Puerperal infections

Puerperal infections

1. PUERPERAL INFECTIONS Mrs.Jagadeeswari.J M.Sc (N )

2. DEFINITION Puerperal infection 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. CAUSATIVE ORGANISMS Doderlein bacillus (60-70%) Yeast like fungus –Candida albicans (25%) Staphylococcus albus or aureus Streptococcus –anaerobic common Beta hemolyticus streptococcus rare E.coli Clostridium welchii

4. INCIDENCE OF PUERPERAL INFECTIONS Puerperal infection morbidity affects 2 - 10% of patient.5 -10 times higher in caesarean delivery . There is marked decline in puerperal infection due to:- Improved obstetric care Availability of wide antibiotic

5. COMMON PUERPERAL INFECTIONS Endometritis Endomyometritis Endoparametritis

6. PREDISPOSING FACTORS Low host resistance Multiplication of organisms in the devitalized tissue usually starts the first two days following delivery Introduction of organisms from outside Increased prevalence of organisms resistance to antibiotics

7. Cont..ANTENATAL FACTORS Malnutrition and anemia Preterm labor Premature rupture of membrane Prolonged rupture of membrane>18 hrs Chronic debilitating illness

8. Cont..INTANATAL FACTORS Repeated vaginal examination Traumatic operative delivery Dehydration and ketoacidosis during labour. Retained bits of placental tissue or membrane. Placenta praevia- placental site lying close to the vagina . Haemorrhage-antenatal or postnatal Caesarean delivery

9. MODE OF INFECTIONS Puerperal infection is essentially a wound infection. Placental site lacerations of the genital tract or caesarean section wounds may be infected.

10. PATHOLOGY Puerperal infection is an wound infection. The primary sites of the infection are :- Perineum Vagina Cervix Uterus

11. PERINUEM Laceration of the perineum are likely to infected. The wound edges become red and swollen. There may be collection of purulent discharge resulting in complete disruption of the wound .

12. VAGINA Vaginal laceration are infected directly or by extension from the perineal infection. The mucosa is swollen and hyperaemic, resulting in necrosis and sloughing.

13. CERVIX AND UTERUS Cervix:- The cervical laceration become the site of infection Uterus :- The uterus is most common site of infection Decidua is common site and infected first The infection usually manifests between 3 rd and 6 th day of delivery

14. SPREAD OF INFECTIONS Pelvic cellulitis:- Infection of the pelvic peritoneum and levator ani muscles . Salpingitis:- I nfection of the fallopian tube and ovaries with the formation of Tubo ovarian mass Peritonitis :- Localised pelvic abscess

15. CONT… Thrombhophelebitis :- Ovarian vein of one side is usually involved Uterine vein may also involved’ Septicaemia and pyemia:- These may lead to endocarditis, pericarditis, Renal abscess, lung abscess, meningitis or artheritis .

16. CLINCAL FEATURES Local infection - slight raise in temperature, generalised malaise and headache. Redness and the swelling of the local wound Pus formation and disruption of wound

17. CONT.. Uterine infection(Mild) Pyrexia of variable degree and tachycardia. Red , copius and offensive lochia. Subinvoluted , tender and soft uterus . Uterine infection(Severe infection)- Fever with chills and rigor Rapid pulse Scanty , odourless lochia subinvoluted uterus

18. SPREADING INFECTIONS Extra uterine spread is evident by presence of pelvic tenderness Tenderness on the fornix ( Parametritis ) Bulging fluctuant mass in the pouch of Douglas(pelvic abscess)

19. PARAMETRITIS Sustained rise in temperature (7th to 10th day) Constant pelvic pain Tenderness on either side of the hypogastrium Unilateral , tender mass felt on vaginal examination leukocytosis

20. PELVIC PERITONITIS Pyrexia with increased pulse rate Lower abdominal pain and tenderness Collection of the pus in pouch of Douglas

21. GENERALISED PERITONITIS High fever with rapid pulse Vomiting Abdominal pain Tender and distended abdomen THROMBOPHELEBITIS swinging fever with chills and rigor Features of pyemia

22. SEPTICEMIA High temperature with rigor Rapid pulse Headache , insomnia or mental confusion Positive blood culture Sign/symptoms of infection in the lungs,meninges or joint

23. INVESTIGATIONS PRINCIPLES To locate the site of infection To identify the organisms To assess the severity of the disease.

24. HISTORY ANTENATAL HISTORY History of Anemia Ante partum haemorrhage Presence of septic foci in teeth and gums and tonsils Debilitating disease like heart disease ,diabetes, tuberculosis and urinary tract infection or malaria.

25. INTRANATAL HISTORY Preterm labour. Duration of rupture of the membranes. Number of internal examination done outside and inside the hospital. Duration of labour. Method of delivery. Nature of intrauterine manipulation.

26. POSTNATAL DETAILS Nature of fever and associated symptoms with the site of lesion.

27. BACTERIOLOGICAL STUDY Smear Culture and antibiotic sensitivity of purulent material High vaginal and cervical swabs Peritoneal fluids Blood culture

28. URINE Routine and microscopic examination Culture if infection is suspected

29. OTHER INVESTIGATIONS COMPLETE BLOOD COUNT ULTRASONOGRAPHY (For diagnosis of pelvic mass) Pelvic abscess Pelvic peritonitis Retained bits of placenta and/ or membrane OTHER SPECIFIC INVESTIGATIONS X – ray Blood for malaria parasite

30. PROPHYLAXIS OF PUERPERAL INFECTIONS ANTENATAL: Improvement of general condition Treatment of septic cocci Abstinence from sexual intercourse in the last two months Care about personal hygiene – bathing in dirty water to be avoided Avoiding contact with people having infection, such as cold, boils. Avoiding unnecessary vaginal examinations and douches in the later months.

31. PROPHYLAXIS OF PUERPERAL INFECTIONS INTRANATAL: Staff attending on labor client should be free of infections. Full surgical asepsis to be taken while conducting delivery Women having respiratory tract infection or skin infection should be admitted in single room or separate ward Membranes should be kept intact as long as possible and vaginal examination should be restricted to minimum

32. CONT..INTRANATAL HISTORY Traumatic vaginal delivery and intrauterine manipulation should be preferably avoided. If required should be done using fresh (sterile) gloves with liberal use of strong antiseptic solution. Laceration of the genital tract should be repaired promptly and meticulously with perfect homeostasis Excessive blood loss during delivery should be replaced promptly by transfusion to improve the general body resistance Prophylactic antibiotic must be administered in cases of premature rupture of membranes, prolonged labor or following traumatic delivery.

33. PROPHYLAXIS OF PUERPERAL INFECTIONS POSTNATAL HISTORY: Take aseptic precautions while dressing the perineal wound Restriction of the visitor in the postpartum ward Mothers to be instructed to use sterile sanitary pads and to change them frequently Vulva and perineum to be cleaned with mild antiseptic solution following urination and defecation Infected mothers and babies are to be isolated

34. TREATMENT NURSING CARE Isolation Adequate fluid and calorie is supplied if needed by IV infusion Anemia is corrected by oral Iron and if needed by blood transfusion Pain is relieved by adequate analgesia An indwelling catheter is used to relive any urine retention due to pelvic abscess. Chart is maintained by recording vital signs, lochial discharge and fluid intake and output.

35. ANTIBIOTICS Ideal antibiotics regime should depend on the culture and sensitivity report. Gentamycin 2mg/kg IV loading dosed followed by 1.5 mg/kg IV Q8H and Amphicllin 1gm IV Q6H or Clindamycin 900mg IV Q8H should be started Or IV Ceftaxime 1gm Q8H Metronidazole 0.5 IV Q8H to control anaerobic group Treatment should be for 7-10 days

36. SURGICAL TREATMENT There is a very little role of major surgery in the treatment of puerperal sepsis PUERPERAL WOUND The stitches of the perineal wound may have to be removed to facilitate drainage of pus and relieve pain.

37. RETAINED UTERINE PRODUCTS With a diameter of 3cm or less may be disregarded and left alone. Otherwise surgical evacuation after antibiotic coverage for 24hrs should be done to avoid the risk of septicemia.

38. SEPTIC PELVIC THROMBOPHELEBITIS Treated with IV Heparin for 7-10 days

39. PELVIC ABSCESS Pelvic abscess should be drained by colpotomy under ultrasound guidance. Abscess above the poupart’s ligaments should be incised and the pus drained

40. LAPROTOMY(Limited indication) Maintenance of electrolyte balance by intravenous fluids along with appropriate antibiotic therapy usually control the Peritonitis. However in unresponsive Peritonitis laprotomy is indicated .even if no palpable pathology is found ,drainage of pus may be effective.

41. HYSTERECTOMY It is indicated in cases with rupture or Perforation having multiple abscess ,gangrene infection , Ruptured Tubo-Ovarian abscess should be removed.

42. MANAGEMENT OF BACTERAEMIC SEPTIC SHOCK Fluid and electrolyte balance (to maintain CVP) Respiratory support (to maintain arterial Po2 and Pco2) Circulatory support Infection control Surgical removal of septic foci Specific management(as haemodialysis for renal failure)

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