PUERPERAL SEPSIS

puerperal sepsis is a leading cause of maternal deaths. This ppt involves the complete information regarding its prevention, causes, and management.

1. Puerperal sepsis PRESENTED BY: TRIPTI SHARMA ROLL NO. 22 YEAR: 4 TH

2. CONTENTS INTRODUCTION PREDISPOSING FACTORS ORGANISMS OF NORMAL VAGINAL FLORA CAUSAL ORGANISMS SOURCES OF INFECTION PATHOGENESIS SPREAD OF INFECTION SIGN AND SYMPTOMS DIAGNOSTIC EVALUATION PROPHYLAXIS TREATMENT RESEARCH STUDY SUMMARY BIBLIOGRAPHY

3. PUERPERAL SEPSIS According to The World Health Organization (WHO), puerperal sepsis is defined as the infection of the genital tract occurring at labor or within 42 days of the postpartum period. An infection of the genital tract which occurs as a complication of delivery or miscarriage is termed as puerperal sepsis. (DC DUTTA) The primary sites of infection are: (1) perineum, (2) vagina,(3)cervix, (4) uterus.

4. DIFFERENCE BETWEEN PUERPERAL SEPSIS An infection of the genital tract which occurs as a complication of delivery OR miscarriage within 6 weeks is termed puerperal sepsis . REPRODUCTIVE TRACT INFECTION Infection of external and/or internal reproductive organs .

5. PREDISPOSING FACTORS ANTEPARTUM Malnutrition Anemia Preterm labor Early rupture/PROM/PPROM Precipitate delivery Immunocompromised ( eg:AIDS ) Diabetes Obesity Organisms of normal vaginal flora INTRAPARTUM Repeated vaginal examinations Dehydration Ketoacidosis during labor Traumatic vaginal delivery APH or PPH Retained bits of placental tissue or membranes Prolonged labor Obstructed labor Caesarean or Instrumental delivery.

6. Organisms of normal vaginal flora Vaginal flora : The vaginal flora in late pregnancy and at the onset of labor consists of the following organisms : Doderlein’s bacillus Candida albicans Staphylococcus aureus Streptococcus Escherichia coli Bacteroides group Clostridium welchii

7. Puerperal sepsis is commonly due to— endometritis , ( ii) endomyometritis , (iii) endoparametritis or a combination of all these when it is called pelvic cellulitis.

8. Causal organisms AEROBIC Group A beta- hemolytic Streptococcus (GAS) Group B beta- hemolytic Streptococcus ( GBS) Methicillin-resistant Staphylococcos aureus (MRSA) ANAEROBIC Streptococcus , Peptococcus , Bacteroides ( fragilis , bivius ), Fusobacteria , Mobiluncus and Clostridia . Others- Staphylococcus pyogenes S. aureus , E. coli, Klebsiella , Pseudomonas, Proteus, Chlamydia.

9. Sources of infection endogenous Autogenous exogenous

10. pathogenesis Endometrium (placental implantation site), cervical lacerated wound, vaginal wound or perineal lacerated wound are the favorable sites for bacterial growth and multiplication. The devitalized tissue, blood clots, foreign body (retained cotton swabs), and surgical trauma favour polymicrobial growth, proliferation and spread of infection. This ultimately leads to metritis , parametritis , endomyometritis and/or cellulitis.

11. Spread of infection Pelvic cellulitis Salpingitis Pelvic abscess Septic pelvic Thrombophelebitis Septicemia and septic shock

12. Pelvic cellulitis Due to spread of infection to the pelvic cellular tissues by direct or by lymphatic or hematogenous routes. The infection causes exudation and formation of indurated mass, which is usually confined to one side of uterus. Peritonitis is common following metritis after cesarean delivery. Patient presents with bowel distension and a dynamic ileus.

13. S alpingitis Salpingitis is the inflammation of the fallopian tubes. Inflammation can spread easily from one tube to the other, so both tubes may become affected. If left untreated, salpingitis can result in long-term complication It can be interstitial (due to lymphatic spread) or perisalpingitis (following pelvic peritonitis).

14. Pelvic abscess A life-threatening collection of infected fluid in the pouch of Douglas, fallopian tube, ovary, or parametric tissue Pelvic abscess following pelvic peritonitis maybe due to spread of infection: Directly through tubes Lymphatic spread Bursting of parametrial abscess.

15. Septic pelvic thrombophlebitis pelvic infection leads to infection of the vein wall and intimal damage leading to thrombogenesis in the veins   Involves the ovarian veins, uterine veins , pelvic veins and rarely, inferior vena cava. The infected thrombus may undergo complete resolution or suppuration. At times, emboli may occlude the microcirculation of the vital organs like lungs or kidney.

16. Septicemia and septic shock May be due to hemolytic streptococci or anaerobic streptococci. Release of bacterial endotoxin causing circulatory inadequacy and tissue hypoperfusion . Septicemia may cause lung abscess, meningitis, pericarditis, endocarditis or multiorgan failure. Death occurs in 30% cases.

17. Signs and symptoms Local infection Uterine infection Spreading of infections

18. LOCAL INFECTION (WOUND INFECTION) rise of temperature generalized malaise Headache local wound becomes red and swollen Pus chills and rigor Sero purulent discharge

19. Uterine infection Mild — rise in temperature (>100.4°F) Rise in pulse rate (>90) Lochial discharge becomes offensive and copious The uterus is subinvoluted and tender

20. Severe — high rise of temperature with chills and rigor Pulse rate is rapid Breathlessness, cough, Abdominal pain and Dysuria Lochia – scanty and odorless Uterus may be subinvoluted , tender and softer.

21. Spreading infection Extra uterine spread Evident by presence of : pelvic tenderness ( pelvic peritionitis ) Tenderness on the fornix ( parametritis ) Bulging fluctuant mass in the pouch of douglas (pelvic abscess)

22. Diagnostic evaluation General principles in investigations are: To locate the site of infection To identify the organisms To assess the severity of the disease .

23. History Clinical examination includes thorough general, physical and systemic examinations. Abdominal and pelvic examinations- note involution genital organs and locate the site of infection Legs should be examined for thrombophlebitis or thrombosis.

24. Investigations include: High vaginal and endocervical swabs for culture ( 2) “Clean catch” midstream specimen of urine for analysis and culture ( 3) 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. ( 4) Blood culture, if fever is associated with chills and rigor.

25. Other specific investigations : ( 5) Pelvic ultrasound (6) CT and MRI (7) X-ray chest (CXR) ( 8) Blood urea and electrolytes ( 9) laparotomy- to further examine the abdominal organs

26. prophylaxis Antenatal prophylaxis improvement of nutritional status (to raise hemoglobin level) of the pregnant woman and eradication of any septic focus (skin, throat, tonsils) in the body

27. Intranatal prophylaxis — Full surgical asepsis during delivery Screening for Group B Streptococcus in a high risk patient. Prophylactic use of antibiotic at the time of cesarean section has significantly reduced the incidence of wound infection, endometritis , urinary tract infection and other serious infections

28. Postpartum prophylaxis aseptic precautions for at least 1 week, following delivery until the open wounds in the uterus, perineum, vagina are healed up. Too many visitors are restricted. Sterilized sanitary pads are to be used. Infected babies and mothers should be in isolated room.

29. treatment Medical management Surgical management Nursing management

30. Medical management Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity report. • Gentamicin (1.5mg/kg/8 hourly) + Clindamycin (900mg/8 hourly) • Metronidazole ( 500mg/8hr) – for anaerobic group • Antibiotic Regimens- (severe sepsis) A combination of either piperacillin-tazobactam or carbapenem + clindamycin • Women with MRSA infection should be treated with vancomycin or teicoplanin .

31. Surgical management perineal wound surgical evacuation Colpotomy Laparotomy Hysterectomy

32. Perineal wound Removal of stitches of perineal wound Wound is cleaned with sitz bath, dressed with an antiseptic ointment/powder After infection is controlled, secondary suture is given .

33. Retained uterine products Diameter <3 cm , left alone To avoid the risk of septicemia, surgical evacuation is done after antibiotic coverage for 24 hours. Septic pelvic thrombophlebitis, treated with IV heparin for 7-10 days.

34. Pelvic abscess Drained by colpotomy under ultrasound guidance.

35. Wound dehiscence Dehisence of episotomy or abdominal wound following cesarean section Managed by: scrubbing wound twice daily, Debridement of necrotic tissues Closing the wound with secondary tissue Antimicrobials

36. H ysterectomy Rupture or perforation Mutiple abscesses Gangrenous uterus Gas gangrene infection

37. Necrotizing fascitis Rare, but fatal complication of wound infection ( abdominal, perineal , vaginal ), involving muscle and fascia. Caused by group A beta hemolytic streptococcus Tissue necrosis is significant pathology Treatment: Rehydration Wound scrubbing Debridement of all necrotic tissues High dose broad spectrum antibiotics

38. Bacteremia/ septic shock Management Fluid and electrolyte balance Respiratory supports Circulatory support Infection control Specific management

39. NURSING MANAGEMENT The nursing management of clients with puerperal infection includes preventing the control spread of infection, promoting healing, and improving the attachment/bonding of parent and infant.

40. Nursing diagnosis Risk For Infection Acute Pain Risk For Altered Parent-Infant Attachment Imbalanced Nutrition: Less Than Body Requirements

41. Risk For Infection Demonstrate and maintain a strict hand-washing policy for staff, client, and visitors . Demonstrate correct perineal cleaning after voiding and defecation, and frequent changing  of peripads . Demonstrate proper fundal massage . Monitor oral/parenteral intake, stressing the need for at least 2000 ml fluid per day Monitor temperature, pulse, and respirations. Note presence of chills or reports of anorexia or malaise . Observe perineum/incision for other signs of infection (e.g., redness, edema , ecchymosis, discharge and approximation). Note  subinvolution of uterus, extreme uterine tenderness . Encourage semi-Fowler’s position.

42. Acute Pain Assess location and nature of discomfort or pain, rate pain on a 0–10 scale . Provide instruction regarding, and assist with, maintenance of cleanliness and warmth . Instruct client in relaxation techniques; provide diversionary activities such as radio, television, or reading . Encourage continuation of breastfeeding as client’s condition permits.  Change client’s position frequently. Provide comfort measures; e.g., back rubs, linen changes . Encourage the woman to ask for pain medications before the pain becomes severe/intolerable . Apply local heat using sitz bath  if indicated . A dminister analgesics or antipyretics.

43. Risk For Altered Parent-Infant Attachment Monitor client’s emotional responses to illness and separation from infant, such as depression and anger. Encourage client to verbalize feelings  Observe maternal-infant interactions Provide opportunities for maternal-infant contact whenever possible . Encourage father or other family members to care and interact with the infant.

44. Imbalanced Nutrition: Less Than Body Requirements Discuss eating habits including, food preferences and intolerances . Promote intake of at least 2000 ml/day of juices, soups, and other nutritious fluids . Encourage choice of foods high in protein, iron, and vitamin C when oral intake permitted . Encourage adequate sleep/rest . Administer iron preparations and/or vitamins, as indicated.

45. summary Puerperal sepsis  is an infective condition in the mother following childbirth. It is the third most common cause of maternal death worldwide as a result of child birth after haemorrhage and abortion. According to World Health Organization (WHO) estimates puerperal sepsis accounts for 15% of the maternal deaths annually. In low and middle income countries puerperal infections are the sixth leading cause of disease burden in women during their reproductive years. Puerperal sepsis can cause long-term health problems such as chronic pelvic inflammatory disease (PID) and infertility in females.

46. RESEARCH STUDY To determine the incidence, risk factors and mortality in women presenting with puerperal sepsis in a tertiary care health facility in India . Article information : Published on 1 st may 2017, JOURNAL OF DIGNOSTIC AND CLINICAL RESEARCH Sheeba Marwah , Sonam R Toden , Manjula Sharma, Ritin Mohindra and Pratima Mittal.

47. A bstract Introduction Sepsis remains one of the foremost cause of preventable maternal death worldwide even decades after the advent of effective low cost novel antimicrobials. It is one vital member of the deadly triad, along with hemorrhage and hypertensive disorders, that contributes greatly to maternal morbidity and mortality. Chiefly in settings like India, where the paramount impediment to intervention is poverty, maternal mortality due to sepsis is a continuing representation of maternal health inequality . According to reports of WHO, puerperal sepsis has been stated to be the second leading cause of maternal mortality in developing countries 

48. Materials and Methods This retrospective study was carried out in VMMC and Safdarjung Hospital, New Delhi from January 2016 to June 2016 in Obstetrics and Gynaecology department. During this period, 366 women with puerperal sepsis admitted in the hospital were enrolled into the study . Inclusion criteria were any patient presenting: a) either immediately after or within 42 days of vaginal delivery, caesarean section (LSCS) or miscarriage; b) associated with pain abdomen, malodorous lochia, abdominal distention, uterine tenderness, pelvic abscess, peritonitis, mechanical or foreign body injury, any system/organ failure and shock. Exclusion criteria consisted of: a) fever during pregnancy or more than 42 days after delivery, LSCS or miscarriage; b) fever due to medical causes; c) wound/surgical site infection; d) mastitis; e) UTI; and f) thrombophlebitis. A total of 33 women with severe maternal sepsis were finally enrolled for the study and their case records were reviewed.

49. Results During the study period, a total of 33 cases met the inclusion criteria. Of these, 90% were referred cases. Anaemia , prolonged labour , delivery by an untrained person and unsafe abortion were the main identifiable risk factors. Surgical management was required in 75% cases, while 70% women succumbed to their illness, mostly due to multiorgan failure. Conclusion Maternal mortality due to maternal sepsis is very high; Lack of safe and hygienic practices for conducting delivery and abortion are important contributory factors.

50. bibliography NAME OF TEXTBOOK AUTHORS’S NAME EDITION PAGE NO. DC Dutta’s Textbook of Obstetrics DC Dutta 9 th Edition 406-410 A textbook of midwifery and gynaecologicaal nursing Neelam kumari , Shivani Sharma, Dr. Preeti gupta 2020 555-563 WEBSITES https://www.ncbi.nlm.nih.gov https://www.healthline.com Google images https://nurseslabs.com