PEURPERAL PYREXIA - iuiu 3rd years.pptx

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1. Abnormalities of puerperium: Puerperal Pyrexia and Sepsis Teituk Abdullahi: MBChB, Mmed OBS/GYN

2. Presentation outline Introduction and definitions Incidence and etiology Risk factors Clinical presentations Investigations Management: local protocols. Complications Take home message

3. Introduction and definitions Pregnant and recently pregnant women easily develop infections and are particularly prone to rapid progression to sepsis. Infection, especially sepsis contributes significantly to global morbidity and mortality, particularly in vulnerable populations. Maternal infections can have serious considerable impacts on the health of women and neonates. Pyrexia in the postpartum period is a common finding. Differentiating between potentially fatal and benign causes is fundamental in reducing the mortality rate from sinister causes.

4. Introduction and definitions Puerperal pyrexia : There is not a single agreed upon definition of what temperature constitutes a pyrexia, with a range spanning 37.5-38.3 o C used in the literature. Pyrexia can be defined therefore, as a body temperature above the normal range within 42 days of delivery (excludes first 24hrs). Puerperal Sepsis : Infection of the genital tract occurring at any time from onset of ROM or labour to 42 days post-partum in which 2 or more of the following are present; pyrexia, pelvic pain, abnormal/offensive vaginal discharge, or delayed involution.

5. Introduction and definitions Pathophysiology of puerperal pyrexia :

6. Incidence and etiology Burden in Uganda Causes of MM

7. Differentials of puerperal pyrexia Genital tract infection ( puerperal sepsis ). Milk engorgement ,mastitis & breast abscess DVT & PE. Urinary tract infection. Chest infection-Pneumonia. CS delivery; Wound infection & Fasciitis. Meningitis. Malaria

8. Risk factors Ante-partum : Anemia, UTIs, GBS/GAS colonization, malnutrition, TORCHES, HIV, DM, PET. Intra-partum : EROM/PROM/PPROM, multiple pelvic examinations, poor aseptic practice, interventions (episiotomy, vacuum, forceps delivery), perineal tears, herbal medicines into the birth canal, prolonged/obstructed labour. Post-partum : Retained products, poor hygiene, PPH and its management interventions, unrepaired perineal tears.

9. Causative organisms Group B Streptococcus. Mycoplasma species. Others: Gram positive; beta-hemolytic streptococcus (group A, B, D) staphylococcus aureus, staphylococcus faecalis. Gram negative; E coli, Hemophilus influenzae, Gardenella vaginalis. Anaerobes; Bactroides fragilis. Miscellaneous; Chlamydia trachomatis

10. Mastitis/breast abscess Unilateral, painful swelling, feels warm, reddened, purulent nipple discharge. Investigations: CBC, pus swab Rx: antibiotics, analgesics (NSAIDs)/+_I&D.

11. Puerperal sepsis Refers to infection of the genital tract occurring at any time from onset of ROM or labour to 42 days post-partum in which 2 or more of the following are present; pyrexia, pelvic pain, abnormal/offensive vaginal discharge, or delayed involution. Features : pyrexia, offensive pv d/c, pelvic/abdominal pain, abdominal distension, sub-involuted uterus, septic perineal tears/episiotomies, tachypnea, tachycardia, signs of septic shock in severe sepsis.

12. Puerperal sepsis Investigations : Labs: CBC, BS, RBS, Urine analysis, LFTs, RFTs, electrolytes, pus swab/blood cultures. Imaging: Ultrasound scan, X-ray Management : Antibiotics, fluids, surgical toilet/wound care, vaginal toilet, re-lap in pelvic abscess.

13. Signs and symptoms of puerperal sepsis Fever, chills and rigors usually occurring 24 hours or more after delivery, typically on 3 rd or 4 th day. Severe headache, vomiting and abdominal pain Fast pulse: Pulse rate may rise before fever occurs Lochia: Red and profuse at first then may become scanty and either foul smelling or odourless Wound Infection e.g. Perineum, vagina, cervix and/or abdomen. The wound may be painful, swollen, hot and with a discharge.

14. Causes of Puerperal Sepsis Endogenous bacteria Exogenous bacteria

15. Endogenous bacteria These bacteria normally live in the vagina and rectum without causing any harm. Examples include: types of streptococci & staphylococci, E. Coli etc Endogenous bacteria can become harmful & cause infection if they are brought into the uterus by vaginal examination or instruments during pelvic examinations

16. Exogenous bacteria These bacteria are introduced into the vagina from the outside (streptococci, staphylococci, clostridium tetani etc) Exogenous bacteria can be introduced by: Unclean hands and unsterile instruments By foreign substances that are inserted in the vagina e.g. Herbs, oil, cloth By sexual intercourse (STI)

17. POSTPARTUM TETANUS Is an infection of the mother and baby caused by clostridium tetani. Tetanus bacteria live in soil – especially moist soil that is rich in animal manure. Tetanus bacteria gets to the mother through unclean hands, cloths, cow dung or herbs inserted in the vagina To the baby through instruments, or herbs or cow dung are used to dress the cord.

18. Factors that predispose a woman to Puerperal sepsis In health facility Inadequate bacteriological investigations in women with puerperal sepsis Lack of equipment for monitoring TPR/BP during labour and after delivery Inadequate supplies e.g. Gloves, syringes, needles Lack of blood transfusion Inadequate treatment with appropriate antibiotics Lack of facilities for appropriate operative interventions

19. The service provider: Attitudes and practices e.g. Failure to adhere to infection prevention measures Lack of knowledge and skills of infection prevention measures Repeated vaginal examinations without observing aseptic technique

20. The patient: Poor hygiene Pre-existing anaemia and malnutrition Prolonged or obstructed labour Early rupture of membranes Pre-existing sexually transmitted infection

21. In the community Lack of transport and resources Great distance from a woman’s home to a health facility Low socio-economic status Cultural factors which delay care seeking behaviour, low status of women

22. Steps in the management of puerperal sepsis: Preventive: Good antenatal care characterised by health education on importance of attending antenatal care, nutrition and hygiene Importance of appropriate management of abnormal conditions identified e.g. Anaemia and Sexually Transmitted Diseases Identify and refer high risk patients Strict observation of infection prevention measures

23. Avoid unnecessary vaginal examinations and prolonged labour Use prophylactic antibiotics for emergency C-section Give antibiotics in case of premature rupture of membranes Isolate all infected patients

24. Treatment : Admit the patient to hospital Apply measures to bring down the temperature e.g. Tepid sponging, antipyretics.

25. Treatment : Maintain fluid intake and output Give broad-spectrum antibiotics e.g. Ampicillin, Erythromycin and Flagyl Check the haemoglobin concentration and transfuse if necessary

26. Treatment : If a patient has an infected wound, manage accordingly . If a patient has offensive lochia and sub-involution of the uterus, the cervical OS remains open and retained placental products are present, evacuation of the uterus should be done Drain any abscesses where possible

27. Local protocols-EMNCGs

28. Complications Long hospital stay and costs associated, organ damage-AKI, infertility-Sheehan syndrome, hysterectomy, tubal damage from pelvic infections, ectopic pregnancy.

29. Take home message Puerperal Sepsis is the most common cause of postpartum pyrexia. Postpartum women are vulnerable to rapidly evolving sepsis, with the genital tract being the most frequent source. Preventive measures, Prompt recognition, and timely treatment of sepsis substantially reduce mortality and morbidity. Of the non-infective causes of postpartum pyrexia, venous thrombo-embolism is the only potentially fatal cause.

30. Thank you