Puerprium ,peurpral fever and peurpral sepsis (1)

Undergraduate course lectures in Obstetrics&Gynecology,Faculty of medicine,Zagazig University,Egypt, Prepared by DR Manal Behery

1. Normal
puerperium
.

2. Definition of Normal Puerperium
It is the period following delivery of the baby It is the period following delivery of the baby
and placenta to and placenta to 6 weeks6 weeks postpartum. postpartum.
It is the period during it ,the It is the period during it ,the reproductive reproductive
organsorgans & & maternal physiologymaternal physiology returns returns
towards the pre pregnancy state .towards the pre pregnancy state .

3. –First 24 hoursFirst 24 hours
–Early- up to 7 daysEarly- up to 7 days
–Remote- up to 6 weeksRemote- up to 6 weeks
Divided into

4. Objectives
To monitor physiological changes of To monitor physiological changes of
puerperiumpuerperium
To diagnose and treats any To diagnose and treats any postnatal postnatal
complications complications
To establish infant feedingTo establish infant feeding
To advise about contraceptionTo advise about contraception

5. Physiological changes in Normal
Puerperium
Changes in Genital TractChanges in Genital Tract
Changes in breast and Lactation Changes in breast and Lactation
Changes in other systemsChanges in other systems

6. Changes in Genital Tract
Involution of the Uterus Involution of the Uterus
LochiaLochia
Involution of Other Pelvic OrgansInvolution of Other Pelvic Organs
MenstruationMenstruation

7. Uterine involutionUterine involution
A. Immediately after delivery:A. Immediately after delivery:
fundus palpable atfundus palpable at
level of umbilicuslevel of umbilicus
B. 10-14 days later, B. 10-14 days later,
At level of theAt level of the
symphysis pubis.symphysis pubis.
C. 6 WKS post partun C. 6 WKS post partun ::
non pregnant sizenon pregnant size

8.  Decidua is cast off as a result of Decidua is cast off as a result of ischemia ischemia
®® lochial flowlochial flow
 Lochia= blood, leucocytes, shreds Lochia= blood, leucocytes, shreds of of
decidua and organisms.decidua and organisms.
 Initially; dusky red3-4 days(rubra), fades Initially; dusky red3-4 days(rubra), fades
after after one-two week(serosa), clears within 4 one-two week(serosa), clears within 4
weeks weeks of delivery(alba). of delivery(alba).
 New endometrium grows from New endometrium grows from basal basal
layer of decidua.layer of decidua.
Endometrium Cavity

9. Cervix:

It has reformed within several hours of It has reformed within several hours of
 delivery delivery
 it usually admits only one finger by 1 it usually admits only one finger by 1
weeks weeks
 the external os is fish-mouth-shapedthe external os is fish-mouth-shaped
 it return to its normal state at 4 weeks it return to its normal state at 4 weeks
after birth after birth

10. Ovarian function
Return of menstruationReturn of menstruation
* * non-nursing mothers:non-nursing mothers:
menstruation returns by 6 menstruation returns by 6 –– 8 weeks. 8 weeks.
** nursing mothers: nursing mothers:
may develop lactating amenorrhea.may develop lactating amenorrhea.
time of ovulation is 3 months in non- time of ovulation is 3 months in non-
breast -feeding women breast -feeding women

11. Changes in Breast and Lactation
Mamogenesis (Mammary duct-Mamogenesis (Mammary duct-
gland growth & dev.) gland growth & dev.)
Lactogenesis (Initiation Of Lactogenesis (Initiation Of
milk secretion in alveoli)milk secretion in alveoli)
Galactopoiesis (Maintenance of Galactopoiesis (Maintenance of
Lactation)Lactation)

12. Changes in other systems
Pulse slowPulse slow
Temp. subnormalTemp. subnormal
ShiveringShivering
Fever up to first 24 hoursFever up to first 24 hours
Hb. RisesHb. Rises
TLC increasesTLC increases
Diuresis- 2Diuresis- 2
ndnd
to 5 to 5
thth
day post delivery day post delivery

13. OTHER SYSTEMS:OTHER SYSTEMS:
Bladder & UrethraBladder & Urethra
- Within 2-3 weeks- Within 2-3 weeks
Hydroureter and calycial dilatation of pregnancy is much less evident.Hydroureter and calycial dilatation of pregnancy is much less evident.
- Complete return to normal - Complete return to normal ®® 6-8 weeks 6-8 weeks
Cardiovascular systemCardiovascular system
** cardiac output cardiac output & & plasma volume plasma volume gradually gradually
returns to normal during the first returns to normal during the first 2 weeks2 weeks..
** marked marked weight loss weight loss occurs in the first week occurs in the first week
as a result of the decrease of plasma volume as a result of the decrease of plasma volume
and the deuresis of the extracellular fluid.and the deuresis of the extracellular fluid.
OTHER SYSTEMS:

15. Daily round by physical staff should
incluid:
Uterus:Uterus: palpate uterine funds to evaluate palpate uterine funds to evaluate
level and tonelevel and tone
AbdomenAbdomen: examine for distension especially : examine for distension especially
postoperativepostoperative
LochiaLochia :for quantity ,and unusual odors :for quantity ,and unusual odors
PerineumPerineum: inspected for hematoma : inspected for hematoma
formation ,signs of infections, or wound formation ,signs of infections, or wound
breakdown.breakdown.

16. BladderBladder: function may be abnormal after : function may be abnormal after
traumatic delivery or epidural anethesia.traumatic delivery or epidural anethesia.
(Catheter may be left in place for 24 hr if there (Catheter may be left in place for 24 hr if there
is marked periurtheral edema or repair).is marked periurtheral edema or repair).
Breasts Breasts :examined for engorgement or signs :examined for engorgement or signs
of infectionof infection
LungsLungs :evaluated in all post CS patients. :evaluated in all post CS patients.
ExtremitiesExtremities :because post partum pt are at :because post partum pt are at
increased risk of DVT especially post CS.increased risk of DVT especially post CS.

17. Post partum immunization
Adminster a booster dose in Adminster a booster dose in
Rubella non immune wommen or Rubella non immune wommen or
MMR vacine.MMR vacine.
Adminster 300 ug of RhoGAM Adminster 300 ug of RhoGAM
within first 72 hours after delivery within first 72 hours after delivery
to RH –ve mothers .to RH –ve mothers .

18. Breast feeding should be Encouraged
Help in rapid uterine involution, decreased risk Help in rapid uterine involution, decreased risk
of ovarian ,breast cancer,osteprosis.of ovarian ,breast cancer,osteprosis.
Women shouldn't breastfed Women shouldn't breastfed if:if:
Have infant with galactosemiaHave infant with galactosemia
Are infected with HIV.Are infected with HIV.
Have active untreated TB.Have active untreated TB.
Are being treated for breast cancer.Are being treated for breast cancer.

19. Contraceptive advice
Breast feeding women shouldn’t relay on Breast feeding women shouldn’t relay on
lactation amenorrhea as a method of lactation amenorrhea as a method of
contraception (98% protection in first 6 contraception (98% protection in first 6
months provided that feeding every 4 hours months provided that feeding every 4 hours
daily ,6 hours at nigth ,formula supply 10-daily ,6 hours at nigth ,formula supply 10-
15%)15%)
Use a barrier method or hormonal Use a barrier method or hormonal
contraception .POP 2-3 weeks postpartum contraception .POP 2-3 weeks postpartum
DMPA 6 weeks postpartum DMPA 6 weeks postpartum

20. Health & nutrition education
Calorie need per day-2200+700 =2900Calorie need per day-2200+700 =2900
Care of MLE stitches if anyCare of MLE stitches if any
Care of nipples and areola Care of nipples and areola
Sexual intercourse can be resumed after 6 Sexual intercourse can be resumed after 6
weeks after deliveryweeks after delivery
Immunization of childImmunization of child
Health & nutrition education

21. Puerperal fever

22. Definition
Temperatures reach 100.4F(38.0C) or Temperatures reach 100.4F(38.0C) or
higher on any two of the first 10 days higher on any two of the first 10 days
postpartum, exclusive of the first 24 postpartum, exclusive of the first 24
hours. hours.
  

23. Benign single-day fevers following
vaginal delivery

Fever in the first 24 hours after Fever in the first 24 hours after
delivery often resolves spontaneously delivery often resolves spontaneously
and cannot be explained by an and cannot be explained by an
identifiable infection. identifiable infection.

24. Significance
Fever is not an automatic indicator of Fever is not an automatic indicator of
puerperal infection. puerperal infection.
A new mother may have a fever owing to prior A new mother may have a fever owing to prior
illness or an illness unconnected to childbirth. illness or an illness unconnected to childbirth.
However, any fever within 10 days postpartum However, any fever within 10 days postpartum
is aggressively investigated.is aggressively investigated.
 Physical symptoms such as pain, malaise, loss Physical symptoms such as pain, malaise, loss
of appetite, and others point to infection. of appetite, and others point to infection.
Significance

25. Endometritis (most common),Endometritis (most common),
Milk engorgment, Mastitis,breast abscessMilk engorgment, Mastitis,breast abscess
Urinary tract infectionUrinary tract infection
pneumonia\atlectasis, pneumonia\atlectasis,
CS ,perineal wound infection, fasiaties.CS ,perineal wound infection, fasiaties.
Septic pelvic thrombophlebitis. Septic pelvic thrombophlebitis.
Causes

26. = uncommon complication usually
develops after 2 – 4 weeks.
 symptoms & signs
low grade fever , chills , indurated ,red
and painful segment of the breast.
caused by Staphylococcus aureus
bacteria from the infant’s oral pharynx.


Mastitis :

27. Mastitis

28.  Mother should start antibiotics immediately,
such as dicloxacillin for 7-10 days.
 Breastfeeding may be discontinued so, breast
pump can be used to maintain lactation .
 however , suppression of lactation is
advisable.
 if a breast abscess develops , it should be
surgically drained.


Treatment

29. Endometritis
The most typical site of infection is the The most typical site of infection is the
genital tract. genital tract.
Endometritis, which affects the uterus, Endometritis, which affects the uterus,
is the most prominent of these is the most prominent of these
infections. infections.
Endometritis is much more common if Endometritis is much more common if
a small part of the placenta has been a small part of the placenta has been
retained in the uterus. retained in the uterus.

30. Atelectasis
Caused by hypoventilation and is Caused by hypoventilation and is
best prevented by coughing and deep best prevented by coughing and deep
breathing on a fixed schedule breathing on a fixed schedule
following surgeryfollowing surgery

31. Acute pyelonephritis Acute
Has a variable clinical picture, and Has a variable clinical picture, and
postpartum, the first sign of renal postpartum, the first sign of renal
infection may be fever, followed infection may be fever, followed
later by costovertebral angle later by costovertebral angle
tenderness, nausea, and vomiting.tenderness, nausea, and vomiting.

32. Incisional abscesses that develop following Incisional abscesses that develop following
cesarean delivery usually cause persistent cesarean delivery usually cause persistent
fever beginning fever beginning about the about the fourth dayfourth day

Perineal infection uncommon , caused by
bacterial contamination during delivery
Antimicrobials and surgical drainage, with Antimicrobials and surgical drainage, with
careful inspecticareful inspection on to ensure that the fascia to ensure that the fascia
is intact.is intact.
Wound infections

34. Septic Thrombophlebitis

A dignosis of exclusion .
Thrombous spread by lymphatic's to
the iliac vessels or directly via the
ovarian vessels.
 Suspected by intermittent spiky fever
which fails to response to ordinary
antibiotics and improved with heparin
.

36. Puerpral sepsis

37. Incidence
3%- 7% of all direct maternal deaths ,
excluding deaths after abortion.
Etiology:
Puerperal infection is usually poly
microbial involves contaminants from
the bowel that colonize the perineum and
lower genital tract.

39. clinical course & severity of the infection is determined by
1. general health and resistance of the
woman.
2. virulence of the causative organisms.
3. presence of predisposing factors as bl.
Clots, hematoma or retained products of
conception.
4. timing of antibiotic therapy.

Clinical course & severity of the infection is
determined by

40. Risk factors
Prolonged PROMProlonged PROM
Prolonged (more than 24 hours) labor Prolonged (more than 24 hours) labor
 Frequent vaginal examinationsFrequent vaginal examinations
 Retained products of conception Retained products of conception
Hemorrhage Hemorrhage
 Anemia, poor nutrition during Anemia, poor nutrition during
pregnancy.pregnancy.
Obesity. Obesity.
Diabetes. Diabetes.

41. Risk factors (CONT ..)
Cesarean birth (20-fold increase in Cesarean birth (20-fold increase in
risk for puerperal infection). risk for puerperal infection).
 Genital or urinary tract infection Genital or urinary tract infection
prior to delivery. prior to delivery.
Urinary catheterUrinary catheter
Fetal scalp electrode, internal FHR Fetal scalp electrode, internal FHR
during labor.during labor.

42. Pathogenesis
of puerperal sepsis

43. Puerperal infection following vaginal delivery Puerperal infection following vaginal delivery
primarily involves the primarily involves the placental implantation site, placental implantation site,
decidua and adjacent myometrium, or decidua and adjacent myometrium, or
cervicovaginal lacerations.cervicovaginal lacerations.

Uterine infection following cesarean delivery is that Uterine infection following cesarean delivery is that
of of an infected surgical incisionan infected surgical incision

Bacteria that colonize the cervix and vagina gain Bacteria that colonize the cervix and vagina gain
access to amnionic fluid during labor, and access to amnionic fluid during labor, and
postpartum, they invade devitalized uterine tissue. postpartum, they invade devitalized uterine tissue.

44. Postpartum uterine infection has been called Postpartum uterine infection has been called
variously variously endometritis, endomyometritis,endometritis, endomyometritis, and and
endoparametritis.endoparametritis.
 Because infection involves not only the Because infection involves not only the
decidua but also the myometrium and decidua but also the myometrium and
parametrial tissues, the inclusive term parametrial tissues, the inclusive term metritis metritis
with pelvic cellulitiswith pelvic cellulitis..
UTERINE INFECTIONS

45. The The route of deliveryroute of delivery is the single most is the single most
significant risk factor for the development significant risk factor for the development
of uterine infection of uterine infection
 1- to 6-% 1- to 6-% incidence of metritis after incidence of metritis after
vaginal delivery. vaginal delivery.
If there is intrapartum chorioamnionitis, the If there is intrapartum chorioamnionitis, the
risk of persistent uterine infection increases risk of persistent uterine infection increases
to to 13 %13 %
Predisposing factor

46. CESAREAN DELIVERY
Single-dose perioperative antimicrobial Single-dose perioperative antimicrobial
prophylaxis prophylaxis is given almost universally is given almost universally
at CSat CS
10-50%10-50% incidence of metritis after CS incidence of metritis after CS
Women with CS after labor (risk factors Women with CS after labor (risk factors
factors) who were not given perioperative factors) who were not given perioperative
prophylaxis had prophylaxis had a a 90-percent 90-percent serious serious
pelvic infection ratepelvic infection rate

48. A. Clinical Picture
symptoms:
• fever ,rigors, malaise, headache.
• vomiting and diarrhoea.
• abdominal discomfort.
• offensive lochia.
• 2ry PP Hge.

Diagnosis

49. Pyrexia and tachycardia
Uterus is large and tender
Parametrial tenderness (parametritis)or Parametrial tenderness (parametritis)or
fullness in pelvis due to abscess is is
elicited on abdominal and bimanual elicited on abdominal and bimanual
examination examination
peritoneum and paralytic ileus (severe
cases).
•

Signs

50. 
1. CBC anaemia, Leukocytosis Leukocytosis
may range from may range from 15,000 to 30,000 cells/L15,000 to 30,000 cells/L, ,
but recall that cesarean delivery itself but recall that cesarean delivery itself
increases the leukocyte count increases the leukocyte count
2. Coagulation Profile DIC.
3 Arterial blood gas acidosis &
hypoxia. ( septiceamic shock)
Investigations

51. Bacterial cultures
4-Routine pretreatment genital tract
cultures are of little clinical use and
add significant costs
5-Similarly, routine blood cultures
seldom modify care(25% +ve in septic
Pelvic thrombo phelbities.

52. 6.Urine analysis: white blood cell
casts is diagnostic of pyelonephrities.
7-Pelvic US :
 Retained products
 Adnexal mass in pelvic abscess.
CT: Occult abscess or thrombous in
tthrombophelbities.
Investigations

53. Management

54. Awareness of general hygiene
principles
 Good surgical technique with proper
hemostasis.
 Prophylactic antibiotics especially in
emergency CS.a single intra operative
dose of cphalosporin+ metronidazole.


Prevention

55. Treatment
Begins with I.V. infusion of broad Begins with I.V. infusion of broad
spectrum antibiotics and is continued spectrum antibiotics and is continued
for 48 hours after fever is resolved.for 48 hours after fever is resolved.
Surgery may be necessary to remove Surgery may be necessary to remove
any remaining products of conception any remaining products of conception
or to drain local lesions, such as an or to drain local lesions, such as an
infected episiotomy .infected episiotomy .


57.  had a 95-percent response rate still considered by had a 95-percent response rate still considered by
most to be the standard by which others are most to be the standard by which others are
measured measured
Because enterococcal infections may persist despite Because enterococcal infections may persist despite
this standard therapy, many add this standard therapy, many add ampicillinampicillin to the to the
clindamycin-gentamicin regimen, either initially or clindamycin-gentamicin regimen, either initially or
if there is no response by 48 to 72 hours.if there is no response by 48 to 72 hours.
CLINDAMYCIN-GENTAMICIN
REGIMEN

58. Patients with persistant fever despite
antibiotics TTT are assessed for
Ratained product of conceptionRatained product of conception
Wound infectionWound infection
Pelvic abcessPelvic abcess
Ovarian vein thrombosisOvarian vein thrombosis
Septic pelvic thrombophelbitiesSeptic pelvic thrombophelbities..

59. Complications

60. 1- Metritis and parametitis.
2. Pelvic abscess
3 Pelvic Peritonitis
4. Septic Thrombophlebitis

61. *
 Fatal infection of skin ,fascia
and muscle. It occurs in the
perineal tears, episiotomy sites &
CS wounds.
 caused by a variety of bacteria
including anaerobes.
*


Necrotizing Fasciitis

62. Necrotizing fasciitis of the episiotomy site Necrotizing fasciitis of the episiotomy site
may involve any of the several superficial or may involve any of the several superficial or
deep perineal fascial layers, and thus may deep perineal fascial layers, and thus may
extend to the thighs, buttocks, and abdominal extend to the thighs, buttocks, and abdominal
wall wall

63.  in addition to signs of infection ,there
is extensive necrosis
managed by surgical removal of the
necrotic tissue under general
anesthesia and split-thickness skin
grafts

64. CASE SCENARIO

65. A 28-year-old primigravid underwent a A 28-year-old primigravid underwent a
cesarean section secondary to having a cesarean section secondary to having a
breech presentation and rupture of breech presentation and rupture of
membranes at 36 weeks gestation. membranes at 36 weeks gestation.
The cesarean section was The cesarean section was
uncomplicated, but on postpartum day uncomplicated, but on postpartum day
two the patient was having fever two the patient was having fever
(38.5C) and uterine tenderness. (38.5C) and uterine tenderness.

66. A diagnosis of postpartum A diagnosis of postpartum
endometritis was made and the endometritis was made and the
infection was treated with Mefoxine infection was treated with Mefoxine
1 g IV Q8H.1 g IV Q8H.

67. After 24 hours of antibiotics, the patient After 24 hours of antibiotics, the patient
presented pain in the right lower abdomen presented pain in the right lower abdomen
and loin, and her WBC count was and loin, and her WBC count was
12000/mm3. She continued to spike fevers .12000/mm3. She continued to spike fevers .
On Abdominal exam On Abdominal exam ::
Soft, flat abdomen Soft, flat abdomen
Tenderness on the right iliac fossa Tenderness on the right iliac fossa
No rebound-tenderness, No rebound-tenderness,
McburneyMcburney’’s point (+/-),Murphys point (+/-),Murphy’’s sign(-),s sign(-),
 Kindey region percussion (-).Kindey region percussion (-).

68. investigation
Urinalysis was unremarkable.Urinalysis was unremarkable.

69. On postpartum day four

The patientThe patient’’s condition showed no s condition showed no
improvement after antibiotic treatment,improvement after antibiotic treatment,
An abdominal CT scan was obtained.An abdominal CT scan was obtained.
 A right ovarian vein thrombosis was noted A right ovarian vein thrombosis was noted
on the imaging.on the imaging.
Diagnosis : ovarian vein thrombophlebitis Diagnosis : ovarian vein thrombophlebitis

70. The patient started therapeutic The patient started therapeutic
enoxaparin(clexane). enoxaparin(clexane).
After 48 hours of anticoagulation, the patient After 48 hours of anticoagulation, the patient
was afebrile and asymptomatic. was afebrile and asymptomatic.
The patient was discharged home after being The patient was discharged home after being
anticoagulated with warfarin anticoagulated with warfarin
After 6 weeks a CT scan was repeated. The After 6 weeks a CT scan was repeated. The
right ovarian thrombosis was not present in right ovarian thrombosis was not present in
the images and warfarin was discontinuedthe images and warfarin was discontinued

71. How to prevent ?
Avoid the risk factorsAvoid the risk factors
Keep the episiotomy site clean Keep the episiotomy site clean
Careful attention to antiseptic procedures Careful attention to antiseptic procedures
during childbirth is the basic key of during childbirth is the basic key of
preventing infection.preventing infection.
 Administer prophylactic antibiotics with Administer prophylactic antibiotics with
Cesarean section, PROM, cardiac Cesarean section, PROM, cardiac
,diabetic patients and with any uterine ,diabetic patients and with any uterine
manipulationmanipulation. .

72. MCQ

73. Which change can be seen in puerperium?
A-maternal heart beat is increased 2 days after A-maternal heart beat is increased 2 days after
deliverydelivery
B- endometrium repair is resumed three B- endometrium repair is resumed three
weeks after deliveryweeks after delivery
C- Ureters will return to non pregnant state C- Ureters will return to non pregnant state
after 8 weeks after 8 weeks
D- Vaginal rugae appear after 3 months from D- Vaginal rugae appear after 3 months from
deliverydelivery
Ans:CAns:C

74. med-ed-online
Which is true about puerpural changes?
A- total number of uterine muscular cells is A- total number of uterine muscular cells is
not reducednot reduced
B-vaginal rugae occur in the third month from B-vaginal rugae occur in the third month from
deliverydelivery
C-uterine connective tissue won’t changeC-uterine connective tissue won’t change
D-uterine is re-epithelialized totally in the D-uterine is re-epithelialized totally in the
first week of pregnancy first week of pregnancy
Ans:AAns:A

75. Which organism is the least responsible in
puerpural infection?
A- peptostreptococcusA- peptostreptococcus
B-enterococcusB-enterococcus
C- chlamydia trachomatisC- chlamydia trachomatis
D-mycoplasmaD-mycoplasma
Ans:DAns:D

76. med-ed-online
A patient comes to the clinic because of fever 4
days after C/S which persists 72 hours from
antibiotic administration. What is the most likely
reason of antibiotic failure?
A- wound infectionA- wound infection
B- pelvic thrombophlebitisB- pelvic thrombophlebitis
C- pyelonephritisC- pyelonephritis
D- adenexal infectionD- adenexal infection
Ans:AAns:A

77. What is wrong about puerpural immunization?
A- tetanus and diphtheria vaccine before A- tetanus and diphtheria vaccine before
discharge from hospital is advocateddischarge from hospital is advocated
B-a woman already injected measles vaccine B-a woman already injected measles vaccine
does not need a booster dosedoes not need a booster dose
C- Rh negative women with an Rh positive C- Rh negative women with an Rh positive
newborn should take RhoGamnewborn should take RhoGam
D- women who have never taken rubella D- women who have never taken rubella
vaccine should be vaccinatedvaccine should be vaccinated
Ans:BAns:B

78. Which is wrong about fever after
delivery?
A-fever more than 39 c in the first 24 hours after A-fever more than 39 c in the first 24 hours after
delivery is a sign of severe infectiondelivery is a sign of severe infection
B-fever in bacterial mastitis usually is late and B-fever in bacterial mastitis usually is late and
persistent persistent
C-pulmonary infection usually occurs in the first C-pulmonary infection usually occurs in the first
24 hours mostly after C/S 24 hours mostly after C/S
D-pyelonephritis is one of the most common D-pyelonephritis is one of the most common
reason of infection and is most often mistaken reason of infection and is most often mistaken
for pelvic infectionfor pelvic infection
Ans: DAns: D

79. A woman has gone through C/S 7 days ago .
Three days after the operation chills and fever
(enigmatic fever) occured. She is given
antibiotic with no improvement in her condition.
She doesn’t look ill. What is your diagnosis?
A-pelvic abscessA-pelvic abscess
B-parametrial phlegmonB-parametrial phlegmon
C-pelvic septic thrombophlebitisC-pelvic septic thrombophlebitis
D-adenexal infectionD-adenexal infection
Ans:CAns:C

80. Who can lactate?
A- mother of a galactosemic newbornA- mother of a galactosemic newborn
B- mother with HBV B- mother with HBV
C- mother with active untreated TBC- mother with active untreated TB
D-mother with breast herpetic lesionsD-mother with breast herpetic lesions
Ans:BAns:B

81. An infection after C/S which is not
responsive to clinda+genta is because of:
A-clostridiumA-clostridium
B-enterococcusB-enterococcus
C-bacteroid fargilisC-bacteroid fargilis
D-chlamydia trachomatisD-chlamydia trachomatis
Ans:BAns:B

82. What is true about lactation period
mastitis?
A-It occurs in the last days of the first weekA-It occurs in the last days of the first week
B- Most of the time it is bilateralB- Most of the time it is bilateral
C-nose and throat of the newborn is the C-nose and throat of the newborn is the
source of infectionsource of infection
D-it is mostly a result of coagulase-negative D-it is mostly a result of coagulase-negative
staphstaph
Ans:C Ans:C

83. THANK YOU
Thank
you