5th-day post-op causing RATE significant and severe tissue necrosis Spontaneous separation of the placenta Involve skin, superficial and deep subcutaneous tissues and Exteriorizing the uterus during uterine closure abdominopelvic fascial layers In some cases, muscles may be involved causing myofasciitis MANEUVERS THAT DO NOT ALTER POST-CESAREAN ○ Clinical findings may vary and is frequently difficult to INFECTION RATE differentiate more innocuous superficial wound infections from Changing gloves after placental delivery a deep fascial one Cleaning the intrauterine cavity Infection is so severe that mortality rate is 100% if untreated; Dilating the lower uterine segment and cervix 25% if treated Severe abdominal pain E. COMPLICATIONS OF UTERINE INFECTIONS 1 Symptoms Swelling of the incision site If the infection is not diagnosed and treated early and Fever appropriately, complications may arise. Polymicrobial (predominantly anaerobes) 1. ABDOMINAL INCISIONAL INFECTIONS / ABDOMINAL 2 Microbiology Normal vaginal flora WOUND INFECTIONS Group A B-hemolytic Streptococcus Wound infection is a common cause of persistent fever in women treated for metritis Higher percentage risk following cesarean section Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 3 of 8  Early diagnosis Abdominal or flank pains on the 2nd-3rd Surgical debridement Signs and day postpartum 1 3 Treatment Antimicrobials Symptoms Chills and high grade fever despite >5 days Intensive care of antibiotic treatment IV antibiotics 2 Diagnosis Can be confirmed by CT Scan or MRI 4. OVARIAN ABSCESS/ADNEXAL INFECTION IV Antibiotics, +/- heparin The use of heparin is controversial, since Rare, usually unilateral 3 Treatment some studies show that heparin does not Develops 1-2 weeks after delivery hasten recovery or improve the outcome Caused by bacterial invasion through a rent in the ovarian capsule Pulmonary embolism 4 Complications Rupture is common causing peritonitis Pleural effusion Patients with CS: RARE occurrence Signs and Adynamic ileus 1 Symptoms Severe abdominal pain Medical or surgical (depending on the 2 Treatment condition of the patient) 5. PARAMETRIAL PHLEGMON/PELVIC ABSCESS In the presence of severe nephritis, parametrial phlegmon or pelvic abscess may develop as area of induration within the leaves of the broad ligament These infections are considered when fever persists for more than 72 hours despite IV antibiotics Unilateral and frequently limited to the parametrium at the base of the broad ligament Figure 3. Septic Pelvic Thrombophlebitis Dr. Tamon’s Video Lecture on Puerperal Infection, Part 1 If there is intense inflammatory reaction, cellulitis may extend most commonly laterally along the broad ligament with a tendency to extend to the pelvic sidewall IV. INFECTIONS OF THE VAGINA, PERINEUM AND CERVIX ○ Occasionally, it may also extend posteriorly into the In vaginal delivery, the episiotomy and the laceration of the vagina, rectovaginal septum producing a firm mass posterior to the and cervix can get infected, and may even lead to necrotizing cervix fasciitis. Broad spectrum antimicrobials 1 Infections of episiotomy wound CT drainage of abscess 2 Infections of vaginal lacerations ○ Might be necessary for severe cellulitis, especially for women with intra-abdominal 3 Infections of cervical lacerations 1 Treatment abscess formation Hysterectomy A. EPISIOTOMY WOUND DEHISCENCE ○ Reserved for women in whom uterine Most commonly associated with infection incisional necrosis is suspected Patients at a higher risk: ○ Smokers 6. PERITONITIS ○ (+) coagulation disorders Started as infection involving the the uterine incision causing ○ (+) Human Papillomavirus infection (HPV) necrosis and dehiscence, and from rupture of adnexal abscess Develop after uterine incisional necrosis and dehiscence or rupture of parametrial or adnexal abscess Severe abdominal pain Signs and Ileus 1 Symptoms Bowel distention Abdominal rigidity Antimicrobials 2 Treatment Surgical drainage of abscess Relief of intestinal obstruction 7. SEPTIC PELVIC THROMBOPHLEBITIS Figure 4. Episiotomy wound dehiscence Also called postpartum ovarian vein thrombosis Dr. Tamon’s Video Lecture on Puerperal Infection, Part 1 Occurs when there is bacterial infection of the placental site causing thrombosis of the myometrial vein which supports 1. PATHOGENESIS anaerobic bacterial proliferation Perineal laceration infection may be complicated by dehiscence Arises as an extension along venous routes and thus causing Risk Factors: coagulation disorders, smoking, human thrombosis. papillomavirus infection Risk factors: chorioamnionitis, endometritis, wound Clinical Presentation: infection/complication ○ With infection, local pain, and dysuria with or without urinary Usually lack symptoms, some may have chills and occasional retention are common symptoms lower abdominal pain ○ Most common: perineal pain, purulent discharge, fever Only approximately 20% present with persistent fever following Extreme cases: Vulva may be edematous, ulcerated and covered more than 5 days of antimicrobial therapy with exudate The ovarian veins are usually involved because they drain the Septic shock / necrotizing fasciitis upper part of the uterus, which is the normal site of placental ○ Life threatening but rare implantation The septic thrombosis may extend to the inferior vena cava More common after cesarean delivery Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 4 of 8 2. TREATMENT: EARLY REPAIR OF EPISIOTOMY ○ Stasis DEHISCENCE ○ Sitting for long periods of time ○ Oral contraceptive use before conception Infected episiotomy with cellulitis but no purulent discharge ○ Deficiency of certain proteins in coagulation inhibition or in the would require close observation and broad spectrum antibiotics fibrinolytic system In the presence of wound dehiscence, wound repair may be necessary after infection has subsided ○ The surgical wound must be properly cleaned and cleared of 1. SUPERFICIAL VENOUS THROMBOSIS infection prior to repair Superficial veins of saphenous system ○ The wound must be completely opened, sutures removed, ○ Veins affected in superficial venous thrombosis debride necrotic tissue and cleaned ○ Present with thrombophlebitis (inflamed vein due to blood Inspect for necrotizing fasciitis is very important clot) present with painful induration and redness of the IV antibiotics are also given — no clear cut recommendation affected extremities Secondary wound closure when afebrile, wound is free of Associated with superficial varicosities exudate and covered with pink healthy granulation tissue Treatment: Analgesia, use of elastic support, rest, and Post op care: local wound care, sitz bath, stool softeners, elevation of involved extremity nothing inserted in vagina or rectum 2. DEEP VENOUS THROMBOSIS V. TOXIC SHOCK SYNDROME Also called Phlegmasia alba dolens or milk leg May be caused by puerperal infection Presents with abrupt onset of severe pain, edema of leg and Acute febrile illness with severe multisystem derangement thigh, and arterial reflex spasm Case fatality rate: 10-15% ○ Consider possible presentation of calf pain due to Common pathogens: inappropriate contact between the calf and the delivery room ○ Staphylococcus aureus table leg holder during labor and delivery produces exotoxin toxic shock syndrome toxin 1 (TSST-1) Diagnosis: Venography, Real time beta mode ultrasound, CT causing endothelial injury scan ○ Virulent Group A Beta-hemolytic Streptococcus Treatment: Giving heparin, bed rest, analgesia ○ Clostridium perfringens and C. sordellii Rarely seen in CS deliveries A. CLINICAL PRESENTATION 3. PELVIC VENOUS THROMBOSIS Fever, headache, mental confusion, diffuse macular erythematous May form in any dilated pelvic vein rash, subcutaneous edema, nausea and vomiting, watery diarrhea Can cause septic pelvic thrombosis Marked hemoconcentration → renal failure and hepatic failure → ○ If present with uterine infection and pulmonary embolism disseminated intravascular coagulopathy → circulatory collapse Diagnosis: CT scan Treatment: Antibiotics administration B. TREATMENT Supportive while allowing reversal of capillary endothelial injury B. DISEASES AND ABNORMALITIES OF UTERUS Antibiotic treatment with polymicrobial coverage especially There are diseases and abnormalities of the uterus aside from covering for Staphylococcus and Streptococcus are given uterine infection that are encountered during the puerperium Surgical Management – extensive wound debridement and even hysterectomy 1. UTERINE SUBINVOLUTION Arrest or retardation of uterine involution after delivery VI. EXTRAGENITAL CAUSES OF PUERPERAL FEVER Caused by retained placental fragments and pelvic infection Must be included in the differential diagnosis of puerperal infection Patients will present with prolonged lochial discharge and irregular Fever occurring within the first 24 hours after cesarean section or or excessive uterine bleeding vaginal delivery under general anesthesia can be due to: Pelvic Exam: Uterus is larger and soft Treatment: Antibiotics and uterotonics like ergonovine and A. RESPIRATORY COMPLICATIONS: PULMONARY methylergonovine ATELECTASIS Caused by hypoventilation brought about by the normal flora that C. DISEASES OF URINARY TRACT proliferates distal to the obstructing mucus plug 1. URINARY TRACT INFECTION It is best prevented by coughing, deep breathing exercises, and early ambulation Not common postpartum because of normal diuresis occurring after delivery Acute pyelonephritis presents with fever, dysuria, and B. PYELONEPHRITIS costovertebral angle tenderness with nausea and vomiting Fever, dysuria, chills, and flank pains due to acute pyelonephritis is If urinary catheterization is needed during labor and delivery, it is a variable clinical picture important to observe the aseptic technique Urinary tract infection Purpura complaining of dysuria and inability to void must be ○ Uncommon because normal diuresis occurs on postpartum assessed for possible overdistended bladder Management: IV antibiotics (hospital) or Oral antibiotics (home) Causes: Catheterization Treatment: Antibiotics C. SUPERFICIAL THROMBOPHLEBITIS Typically seen in association with varicosities or as sequelae of 2. OVERDISTENDED BLADDER indwelling intravenous catheter which is inserted for intravenous Inability to void freely several hours postpartum fluid and medications during labor and delivery Causes: ○ Oxytocin use during prolonged labor = antidiuretic effect D. BREAST ENGORGEMENT ○ General anesthesia Breast fever is seen in the first few days postpartum ○ Genital tract trauma It should be differentiated from mastitis since management differs ○ Hematoma if episiotomy is done Treatment: VII. OTHER DISORDERS OF PUERPERIUM ○ Insertion of indwelling foley catheter DO NOT let it stay for long periods of time A. THROMBOEMBOLIC DISEASE Retain ONLY for at least 24 hrs (remove if there is 5x more common in pregnancy and during puerperium tendency of voiding) Types: Superficial, Deep, Pelvic ○ No need for antibiotics since cause is not infection Predisposing factors: ○ Inappropriate position of the patient during dorsal lithotomy position Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 5 of 8 D. DISORDERS OF THE BREAST E. POSTPARTUM PSYCHOSIS Some mothers may experience postpartum psychosis or 1. BREAST ENGORGEMENT postpartum blues within the first week postpartum Exaggeration of normal venous and lymphatic channels of breast It is usually mild and self-limiting but has a 50% recurrence rate in Common among non-breastfeeding mothers the succeeding pregnancy Fever or commonly termed as breast fever is commonly seen in Common in women with unwanted pregnancy and with marital patients with breast engorgement, thus it is considered as one of problems the differential diagnosis of puerperal fever ○ However, fever seldom persists for more than 4 to 16 hours CAUSES (rarely persist for more than 16 hours) Emotional letdown following the excitement and fears during Other symptoms of breast engorgement include milk leakage and pregnancy and delivery breast pain which peak three to five days after delivery Discomfort of early puerperium and delivery Treatment: breast support (with brassiere), ice cap, breast pump Fatigue from loss of sleep during labor and postpartum (or manual expression of milk), and analgesics Anxiety over her capabilities to care for the baby Fear of being less attractive 2. MASTITIS/BREAST ABSCESS Presence of parenchymal infection of the mammary glands MANAGEMENT ○ This has to be differentiated from breast engorgement since Anticipation, recognition, and reassurance to the mother that this is the management is different self-limiting is important in the management of postpartum blues Bacteria in mastitis enters the breast through the abrasions and If the condition persists or worsens, an evaluation for major fissures in the nipple depression is necessary Commonly seen in mothers who have difficulty breastfeeding Suicidal or infanticidal ideation should be dealt with emergently Risk factors: difficulty in nursing cracked nipples, oral antibiotic therapy VIII. SUMMARY Unilateral involvement of the breast Puerperal infection is the most common cause of fever after ○ Infection is almost invariably unilateral and marked childbirth engorgement usually precedes inflammation It is caused by polymicrobials that are indigenous in the female ○ Chills, fever, tachycardia, severe breast pain genital tract but due to consequence of labor and delivery, Methicillin resistant Staphylococcus aureus, Coagulase-negative anaerobic bacterial proliferation with tissue invasion leading to Staphylococci, Streptococcus viridans endomyoparametritis and its complication may occur and should ○ MRSA - most common isolated organism in breast infections be diagnosed, managed, and treated appropriately. ○ The immediate source of mastitis-causing organisms is almost Treatment would require medical and surgical intervention. always the newborns’ nose and throat Other extragenital causes of puerperal fever should be considered ○ The infecting organism can be cultured from the milk in the differential diagnosis of puerperal infection. Other concerns or disorders encountered by the puerpera should SYMPTOMS be identified and addressed by the health provider Usually occur on the 3rd-4th week postpartum, with marked breast engorgement preceding inflammation Symptoms include chills, which are soon followed by fever and IX. REFERENCES tachycardia Cunningham, et al, Williams Obstetrics, 26th edition, Chapter 37 Pain is usually severe and the breast becomes hard and red POGS Inc, Clinical Practice Guidelines for Intrapartum and Approximately 10% will develop breast abscess Immediate Postpartum Care, 2nd edition. WHO Department of Child and Adolescent Health and Development 2000. Mastitis, causes and Management, page 24. X. REVIEW QUESTIONS No. QUESTIONS 1 This is a type of Uterine Infection that causes a separation of the 7th-10th fascial layer. A. Abdominal Incisional Infections B. Parametrial Phlegmon C. Abdominal Wound Dehiscence Figure 5. Mastitis D. Peritonitis Puerperal Infections and Disorders of the Puerperium Part 2 Lecture 2 This Regimen is considered the gold standard for pelvic infection. MANAGEMENT A. Clindamycin + Gentamicin Dicloxacillin 500 mg QID (4x a day) B. Clindamycin + Aztreonam Erythromycin for Penicillin sensitive C. Vancomycin ○ For those allergic to penicillin, erythromycin may be given D. Carbapenems empirically while waiting for the result of the breast milk culture Vancomycin, Clindamycin or Trimethoprim-sulfamethoxazole for 3 This is considered as the the most common or the most Penicillinase resistant organisms important criterion for the diagnosis of postpartum uterine ○ Given for 10-14 days infection and sepsis syndrome. Surgical drainage/ultrasound-guided needle aspiration for abscess A. Leukocytosis ○ If fever persists for >48-72 hours despite antimicrobial B. Fever therapy and there is palpable breast mass, breast abscess C. Abdominal Pain should be considered D. Foul Smelling Lochia ORAL antibiotics → PARENTERAL antibiotics → DRAINAGE 4 The following are maneuvers that do not alter infection OF ABSCESS rate, EXCEPT: A. Changing gloves after placental delivery BREASTFEEDING AND MASTITIS B. Cleaning the intrauterine cavity It is safe, and important both for the mother’s recovery and the C. Dilating the lower uterine segment and cervix health of the infant D. Exteriorizing the uterus during uterine closure If pus is observed in the breast milk: ○ Manual expression is done and the milk is discarded Once the mastitis resolves: breastfeeding is resumed Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 6 of 8  5 TRUE OR FALSE. Pathogens that cause pelvic infections 2 CORRECT ANSWER: A. Clindamycin + Gentamicin are usually caused by bacteria that are indigenous to the For infection following vaginal deliveries, 90% of women will normal genital tract respond well to Ampicillin + Gentamicin regimen. A. TRUE B. FALSE B is wrong because it is considered as Gentamicin substitute for renal insufficiency 6 What do you call the infection which involves the decidua and myometrium seen in postpartum women? C is wrong because this drug is merely added to other regimens A. Postpartum fever for suspected S. aureus infections B. Metritis C. Endomyoparametritis D is wrong because this drug is reserved for special indications D. Metritis with pelvic cellulitis 7 What is the most common cause of puerperal fever? Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of A. Acute pyelonephritis the puerperium B. Puerperal infection 3 CORRECT ANSWER: B. Fever C. Breast fever D. Pulmonary atelectasis A is wrong because it is important to remember that delivery 8 When does fever usually begin in women who developed itself causes a normal increase in the leukocyte count, and is abdominal wound dehiscence after an emergency cesarean not considered to be the most important criterion section? A. Within 24 hours C is wrong because this may or may not be present in B. 3rd post op day postpartum uterine infection C. 7th-10th post op day D. 5th post op day D is wrong because many women with foul smelling lochia may not have an infection and vice versa 9 A postpartum patient suddenly complained of unbearable hypogastric pain. She was unable to void freely 6 hours Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of after delivery. Internal examination showed an the puerperium overdistended bladder with no hematoma noted. What is 4 CORRECT ANSWER: D. Exteriorizing the uterus during the most appropriate management? uterine closure A. Insert indwelling foley catheter B. Give diuretics A, B, and C is wrong because all of these maneuvers do not C. Early Ambulation alter the infection rate. D. Increase fluid intake 10 A primigravid who delivered via cesarean section Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium developed fever several days postpartum. Intravenous antibiotics were started however fever persisted despite 3 5 CORRECT ANSWER: A. True days of treatment. MRI showed presence of abscess within the leaves of the broad ligament and extending into the Pathogens that cause pelvic infections are usually caused by pelvic sidewalls. What is the most probable cause of her bacteria that are indigenous to the normal genital tract. Most infection? of these infections are polymicrobial which are of low A. Ovarian abscess virulence becoming pathogenic due to the presence of B. Septic pelvic thrombophlebitis hematomas and devitalized tissues. C. Peritonitis D. Parametrial phlegmon Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium XI. RATIONALIZATION 6 CORRECT ANSWER: B. Metritis No. RATIONALIZATION Infections involving the decidua and myometrium go by the names endometritis, metritis, or endomyometritis. 1 CORRECT ANSWER: C. Abdominal Wound Dehiscence A is wrong because postpartum fever is a fever that occurs in Abdominal wounds may not only be infected but may even the postpartum period, which is the time immediately following dehisce, leading to wound disrupture. It is a serious childbirth and extending for several weeks afterward. complication where there is separation of fascial layer with or without bowel evisceration that may require a secondary C and D are wrong because endomyoparametritis and metritis surgical closure with pelvic cellulitis mean the same thing, which is inflammation of the decidua, myometrium, and parametrial tissue. A is wrong because Abdominal Incisional Infections do not directly cause separation of the fascial layer Reference: Batch 2025 Ratio B is wrong because this occurs in the presence of severe nephritis, parametrial phlegmon or pelvic abscess may develop as area of induration within the leaves of the broad ligament D is wrong because it is merely the inflammation of the peritoneum. Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 7 of 8  7 CORRECT ANSWER: B. Puerperal infection B is correct because Puerperal infection is considered to be the most common cause of fever in the puerperium. Puerperal infection can be caused by any bacterial infection of the genital tract after delivery. A is wrong because fever due to acute pyelonephritis is a variable clinical picture and is considered a differential diagnosis of fever after childbirth. C is wrong because breast fever due to breast engorgement seen in the first few days postpartum. It should be differentiated from mastitis since management differs. It is considered a differential diagnosis of fever after childbirth. D is wrong because Pulmonary atelectasis is considered a differential diagnosis of fever after childbirth. It is caused by hypoventilation brought about by the normal flora that proliferates distal to the obstructing mucus plug. It is best prevented by coughing and deep breathing. Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium 8 CORRECT ANSWER: C. 7th-10th post op day Abdominal wounds may not be only infected but may even dehisced leading to wound ruptured. Signs and symptoms of abdominal wound dehiscence include serosanguinous discharge, fascial infection, and tissue necrosis usually noted on the 7th-10th post op. A is wrong because fever occurring at first 24 hours after delivery under general anesthesia can be due to respiratory complications, urinary tract infection, pyelonephritis, thrombophlebitis and breast engorgement. B is wrong because fever that does not go away within 48-72 hours breast abscess should be considered. D is wrong because separation of fascial layer at 5th day post op is associated with necrotizing fasciitis Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium 9 CORRECT ANSWER: A. Insert indwelling foley catheter If a puerpera cannot void within 6 hours, one must insert an indwelling foley catheter. B, C and D are wrong because these are not helpful in the management of an overdistended bladder. Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium 10 CORRECT ANSWER: D. Parametrial Phlegmon The patient has an abdominal wound dehiscence with a serious complication where there is separation of the fascial layer with bower evisceration. When this occurs, secondary closure of the wound is required. Alongside with this, antibiotics and surgical drainage is also given. B is wrong because intravenous antibiotics alone are not sufficient to treat the postoperative complication the patient has. C is wrong because intravenous antibiotics and extensive wound care are not sufficient to treat the wound. Secondary surgical closure is needed. D is wrong because oral antibiotics and daily wound care will not suffice. IV antibiotics are recommended due to the severity of the wound and secondary closure of the wound is needed. Reference: Lecture of Dr. Tamon in Puerperal infections and disorders of the puerperium Group 5B & 6B | Puerperal Infections and Disorders of the Puerperium 8 of 8