peuperal infection pdf for bsc nursing students

Bsc nursing

1. PUERPERAL SEPSIS /PUERPERAL INFECTION

2. DEFINITION Is an infection of the genital tract which occurs as a complication of delivery is termed as Puerperal sepsis /Puerperal infection D.C.DUTTA

3. PUERPERAL SEPSIS Endometritis Endomyometritis Endoparametritis A combination of all these is called Pelvic Cellulitis .

4. INCIDENCE 14.24 per 1,000 person 2.5%.in India

5. INCIDENCE The Kerala Federation of Obstetrics and Gynaecology (KFOG), which has been conducting a confidential review of maternal deaths in the State since 2004, has reported that if in 2006 sepsis accounted for seven per cent of all maternal deaths and was its fifth leading cause, in 2009, it was the third leading cause, responsible for 8 per cent of all maternal deaths.

6. ORGANISMS IN VAGINAL FLORA

7. ORGANISMS IN VAGINAL FLORA

8. PREDISPOSING FACTORS ANTEPARTUM FACTORS Malnutrition and anemia Preterm labor Premature rupture of the membranes

9. PREDISPOSING FACTORS ANTEPARTUM FACTORS Chronic debilitating illness Prolonged rupture of membrane > 18 hours . Ante partum haemorrhage

10. PREDISPOSING FACTORS INTRAPARTUM FACTORS Repeated vaginal examinations Dehydration and keto -acidosis during labor Traumatic operative delivery

11. PREDISPOSING FACTORS INTRAPARTUM FACTORS Hemorrhage— antepartum or postpartum Retained bits of placental tissue or membranes Cesarean delivery.

12. MICRO ORGANISMS AEROBIC Klebsiella Pseudomonas Proteus Chlamydia

13. MICRO ORGANISMS AEROBIC Streptococcus hemolyticus Group A ( GAS Streptococcus hemolyticus Group B ( GBS) Staphylococcus pyogenes & aureus E . coli

14. MICRO ORGANISMS ANAEROBIC Streptococcus Peptococcus Bacteroides ( fragilis , bivius , fusobacteria , mobiluncus ) Clostridia.

15. MODE OF INFECTION

16. ENDOGENOUS where organisms are present in the genital tract before delivery Anaerobic streptococcus is the predominant pathogen.

17. AUTOGENOUS Organisms, present elsewhere (skin, throat) in the body and migrate to the genital organs by blood stream or by the patient herself Streptococcus b hemolyticus , E. Coli, staphylococcus are important.

18. EXOGENOUS Where infection is contracted from sources outside the patient (from hospital or attendants) Streptococcus b haemolyticus , Staphylococcus and E. coli are important.

19. PATHOGENESIS

20. PATHOGENESIS

21. CLINICAL FEATURES Local infection Uterine infection Spreading infection

22. LOCAL INFECTION (WOUND INFECTION ) There is slight rise of temperature, generalized malaise or headache The local wound becomes red and swollen

23. LOCAL INFECTION (WOUND INFECTION) Pus from the wound. When severe (acute), there is high rise of temperature with chills and rigor.

24. UTERINE INFECTION MILD There is rise in temperature and pulse rate Lochial discharge becomes offensive and copious The uterus is subinvoluted and tender.

25. UTERINE INFECTION SEVERE The onset is acute with high rise of temperature, often with chills and rigor Pulse rate is rapid, out of proportion to temperature

26. UTERINE INFECTION SEVERE Lochia may be scanty and odorless Uterus may be subinvoluted , tender and softer There may be associated wound infection (perineum, vagina or the cervix ).

27. SPREADING INFECTION (EXTRA UTERINE SPREAD) PARAMETRITIS The onset is usually about 7–10th day of puerperium Constant pelvic pain Tenderness on either sides on the hypogastrium

28. SPREADING INFECTION (EXTRA UTERINE SPREAD) PARAMETRITIS Vaginal examination reveals an unilateral tender indurated mass pushing the uterus to the contralateral side Rectal examination confirms the induration specially extending along the uterosacral ligament

29. SPREADING INFECTION (EXTRA UTERINE SPREAD) PARAMETRITIS Steady rise of spiky temperature with chills and rigor Intense pain Gradual deterioration of the general condition Leucocytosis .

30. SPREADING INFECTION (EXTRA UTERINE SPREAD) PELVIC PERITONITIS Pyrexia with increase in pulse rate Lower abdominal pain and tenderness Vaginal examination reveals tenderness on the fornix and with the movement of the cervix

31. SPREADING INFECTION (EXTRA UTERINE SPREAD) PELVIC PERITONITIS Muscle guard may be absent Collection of pus in the pouch of Douglas is evidenced by swinging temperature, diarrhea and a bulging fluctuant mass felt through the posterior fornix.

32. SPREADING INFECTION (EXTRA UTERINE SPREAD) GENERAL PERITONITIS High fever with a rapid pulse Vomiting Generalised abdominal pain

33. SPREADING INFECTION (EXTRA UTERINE SPREAD) GENERAL PERITONITIS Patient looks very ill and dehydrated Abdomen is tender and distended Rebound tenderness is often present.

34. SPREADING INFECTION (EXTRA UTERINE SPREAD) THROMBOPHLEBITIS There may be swinging temperature continued for a longer period with chills and rigor The features of pyemia are present according to the organs involved.

35. SPREADING INFECTION (EXTRA UTERINE SPREAD) SEPTICEMIA There is high rise of temperature usually associated with rigor Pulse rate is usually rapid even after the temperature settles down to normal

36. SPREADING INFECTION (EXTRA UTERINE SPREAD) SEPTICEMIA Blood culture is positive Symptoms and signs of metastatic infection in the lungs, meninges or joints may appear .

37. INVESTIGATION History Clinical examination High vaginal and endocervical swabs for culture ‘Clean catch’ mid stream specimen of urine for analysis and culture including sensitivity test

38. INVESTIGATION Blood for total and differential white cell count, hemoglobin estimation. A low platelet count may indicate septicemia or DIC. Thick blood film should be examined for malarial parasites

39. INVESTIGATION Blood culture Pelvic ultrasound CT and MRI X-ray Blood urea and electrolytes

40. PROPHYLAXIS ANTENATAL Improvement of nutritional status (to raise hemoglobin level) of the pregnant woman Eradication of any septic focus (skin, throat, tonsils) in the body. Proper antenatal care and advise

41. PROPHYLAXIS INTRANATAL Full surgical asepsis during delivery Screening for group B streptococcus in a high risk patient Prophylactic use of antibiotic Avoid frequent vaginal examination

42. PROPHYLAXIS POSTPARTUM Aseptic precautions for at least one week following delivery until the open wounds in the uterus, perineum, vagina are healed up Too many visitors are restricted

43. PROPHYLAXIS POSTPARTUM Sterilized sanitary pads are to be used Infected babies and mothers should be in isolated room. Postnatal care and advise

44. TREATMENT GENERAL CARE Isolation of the patient Adequate fluid and calorie Anemia is corrected by oral iron or if needed by blood transfusion

45. TREATMENT GENERAL CARE An indwelling catheter Vitals Monitoring of lochia Antibiotics Management of bacteremic or septic shock

46. TREATMENT Antibiotic regime should depend on the culture and sensitivity report. Gentamicin (2 mg/kg iv loading dose followed by 1.5 mg/kg IV every eight hours) Ampicillin (1 g IV every 6 hours)

47. TREATMENT Clindamycin (900 mg IV every 8 hours) Intravenous administration of cefotaxime 1 g, 8 hourly Metronidazole 0.5 g, IV is given at 8 hours

48. MANAGEMENT OF BACTEREMIC OR SEPTIC SHOCK Fluid and electrolyte balance Monitor CVP Respiratory supports

49. MANAGEMENT OF BACTEREMIC OR SEPTIC SHOCK Circulatory support Infection control Specific management (as hemodialysis for renal failure ).

50. SURGICAL TREATMENT PERINEAL WOUND stitches of the wound may have to be removed to facilitate drainage of pus and relieve pain. The wound is to be cleaned with sitz bath and is dressed with an antiseptic ointment or powder. After the infection is controlled secondary suturing

51. SURGICAL TREATMENT RETAINED UTERINE PRODUCTS Surgical evacuation after antibiotic coverage for 24 hours should be done to avoid the risk of septicemia. Cases with septic pelvic thrombophlebitis are treated with iv heparin for 7–10 days

52. SURGICAL TREATMENT WOUND DEHISCENCE Scrubbing the wound twice daily Debridement of all necrotic tissue and then closing the wound with secondary suture. Appropriate antimicrobials are used following culture and sensitivity.

53. SURGICAL TREATMENT Pelvic abscess – Colpotomy Abscess should be incised and the pus is drained. Laparotomy Hysterectomy