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PUERPERAL INFECTION

PUERPERAL INFECTION. PUERPERAL INFECTION. any bacterial infection of the genital tract after delivery. PUERPERAL FEVER. Most persistent fevers after childbirth are caused by genital tract infection.

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PUERPERAL INFECTION

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  1. PUERPERAL INFECTION

  2. PUERPERAL INFECTION • any bacterial infection of the genital tract after delivery

  3. PUERPERAL FEVER • Most persistent fevers after childbirth are caused by genital tract infection • temperature – 38.0° C (100.4° F) or higher at any 2 of the first 10 days postpartum, exclusive of the first 24 hours and to be taken by mouth by a standard technique at least 4 times daily • high spiking fever within first 24 hours  virulent infection with group A strep

  4. Attributable fever rarely exceeds 39°C in the first few postpartum days and usually lasts less than 24 hours. • Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. • Atelectasis is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery

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

  6. UTERINE INFECTIONS • PREDISPOSING FACTOR The route of delivery is the single most significant risk factor for the development of uterine infection

  7. VAGINAL DELIVERY • Women at high risk for infection because of membrane rupture, prolonged labor, and multiple cervical examinations have a 5- to 6-percent incidence of metritis after vaginal delivery. • If there is intrapartumchorioamnionitis, the risk of persistent uterine infection increases to 13 percent CESAREAN DELIVERY • Single-dose perioperative antimicrobial prophylaxis is given almost universally at cesarean delivery • Important risk factors for infection following surgery ARE: • prolonged labor • membrane rupture,multiple cervical examinations, • internal fetal monitoring Women with all of these factors who were not given perioperative prophylaxis had a 90-percent serious pelvic infection rate

  8. OTHER RISK FACTORS • Lower socioeconomic status • Group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis,Ureaplasma urealyticum, and Gardnerella vaginalis • Cesarean delivery for multifetal gestation • Young maternal age and nulliparity • Prolonged labor induction • Obesity • Meconium-stained amnionic fluid

  9. BACTERIOLOGY • group A -hemolytic streptococcus causing toxic shock-like syndrome and life-threatening infection • skin and soft-tissue infections due to community-acquired methicillin-resistant Staphylococcus aureus—CA-MRSA—have become common • METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS • -these strains are not a common agent of • puerperal metritis, but they are causative in • incisional wound infections

  10. BACTERIAL CULTURES • Routine pretreatment genital tract cultures are of little clinical use and add significant costs • Similarly, routine blood cultures seldom modify care

  11. CLINICAL COURSE • Fever is the most important criterion for the diagnosis of postpartum metritis. • Temperatures commonly are 38 to 39°C. Chills that accompany fever suggest bacteremia. • Women usually complain of abdominal pain, and parametrial tenderness is elicited on abdominal and bimanual examination • Although an offensive odor may develop, many women have foul-smelling lochia without evidence for infection. Other infections, notably those due to group A -hemolytic streptococci, are frequently associated with scanty, odorless lochia • Leukocytosis may range from 15,000 to 30,000 cells/L, but recall that cesarean delivery itself increases the leukocyte count

  12. TREATMENT • If mild metritis develops after a woman has been discharged following vaginal delivery, outpatient treatment with an oral antimicrobial agent is usually sufficient. • For moderate to severe infections, however, intravenous therapy with a broad-spectrum antimicrobial regimen is indicated. Improvement follows in 48 to 72 hours in nearly 90 percent of women treated with one of several regimens.

  13. TREATMENT • The woman may be discharged home after she has been afebrile for at least 24 hours. Further oral antimicrobial therapy is not needed

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

  15. CHOICE OF ANTIMICROBIALS • Because of potential nephrotoxicity and ototoxicity with gentamicin in the event of diminished glomerular filtration, some have recommended a combination of clindamycin and a second-generation cephalosporin to treat such women. • Others recommend a combination of clindamycin and aztreonam, a monobactamcompound with activity similar to the aminoglycosides

  16. CHOICE OF ANTIMICROBIALS LACTAMASE INHIBITORS (CLAVULANIC ACID, SULBACTAM, AND TAZOBACTAM) • combined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extend their spectra. METRONIDAZOLE • superior in vitro activity against most anaerobes. • given with ampicillin and an aminoglycoside provides coverage against most organisms encountered in serious pelvic infections

  17. CHOICE OF ANTIMICROBIALS • IMIPENEM • a carbapenem that has broad-spectrum coverage against most organisms associated with metritis • used in combination with cilastatin, which inhibits renal metabolism of imipenem • it is effective in most cases of metritis

  18. Vancomycin is a glycopeptide antimicrobial active against gram-positive bacteria. It is used in lieu of β-lactam therapy for a patient with a type 1 allergic reaction and given for suspected infections due to Staphylococcus aureus s and to treat C difficile colitis.

  19. PERIOPERATIVE ANTIMICROBIAL PROPHYLAXIS

  20. TREATMENT OF VAGINITIS • Prenatal treatment of asymptomatic vaginal infections has not been shown to prevent postpartum pelvic infections • No beneficial effects for women treated for asymptomatic bacterial vaginosis.

  21. OPERATIVE TECHNIQUE TO PREVENT POSTPARTUM INFECTION

  22. COMPLICATIONS OF PELVIC INFECTIONS • In more than 90 percent of women, metritis responds to treatment within 48 to 72 hours

  23. WOUND INFECTIONS • When prophylactic antimicrobials are given as described above, the incidence of abdominal incisional infections following cesarean delivery is less than 2 percent • The incidence in some cases averaged 6 percent and ranged from 3 to 15 percent • Wound infection is a common cause of persistent fever in women treated for metritis

  24. WOUND INFECTIONS Risk factors: • obesity • diabetes • corticosteroid therapy • immunosuppression • anemia • poor hemostasis with hematoma formation

  25. WOUND INFECTIONS • Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for its persistence beginning about the fourth day. • Wound erythema and drainage usually accompany it. • Treatment includes antimicrobials and surgical drainage, with careful inspection to ensure that the fascia is intact.

  26. WOUND INFECTIONS • With local wound care given two to three times daily, secondary en bloc closure at 4 to 6 days of tissue involved in superficial wound infection can usually be

  27. WOUND DEHISCENCE • refers to separation of the fascial layer • serious complication and requires secondary closure of the incision in the operating room • disruptions manifest about 5th post-op day with serosanguineous discharges TREATMENT • secondary closure of the incision with adequate anesthesia 

  28. Necrotizing Fasciitis • uncommon, severe wound infection is associated with high mortality • may involve abdominal incisions, or it may complicate episiotomy or other perineal lacerations • RISK FACTORS:—diabetes, obesity, and hypertension—are relatively common in pregnant women • caused by a single virulent bacterial species such as group A -hemolytic streptococcus. Occasionally some are caused by rarely encountered pathogens

  29. Necrotizing Fasciitis • TREATMENT • Treatment consists of broad-spectrum antibiotics along with prompt wide fascial debridement until healthy bleeding tissue is encountered. • With extensive resection, synthetic mesh may be required to close the fascial incision • Clindamycin given with a beta-lactam antimicrobial - most effective regimen

  30. PERITONITIS • unusual for peritonitis to develop following cesarean delivery • It is almost invariably preceded by metritis and uterine incisional necrosis and dehiscence. • Other cases may be due to inadvertent bowel injury at cesarean delivery. • Yet another cause is peritonitis following rupture of a parametrial or adnexal abscess. • It may rarely be encountered after vaginal delivery.

  31. PERITONITIS

  32. ADNEXAL INFECTIONS • Ovarian abscess  bacterial invasion through a vent in the ovarian capsule • usually unilateral and present 1-2 weeks after delivery • Rupture is common and peritonitis may be severe TREATMENT • drain and give antibiotics

  33. ParametrialPhlegmon • In some women in whom metritis develops following cesarean delivery, parametrialcellulitis is intensive and forms an area of induration, or phlegmon, within the leaves of the broad ligament • These infections should be considered when fever persists longer than 72 hours despite intravenous antimicrobial therapy

  34. ParametrialPhlegmon • Phlegmons are usually unilateral, and they frequently are limited to the parametrial area at the base of the broad ligament • The most common form of extension is laterally along the broad ligament, with a tendency to extend to the pelvic sidewall. • Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass posterior to the cervix

  35. ParametrialPhlegmon Because puerperal metritis with cellulitis is typically a retroperitoneal infection, evidence of peritonitis suggests the possibility of uterine incisional necrosis, or less commonly, a bowel injury

  36. ParametrialPhlegmon Treatment In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen. Typically, fever resolves in 5 to 7 days, but in some cases, it is longer. Absorption of the induration may require several days to weeks.

  37. ParametrialPhlegmon Treatment • Surgery is reserved for women in whom uterine incisional necrosis is suspected • In rare cases, uterine debridement and resuturing of the incision are feasible. • For most, hysterectomy and surgical debridement are needed and are predictably difficult • Frequently, the cervix and lower uterine segment are involved with an intensive inflammatory process that extends to the pelvic sidewall to encompass one or both ureters • . The adnexaare seldom involved, and one or both ovaries usually can be conserved

  38. PARAMETRIAL PHLEGMONOn bimanual pelvic examination, a phlegmon is palpable as a firm, three-dimensional mass

  39. IMAGING TECHNIQUE A.Pelvic computed tomography scan of dehiscence caused by infection of a vertical cesarean incision. Endometrial fluid (small black arrows) communicates with parametrial fluid (curved white arrows) through the uterine defect (large black arrow). A dilated bowel loop (b) is adjacent to the uterus on the left. B. Supracervical hysterectomy specimen with instrument through uterine dehiscence.

  40. PELVIC ABSCESS • parametrial phlegmon suppurates, forming a fluctuant broad ligament mass that may point above the inguinal ligament • Psoas abscess may rarely follow delivery TREATMENT • antimicrobial therapy • percutaneous drainage

  41. SEPTIC PELVIC THROMBOPHLEBITIS • common complication in the preantibotic era • With the advent of antimicrobial therapy, the mortality rate and need for surgical therapy for these infections diminished • Although there occasionally is pain in one or both lower quadrants, patients are usually asymptomatic except for chills. • Diagnosis can be confirmed by either pelvic CT or MR imaging

  42. PATHOGENESIS OF SEPTIC PELVIC THROMBOPHLEBITIS Routes of extension of septic pelvic thrombophlebitis. Any pelvic vessel and the inferior vena cava may be involved as shown on the left. The clot in the right common iliac vein extends from the uterine and internal iliac veins and into the inferior vena cava.

  43. TREATMENT OF SEPTIC PELVIC THROMBOPHLEBITIS • The addition of heparin to antimicrobial therapy for septic pelvic thrombophlebitis did not hasten recovery or improve outcome. • Certainly, there is no evidence for long-term anticoagulation as given for "bland" venous thromboembolism.

  44. Infections of the Perineum, Vagina, and Cervix

  45. Infections of the Perineum, Vagina, and Cervix

  46. TREATMENT

  47. Technique for Early Repair • Most important is that the surgical wound must be properly cleaned and free of infection • once the surface of the episiotomy wound is free of infection and exudate and covered by pink granulation tissue, secondary repair can be accomplished • Postoperative care includes local wound care, low-residue diet, stool softeners, and nothing per vagina or rectum until healed

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