Puerperium. puerperal fever ,and puerperal sepsis for undergraduate

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• Normal
• puerperium
• .

DR MANAL BEHERY Assistant Professor Zagazig
University 2013
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Definition of Normal Puerperium

• It is the period following delivery of the baby
  and placenta to 6 weeks postpartum.
• It is the period during it ,the reproductive
• organs maternal physiology returns towards the
  pre pregnancy state .

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Divided into

• First 24 hours
• Early- up to 7 days
• Remote- up to 6 weeks

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Objectives

• To monitor physiological changes of puerperium
• To diagnose and treats any postnatal
  complications
• To establish infant feeding
• To advise about contraception

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Physiological changes in Normal Puerperium

• Changes in Genital Tract
• Changes in breast and Lactation
• Changes in other systems

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Changes in Genital Tract

• Involution of the Uterus
• Lochia
• Involution of Other Pelvic Organs
• Menstruation

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

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

Endometrium Cavity
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Cervix

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

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Ovarian function

• Return of menstruation
• non-nursing mothers
• menstruation returns by 6 8 weeks.
• nursing mothers
• may develop lactating amenorrhea.
• time of ovulation is 3 months in non-
• breast -feeding women

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Changes in Breast and Lactation

• Mamogenesis (Mammary duct-gland growth
  dev.)
• Lactogenesis (Initiation Of milk secretion
  in alveoli)
• Galactopoiesis (Maintenance of Lactation)

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Changes in other systems

• Pulse slow
• Temp. subnormal
• Shivering
• Fever up to first 24 hours
• Hb. Rises
• TLC increases
• Diuresis- 2nd to 5th day post delivery

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OTHER SYSTEMS

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

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Management of Normal Puerperium
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Daily round by physical staff should incluid

• Uterus palpate uterine funds to evaluate level
  and tone
• Abdomen examine for distension especially
  postoperative
• Lochia for quantity ,and unusual odors
• Perineum inspected for hematoma formation ,signs
  of infections, or wound breakdown.

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

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Post partum immunization

• Adminster a booster dose in Rubella non immune
  wommen or MMR vacine.
• Adminster 300 ug of RhoGAM within first 72 hours
  after delivery to RH ve mothers .

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Breast feeding should be Encouraged

• Help in rapid uterine involution, decreased risk
  of ovarian ,breast cancer,osteprosis.
• Women shouldn't breastfed if
• Have infant with galactosemia
• Are infected with HIV.
• Have active untreated TB.
• Are being treated for breast cancer.

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Contraceptive advice

• Breast feeding women shouldnt relay on lactation
  amenorrhea as a method of contraception (98
  protection in first 6 months provided that
  feeding every 4 hours daily ,6 hours at nigth
  ,formula supply 10-15)
• Use a barrier method or hormonal contraception
  .POP 2-3 weeks postpartum
• DMPA 6 weeks postpartum

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Health nutrition education
Health nutrition education

• Calorie need per day-2200700 2900
• Care of MLE stitches if any
• Care of nipples and areola
• Sexual intercourse can be resumed after 6 weeks
  after delivery
• Immunization of child

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Puerperal fever
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Definition

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

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Benign single-day fevers following vaginal
delivery

• Fever in the first 24 hours after delivery
  often resolves spontaneously and cannot be
  explained by an identifiable infection.

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Significance
Significance

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

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Causes

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

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• 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 infants oral pharynx.

Mastitis
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• Mastitis

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Treatment

• 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.

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Endometritis

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

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Atelectasis

• Caused by hypoventilation and is best prevented
  by coughing and deep breathing on a fixed
  schedule following surgery

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Acute pyelonephritis Acute

• 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.

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Wound infections

• Incisional abscesses that develop following
  cesarean delivery usually cause persistent fever
  beginning about the fourth day
• Perineal infection uncommon , caused by bacterial
  contamination during delivery
• Antimicrobials and surgical drainage, with
  careful inspection to ensure that the fascia is
  intact.

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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 .

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Puerpral sepsis

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• 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.

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Clinical course severity of the infection is
determined by

• 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.

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Risk factors

• Prolonged PROM
• Prolonged (more than 24 hours) labor
• Frequent vaginal examinations
• Retained products of conception
• Hemorrhage
• Anemia, poor nutrition during pregnancy.
• Obesity.
• Diabetes.

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Risk factors (CONT ..)

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

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Pathogenesis of puerperal sepsis
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• Puerperal infection following vaginal delivery
  primarily involves the placental implantation
  site, decidua and adjacent myometrium, or
  cervicovaginal lacerations.
• Uterine infection following cesarean delivery is
  that of an infected surgical incision
• Bacteria that colonize the cervix and vagina gain
  access to amnionic fluid during labor, and
  postpartum, they invade devitalized uterine
  tissue.

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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.

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Predisposing factor

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

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CESAREAN DELIVERY

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

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Diagnosis

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

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

Signs
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Investigations

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

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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.

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• 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
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Management
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Prevention

• 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.

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Treatment

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

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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.

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Patients with persistant fever despite
antibiotics TTT are assessed for

• Ratained product of conception
• Wound infection
• Pelvic abcess
• Ovarian vein thrombosis
• Septic pelvic thrombophelbities.

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

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

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• 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

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

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

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

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investigation

• Urinalysis was unremarkable.

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On postpartum day four

• The patients condition showed no improvement
  after antibiotic treatment,
• An abdominal CT scan was obtained.
• A right ovarian vein thrombosis was noted on the
  imaging.
• Diagnosis ovarian vein thrombophlebitis

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

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How to prevent ?

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

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• MCQ

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Which change can be seen in puerperium?

• A-maternal heart beat is increased 2 days after
  delivery
• B- endometrium repair is resumed three weeks
  after delivery
• C- Ureters will return to non pregnant state
  after 8 weeks
• D- Vaginal rugae appear after 3 months from
  delivery
• AnsC

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Which is true about puerpural changes?

• A- total number of uterine muscular cells is not
  reduced
• B-vaginal rugae occur in the third month from
  delivery
• C-uterine connective tissue wont change
• D-uterine is re-epithelialized totally in the
  first week of pregnancy
• AnsA

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Which organism is the least responsible in
puerpural infection?

• A- peptostreptococcus
• B-enterococcus
• C- chlamydia trachomatis
• D-mycoplasma
• AnsD

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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 infection
• B- pelvic thrombophlebitis
• C- pyelonephritis
• D- adenexal infection
• AnsA

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What is wrong about puerpural immunization?

• A- tetanus and diphtheria vaccine before
  discharge from hospital is advocated
• B-a woman already injected measles vaccine does
  not need a booster dose
• C- Rh negative women with an Rh positive newborn
  should take RhoGam
• D- women who have never taken rubella vaccine
  should be vaccinated
• AnsB

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Which is wrong about fever after delivery?

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

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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 doesnt look ill. What is your diagnosis?

• A-pelvic abscess
• B-parametrial phlegmon
• C-pelvic septic thrombophlebitis
• D-adenexal infection
• AnsC

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Who can lactate?

• A- mother of a galactosemic newborn
• B- mother with HBV
• C- mother with active untreated TB
• D-mother with breast herpetic lesions
• AnsB

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An infection after C/S which is not responsive
to clindagenta is because of

• A-clostridium
• B-enterococcus
• C-bacteroid fargilis
• D-chlamydia trachomatis
• AnsB

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What is true about lactation period mastitis?

• A-It occurs in the last days of the first week
• B- Most of the time it is bilateral
• C-nose and throat of the newborn is the source of
  infection
• D-it is mostly a result of coagulase-negative
  staph
• AnsC

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THANK YOU
Thank you