Puerperal sepsis

Puerperal sepsis : Introduction, Definition, Risk Factors, Pathology, Causative Organisms, Complications, Management

1. PUERPERAL SEPSIS Presented by Mrs. Pooja Chaware MSc Nursing (OBG) VMPCON AKLUJ

2. INTRODUCTION Sepsis is the leading causes of preventable maternal death not only in developing countries but in developed countries as well. It is an important public health problem contributing to maternal morbidity and mortality.

3. DEFINITION An infection of genital tract which occurs as a complication of delivery usually within 10 days is termed as puerperal sepsis. Puerperal sepsis is commonly due to- 1. Endometritis 2. Endomyometritis 3. Endoparametritis or a combination of all these when it is called as pelvic cellulitis.

4. RISK FACTROS Antepartum factors Malnutrition and anaemia Preterm labour Premature rupture of the membrane Prolong rupture of the membrane > 18 hours Low socio economic status Lack of antenatal care Coitus during late pregnancy

5. Intrapartum factors Frequent vaginal examination Premature rupture of the membrane Prolong labour Chorioamnionitis Traumatic operative delivery Haemorrhage – antepartum or postpartum Retained bits of placental tissue or membranes Caesarean delivery

6. Microorganisms responsible for puerperal sepsis Aerobic microorganism Streptococcus haemolyticus Group A, E coli, beta haemolytic streptococci, non-haemolytic streptococci, staphylococci, klebsiella, Pseudomonas, gonococci  Anaerobic microorganism Anaerobic streptococci, cl. welchi, tetani, mycoplasmas, chlamydia

7. MODE OF INFECTION Endogenous : due to organism present in the vagina and cervix Ex: Anaerobic streptococci which is predominant pathogen. Autogenous : Bacteria from some other part of the body Ex: Streptococcus haemolyticus Group A, E coli, staphylococci are important.

8. Exogenous : where infection is contracted from sources outside the patient (from hospital or attendants). Ex: beta haemolytic streptococci, E coli are important.

9. PATHOLOGY The primary sites of infection are: Perineum Vagina Cervix Uterus The infection is neither localised to the site or spread to distant sites.

10. The lacerations on the perineum, vagina, cervix is often infected by organisms due to presence of blood clot or dead space. The wound become red, swollen and there is associated seropurulent discharges. Diabetes, obesity, low nutritional status is the other high-risk factors for wound infection.

11. PATHOGENESIS Endometrium (placental implantation site) , cervical lacerated wound , vaginal wound or perineal lacerated wound are the favourable sites for bacterial growth and multiplication. Endometrium (placental implantation site) , cervical lacerated wound , vaginal wound or perineal lacerated wound are the favourable sites for bacterial growth and multiplication.

12. CLINICAL FEATURES Symptoms Onset is usually 2-3 days after delivery (in severe cases in 24 hours) Fever with chills and rigor Generalized malaise Headache Nausea, anorexia, vomiting Foul smelling discharge (lochia)

13. Sign General examination Toxic appearance Fever (101-102-degree F, rarely higher) Shock Skin eruption or jaundice Calf tenderness suggest deep vein thrombosis

14. Local examination -- Episiotomy appears swollen, red oedematous, pouting. Wound edges may be red, oedematous and extruding greenish or yellowish offensive pus. -- Red, purulent, foul smelling lochia Per vaginal examination --Uterus sub involuted, boggy, and tender. Bogginess in the fornices or pouch of Douglas suggests pelvic abscess / mass.

15. Sign and symptoms of complication Pelvic abscess - A tender fluctuating bogginess of the Douglas pouch is felt by P /V - Rectal symptoms like tenesmus and diarrhoea may developed. Pelvic peritonitis fever, tachycardia and vomiting lower abdominal pain, tenderness and rigidity

16. Generalised peritonitis high fever with a rapid pulse vomiting Generalised abdominal pain Patients looks very ill and dehydrated Abdomen is tender and distended. Thrombophlebitis Extension of infection to the pelvic veins leads to high fever, rapid pulse and deep-seated pelvic pain   If extension progresses to the femoral vein, pain and tenderness extends to the leg, which becomes swollen, oedematous and hot.

17.   Grade 1 Infection localized within the uterine cavity   Grade 2 Infection involving the parametrium   Grade 3   Generalized infection with complications like peritonitis, septic shock, jaundice, anuria. Septicaemia There is high raise of temperature with rigor, severe headache. Blood culture is positive Grades of puerperal sepsis

18. INVESTIGATION To confirm the diagnosis High vaginal / cervical swab : smear , culture , antibiotic sensitivity Urine routine and SOS culture CBC haemoglobin, WBC total /differential count ESR Peripheral smear to rules out malaria X ray chest Blood culture: during the peak of temperature.

19. To know the extent USG X -ray of abdomen and pelvis Culdocentesis

20. COMPLICATIONS Peritonitis Septicaemia, shock Abscess: pelvic, sub phrenic, sub hepatic Septic pelvic thrombophlebitis Death: septicaemia, shock, gas gangrene, tetanus

21. MANAGEMENT General care Isolation of the patient Adequate fluid and calorie Anaemia is corrected by oral iron or if needed by blood transfusion. An indwelling catheter is used to relieve any urine retention due to pelvic abscess. A chart is maintained by recording pulse, respiration, temperature, lochia discharge and fluid intake and output.

22. Antibiotics: Ideal antibiotic regimen should depend on the culture and sensitivity report. Pending the report, Gentamicin (2 mg / kg IV loading dose followed by 1.5 mg /kg IV every 8 hrs) and Ampicillin (1g IV every 6 hours) or Clindamycin (900 mg IV every 8 hrs) should be started. Metronidazole 0.5g, IV is given at 8 hrs interval to control the anaerobic group. The treatment is continued until the infection is controlled for at least 7 – 10 days.  

23. Surgical treatment Perineal wound : The stitches of the perineal wound may have to be removed to facilitates drainage of pus and relieve pain. The wound is to be cleaned with sitz bath several times a day and is dressed with antiseptic ointment or powder.

24. Retained uterine products are surgically evacuated after antibiotic coverage for 24 hours should be done to avoid the risk of septicaemia. Cases with septic pelvic thrombophlebitis are treated with heparin for 7-10 days. Pelvic abscess should be drained by colpotomy under ultrasound guidance.

25. Wound dehiscence : Wound dehiscence of episiotomy or abdominal wound following caesarean section is managed by scrubbing the wound twice daily, debridement of all necrotic tissue and then closing the wound with secondary sutures. Laparotomy has got a limited indication. Maintenance of electrolyte balance by intravenous fluids along with appropriate antibiotics therapy usually controls peritonitis.

26. Hysterectomy is indicated in cases with ruptured or perforation, having multiple abscess, gangrenous uterus or gas gangrene infection. Ruptured tubo- ovarian abscess should be removed.

27. SUMMARY

28. CONCLUSION Puerperal sepsis is an important public health problem contributing to maternal morbidity and mortality. Majority of predisposing factors are preventable. Optimal antiseptic measures and careful monitoring are needed throughout the labour process.

29. BIBLIOGRAPHY 1 . D.C Dutta ,Text book of obstetrics and gynaecology ,5 th edition page no 432 2. Dawn C.S, Text book of obstetrics and gynaecology , Dawn Books, Calcutta. Page on 457 3. Bennet V Ruth and Brown K Linda , Myle ” text Book For Midwives. Page no 501 4. Menon Krishna and Palaniappan , Clinical Obstetrics, 9 th edition Orient Longman, 1990, Madras.