Puerperal Sepsis.pptx.PUERPERAL PYREXIA..

Puerperal Sepsis.pptx.PUERPERAL PYREXIA..

1. Mrs.I.Vineela Asso.Professor

2. PUERPERAL PYREXIA Definition: A rise of temperature reaching 100.4F(38C) or more measured orally on two separate occasions and 24 hours apart(excluding first 24 hours) within first 10 days following delivery is called puerperal pyrexia.

3. PUERPERAL SEPSIS Definition: An infection of the genital tract which occurs as a complication of delivery is termed as puerperal sepsis. Puerperal pyrexia is considered to be due to genital tract infection unless proved otherwise.

4. There has been marked decline in puerperal sepsis during past few years due to improved obstetric care, availability of wide range of antibiotics.

5. VAGINAL FLORA

6. The vaginal flora in late pregnancy and at the onset of labor consists of the following organisms: Doderleins bacillus (60-70%) Candida albicans (25%) Staphylococcus albus or aureus Streptococcus Escherichia coli Bacteriodes Clostridium welchii on occasion These organisms remain dormant and are harmless during normal delivery conducted in aseptic condition.

7. PREDISPOSING FACTORS The cervico -vaginal mucous membrane is damaged even in normal delivery The uterine surface (placental site) is converted into an open wound by the cleavage of the decidua which takes place during 3 rd stage of labor. The blood clots present at placental site are excellent media for the growth of the bacteria.

8. RISK FACTORS Endometritis Endomyometritis endoparametritis

9. CAUSES Genital tract infection Urinary tract infections Cysitis Pyelonephritis Mastitis Breast abscess Wound infections: CS or episiotomy Septic pelvic thrombophlebitis Malaria or Pulmonary TB Pharyngitis Gastroenteritis

10. MICROORGANISMS RESPONSIBLE FOR PUERPERAL SEPSIS Aerobic Group A: beta hemolytic Streptococcus. Group B: beta hemolytic Streptococcus Gram Negative: E.Coli , Klebsiella , Proteus, Pseudomonas. Gram Variable: Gardnerella Vaginitis Others: Chlamydia, Mycoplasma Anerobes : Peptostreptococcus , peptococcus .

11. MODE OF INFECTION Endogenous: where organisms are present in the genital tract before delivery. Autogenous: where organisms present elsewhere (skin, throat) in the body and migrate to the genital organs by blood stream or by the patient herself. Exogenous: where infection is contracted from sources outside the patient (from hospital to attendants).

12. PATHOPHYSIOLOGY BACTERIAL INFECTION ENDOGENOUS EXOGENOUS BACTERIAL COLONIZATION PERINEUM, VAGINA, CERVIX & UTERUS SEROPURULENT DISCHARGE, PROLIFERTAION & SPREAD OF INFECTION ULTIMATELY LEADS TO ENDOMETRITIS, PARAMETRITIS/CELLULITIS

13. CLINICAL FEATURES Local infection Uterine infection Spreading infection

14. Local Infection (Wound Infection): Slight rise in temperature, generalized malaise, headache, local wound becomes red and swollen, pus may form with leads of infection, in acute or severe high rise of temperature with chills and rigor.

15. Uterine Infection: Mild: there is rise in temperature >100.4 F and pulse rate>90, Lochia discharge becomes offensive and copious, the uterus is subinvoluted and tender. Severe: acute onset and high rise of temperature, often with chills and rigor, pulse rate is rapid, often breathlessness, cough, abdominal pain, dysuria, lochia becomes scanty and odorless, subinvoluted uterus and softer.

16. Extrauterine Spread: it is evident by the presence of pelvic tenderness, peritonitis, pelvic cellulitis with tenderness on the fornix, pelvic abscess, abdominal tenderness, septicemia, toxic shock syndrome, parametrial phlegmon .

17. INVESTIGATIONS

18. History Clinical examination High vaginal endocervical swabs for culture Midstream specimen of urine Urine culture & sensitivity Complete blood picture Serum urea, creatinine and electrolytes Pelvic ultrasound Malarial parasite test CT & MRI Chest X-ray

19. TREATMENT General Care: Isolation of the patient is preferred, especially when hemolytic streptococcus is obtained on culture. Adequate fluid and calorie are maintained by intravenous infusion (IV) Anemia 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. Record urinary intake and output. A chart is maintained by recording pulse, respiration, temperature, lochial discharge. Antibiotics: Gentamicin 2mg/kg IV loading dose, followed by 1.5mg/kg IV every 8 Hours. Clindamycin 900mg IV every 8hrs Metronidazole 0.5mg IV 8hrly, the treatment is continued for atleast 7-10 days. Severe sepsis-combination of piperacillin- tazobactum or cabapenem plus clindamycin. Women with MRSA infection should be treated with vancomycin or teicoplanin .

20. SURGICAL TREATMENT Wound dressing and debridement till healthy granulation tissue develops. Secondary wound repair with nonabsorbable suture. Removal of sutures after 10-12 days. Retained uterine products with a diameter of 3cm or less may be disregarded and left alone. Otherwise surgical evacuation after antibiotic coverage for 24hours s hould be done to avoid the risk of septicemia. Septic pelvic-thrombophlebitis are treated with IV heparin for 7-10 days.

21. Pelvic abscess should be drained by colpotomy under ultrasound. Wound dehiscence of episiotomy or abdominal wound following CS is managed by scrubbing the wound twice daily, debridement of all necrotic tissue and then closing the wound with secondary suture. Laprotomy and Hysterectomy.

22. PROPHYLAXIS Puerperal sepsis is to a great extent preventable provided certain measures are undertaken before, during and following labor. Antenatal: Improvement of Nutritional status, eradication of any sepsis. Intranatal : Full surgical asepsis, screening of Group`B , use of antibiotic at the time of cesarean. Postpartum: aseptic precautions atleast for 1 week, following delivery until the open wounds in the uterus, perineum and 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.