P ERPERAL INFECTION

C] general term used to describe any bacterial

inf ction of the genital tract after delivery
-P ST: constitutes the LETHAL TRIAD of maternal
de th, along with preeclampsia and obstetrical
he orrhage
-P ESENT: maternal deaths from infection have
be ome uncommon due to effective
an imicrobials (13% of maternal deaths)
 Puerperal Fever
Puerp ra ever
-A mperature of 38.00 Cor higher in the puerperium
-Co mon causes of uer era! fever:
1. Genital tract infection
-Cause most persistent fevers after childbirth
2. Breast engorgement
-in 15%of women who don't breastfeed
-rarely exceeds 39.00 C
3. Pyelonephritis
-fever: first sign of renal infection
-signs and symptoms that follow: costovertebral
angle tenderness, nausea and vomiting
puerp ra ever
-Co mon causes of uer eral fever:
4. Respiratory complications after cesarean delivery
-atelectasis: caused by hypoventilation and
best prevented by coughing and deep
breathing on a fixed schedule following
surgery
-fever: follows infection by normal flora that
proliferate distal to obstructing mucus plugs
5. Superficial or deep-venous thrombosis of the legs
-occasionally cause minor temperature
elevations in the puerperium
 Uterine Infection
-Pos partum uterine infection has been called
va iously endometritis, endomyometritis and
en oparametritis
-pre rred term: metritis with pelvic cellulitis
-because infection does not only involve the
de idua but also the myometrium and parametrial
tis ues
predi posing Factors
te of delivery
-si gle most significant factor for the development of uterine
infection
-2 fold increased infection-related mortality with cesarean versus
vaginal delivery
-m nual removal of the placenta increase puerperal metritis 3-fold
-m tritis following vaginal delivery is relatively uncommon
RISK FOR METRITIS
risk women without complications 1-2%
Hi h risk women due to membrane rupture, 5-6%
pr longed labor,and multiple cervical exams
W men with intrapartum chorioamnionitis 13%
PE posing ac ors
1. Rou of delivery
-sin le-dose perioperative prophylaxis is given almost universallyat
cesarean delivery
-Ri kfactors for infectionfollowing surgeryinclude:
-prolonged labor
-membrane rupture
-multiple cervical examinations
-internal fetal monitoring
-Inc eased risk of infection include cesarean deliveryfor:
-multifetal gestation
-young maternal age
-nulliparity
-prolonged labor induction
-obestiy
-meconium-stained amnionic fluid
Pre sposmg actors
2. Lo er socioeconomic status
3. An mia and Poor Nutrition
-in very rare cases
Pr vious bacterial colonization if the lower genital
tra t with certain microorganisms like:
-Group B streptococcus
-Chlamydia trachomatis
-Mycoplasma hominis
-Ureaplasma urealyticum
-Gardnerella vaginalis
 Uterine Infection

Bac e 10ogy
-Most female pelvic infections are caused by bacteria indigenous to
the female genital tract
-Repo s show that group A -hemolytic streptococcus may cause
t0XlC shock-like syndrome and life-threatening infection
-Prem turely ruptured membranes is a prominent risk
-Wom n in whom group A streptococcal infection was manifested
bef re, during, or within 12 hours of delivery had a maternal
mo tality rate of almost 90% and fetal mortality rate of >50%
-Skin nd soft-tissue infections due to community-acquired
me hicillin-resistant Staphylococcusaureus—CA-MRSA—have
bec me common D NOT for puerperal metritis, but for
- ional wound
-Stud : A woman with episiotomy cellulitis with CA-MRSA had
he atogenously spread necrotizing pneumonia
 Uterine Infection

Com on a ogens
-Infec ions are polymicrobial which promotes bacterial synergy
-Othe factors that promote virulence are hematomas and
de italized tissue
-The c rvix and vagina routinely harbor such bacteria BUT the
ute ine cavity is usually sterile before rupture of the amnionic
sac
-Thea nionic fluid and uterus commonly become contaminated
wit anaerobic and aerobic bacteria as the consequence of
lab rand delivery and associated manipulations
-Cultu ed amnionic fluid obtained at cesarean delivery in women in
lab r with membranes ruptured more than 6 hours C] all had
bac erial growth and an average of 2.5 organisms was identified
fro each specimen
Com on a ogens
-Anae obes included Peptostreptococcus and Peptococcus species,
Ba teroides species and Clostridium species
-Aero es included Enterococcus,group B streptococcus, and
Esc erichia coli
-Chla ydial infections have been implicated in late-onset, indolent
me ritis
-Whe cervical colonization of U. urealyticum is heavy,it may
con ribute to the development of metritis
Thr efold risk of puerperal infection in women in whom
bac erial vaginosis was identified in early pregnancy
Uterine Infection

CERVICOVAGINAL BACTERIA
Cervical Examinations
Internal Monitoring
Prolonged Labor
Uterine incision

INNO TION

ANAEROBI NDITIONS
Surgical Trauma
Sutures
Devitalized Tissue
Blood and Serum

CLINICAL INFECTION
BACTERIAL PROLIFERATION
Aero es
-Gra ositive cocci —group A, B, and D streptococci,
ent rococcus, Staphylococcus aureus, Staphylococcus
epi ermidis
-Gra -ne ative bacteria —Escherichia coli, Klebsie//a,Proteus
sp cies
-Gra -variable —Gardnere/la vagina/is
Othe s
-Myc plasma and Chlamydia species, Neisseria gonorrhoeae
Anae obes
-Cocc —Peptostreptococcus and Peptococcusspecies
-Othe s —Clostridium and Fusobacterium species Mobi/uncus
sp cies
Bact rial Cultures
-Rou ine pretreatment genital tract cultures are of
little clinical use and add significant costs
-Rou ine blood cultures seldom modify care
-Bef re perioperative prophylaxis: blood cultures
w re positive in 13 percent of women with
po tcesarean metritis
-Bac eremia in on,y 5 percent of almost 800 women
wi h puerperal sepsis.
 Pathogenesis

-Puer era Inféäiööföl owing vagina e Ivery primari y

inv Ives:
-placental implantation site
-decidua and adjacent myometrium
-cervicovaginal lacerations
-The athogenesis of uterine infection following cesarean
del very is that of an infected surgical incision
-Bact ria that colonize the cervix and vagina gain access to
am ionic fluid during labor and invade devitalized uterine
tissge postpartum
-Parahetrial cellulitis next follows with infection of the pelvic
cet operitoneal fibroareo/ar connective tissue
-With early treatment, infection is contained within the
pa vagina/ tissue but may extend deeply into the pelvis
 PUERPERAL INFECTION:
Clinical Course

me ritis
-Degre of fever is believed proportional to the extent of infection andsepsis
syn rome
-Temp ratures commonly are 38 to 390 C
-Chills hat accompany fever suggest bacteremia
-Wom n usually complain of:
-ab ominal pain
-pa metrial tenderness on abdominal and bimanual examination
-offnsive odor of lochia (but many women have foul-smelling lochia
wit out evidence for infection)
*those due to group A -hemolytic streptococci, are frequently
associated with scanty, odorless lochia
Leuko ytosis may range from 15,000 to 30,000 cells/L
*ce arean delivery itself increases the leukocytecount
 PUERPERAL INFECTION:
Treatment

anorar--
anti icrobial agent is usually sufficient
-Mode ate to severe infections: intravenoustherapy with a broad-spectrum
anti icrobial regimen is indicated
-Impro ement follows in 48 to 72 hours in nearly 90% of women treated
wit one of several regimens
-Persis entfever after 48 to 72 hours mandates a careful search for causes
of r fractory pelvic infection including:
-Par metrial phlegmon—an area of intense cellulitis
-Ab ominal incisional or pelvicabscess
-Inf cted hematoma
-Se tic pelvic thrombophlebitis
-An imicrobial-resistant bacteria or drug side effects D SELDOM
-Patien may be discharged home after she has been afebrile for at least 24
hou s and further oral antimicrobial therapy is NOT needed
 PUERPERAL INFECTION:
Treatment

Choi e of Antimicrobials
-Although therapy is empirical, initial treatment
fol owing cesarean delivery is directed against
m st of the mixed flora which typically cause
pu rperal infections
-Ana robic coverage is included for infections
fol owing cesarean delivery
-Suc broad-spectrum antimicrobial coverage is
o, n not necessary to treat infection following
va inal delivery D respond to regimens such as
a picillin plus gentamicin
 PUERPERAL INFECTION:
Treatment

Anti icrobial Regimens for Pelvic Infection

Fo lowing Cesarean Delivery
Regimen Comments
Clinda ycin 900 mg + gentamicin 1.5 "Gold standard" 90—97%efficacy, once-
mg/kg, q8h intravenously daily gentamicin dosing acceptable

Ampicillin added to regimen with sepsis

Clinda ycin + aztreonam
d-spectrum
Extend d-spectrum cephalosporins
Imipen m + cilastatin
syndrome or suspected enterococcal
infection
Gentamicin substitute with renal
insufficiency
Piperacillin, ampicillin/sulbactam
Cefotetan, cefoxitin, cefotaxime
Reserved for special indications
C 01ceo n micro la s
-Clinda ycin-gentamicin —95% response rate, and this regimen
-stil considered by most to be the standard by which others are
me sured
-Enter coccal infections: add ampicillin to the clindamycin-gentamicin
regi en, either initially or if there is no response by 48 to 72 hours
-Seru gentamicin levels be periodically monitored or only with altered
ren I function
*O ce-daily dosing has a cure rate similar to 8-hourdosing
-Genta icin: potential nephrotoxicity and ototoxicity in the event of
dim nished glomerularfiltration
e
ves' a ee e a u c •o
-Cli damycin and a second-generation cephalosporin
-C!i damycin and aztreonam (monobactam withaminoglycoside-like
acti n)
C 01ce nttrmcro la s
-The sp ctra of -lactam antimicrobials include activity against many anaerobic
pat ogens and are inherently safe and free of major toxicity except for allergic
reac ions
-cep alosporins such as cefoxitin, cefotetan, and cefotaxime
-ext nded-spectrum penicillins such as piperacillin, ticarcillin, and mezlocillin
-The -la tamase inhibitors, clavulanic acid, sulbactam, and tazobactam, have been
com ined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extend
spe ra of lactams
-Metro idazole has superior in vitro activity against most anaerobes
-Giv n with ampicillin and an aminoglycoside to provide coverage against most
orga isms encountered in serious pelvic infections
-Imipen m is a carbapenem that has broad-spectrum coverage against most
orga isms associated with metritis
- —llea with cilastatin, which inhibits renal metabolism of imipenem
*Combination is effective in most cases of metritis, it seems reasonable
fro both a medical and an economic standpoint to reserve it for more serious
infe tions
 PUERPERAL INFECTION:
Prevention

perlO
-Admi istration of antimicrobial prophylaxis at the time ofcesarean
deli ery C] reduce the rate of pelvic infection by 70 t080
*O served benefit applies to both elective and nonelective
ces rean delivery and also includes a reduction in abdominal
inci ional infections
-Singl -dose prophylaxis with ampicillin or a first-generation
cep alosporin is ideal, and both are as effective as broad-spectrum
age ts or a multiple-dose
-Exten ed-spectrum prophylaxis with azithromycin added to standard
sin le-dose prophylaxis showed a significant reduction in
pos cesarean metritis
-Wom n known to be coionized with methicillin-resistant
Sta hylococcusaureus—MRSA—aregiven vancomycin in addition
to cephalosporin
 PUERPERAL INFECTION:
Prevention

Z
Peno EFäfiFfitifiiiZFö6iäT PiööhTaxts
-Infect on rate is lowered more if the selected antimicrobial is given
bef re the skin incision compared with cord clamping
-A nu ber of locally applied antimicrobials have been evaluated to
pre ent puerperal infection
-Int apartum vaginal irrigation with chlorhexidine did not reduce
the incidence of postpartum infection
-Co flicting studies on use of Povidone-iodine:
-vaginal irrigation before cesarean delivery had no effect on
the incidence of fever, metritis, or abdominal incisional infection
-Preoperative vaginal cleansing with povidone-iodine had
a si nificantly lower infection rate following cesarean
versus 14
-Metr nidazole gel: reduction in rate of metritis but nosignificant
effe ton febrile morbidity or wound infections
 PUERPERAL INFECTION:
Prevention

Trea en o aginl IS
-Pren tal treatment of asymptomatic vaginal infections has
no been shown to prevent postpartum pelvic infections
-No b neficial effects for women treated for asymptomatic
ba terial vaginosis
-Simil r postpartum infection rate in women treated for 2nd
tri ester asymptomatic Trichomonas vaginalis infection
co pared with that of placebo-treated women
 PUERPERAL INFECTION:
Prevention

Opera Ive ec mque

-Allo ing the placenta to separate spontaneously compared with
re oving it manually lowers the risk of infection
-Chan ing gloves by the surgical team after placental delivery DOES
NO lower infection rates
-Exter orizing the uterus to close the hysterectomy may decrease
feb ile moridity
-Sin I versus 2-la er uterine closure•no difference in
pos operative infection rate
-Closu e versus Non-closure of Peritoneum: no effect on infection
rat s
-Closu e of subcutaneous tissue in obese wome •does NOT lower
inf ction rate but LOWERS incidence of wound separation
 Complications of Pelvic Infections

oun n ec Ion
-Whe prophylactic antimicrobials are given, incidence of
ab ominal incisional infections following Cesarean delivery is
les than 2%
-Wou d infection is a common cause of persistent fever in women
tre ted for metritis
-Risk f ctors:
-O esity
-Di betes
-Co icosteroid therapy
-1m unosuppression
-An mia
-Hy ertension
-In dequate hemostasis with hematoma formation
 Complications of Pelvic Infections
oun n ec ton
-Incisi nal abscesses that develop following cesarean delivery
usu lly cause fever or cause persisting fever beginning on the 4 th
da —may be accompanied by wound erythema and drainage
-Treat entfor abscess include antimicrobials and surgical
dra nage, with careful inspection to ensure that fascia is intact
-Wou d care given 2-3 times daily: secondary en bloc closure at 4-
6 d ys of tissue involved in superficial wound infection
-After closure: polypropylene or nylon suture of appropriate gauge
ent rs3 cm from one wound edge crosses the wound to
inc rporate the full wound thickness emerges 3 cm from the
0th r wound edge —placed in series to close the opening
-Sutur s may be removed on postprocedural day 10
 Wound Dehiscence

lay
-Req ires secondary closure of the incision in the operating
ro m
-Mos disruptions manifested on 5thpostoperative day and
is ften accompanied by a serosanguineous discharge
-May be associated with concurrent fascial infection and
tis ue necrosis
 Nec otizing Fasciitis of Abdominal Wall Incisions

mon;-severe-wound-infectton-with-necrosiszssociated-with---l
hig mortality
-may i volve abdominal incisions, or may complicate episiotomy or
0th r perineal lacerations
-Risk f ctors: Diabetes, Obesity, Hypertension
-Usua ly are polymicrobial and are caused by organisms that
co prise normal vaginal flora
-Can also be caused by single virulent bacterial species such as
gro p A ß-hemolytic streptococcus
-Treat ent consists of broad-spectrum antibiotics along with
pro pt fascial debridement until healthy bleeding tissue is
enc untered
-fn ext nsive resection, synthetic mesh may be required