Puerperal Infection Disease

DESCRIPTION

Bacterial infection of the genital tract following delivery. Endometritis (infection of the endometrium, myometrium and parametrial tissues) is the most common infection. Less common are vaginal and cervical infections, perineal cellulitis, pelvic cellulitis, septic pelvic vein thrombophlebitis and parametrial phlegmon.

System(s) affected: Reproductive
Genetics: N/A
Incidence/Prevalence in USA:
- Vaginal deliveries - <3%
- Cesarean sections - 15 - 95%
- Accounts for 7% of maternal death
- Fourth leading cause of maternal mortality
Predominant age: N/A
Predominant sex: Female only

SIGNS AND SYMPTOMS

Oral temperature >38.7°C (101.6°F) in first 24 hours post-partum or
Oral temperature >38°C (100.4°F) in two of first 10 days post-partum (excluding first 24 hours)
Uterine tenderness on exam
Other localized tenderness on exam
Ileus
Tachycardia
Chills, malaise, headache, anorexia
Abdominal or localized pain
Purulent or malodorous lochia
Note: Group A or Group B strep bacteremia may have no localizing signs

CAUSES

The risk of endometritis increases 5-30 fold following Cesarean delivery
Endometritis commonly follows chorioamnionitis
Other infections follow trauma to the perineum, vagina, cervix and uterus
Infection is nearly always polymicrobial and involves organisms that have ascended from the lower genital tract:
- Aerobic isolates in 70% - S. faecalis, S. agalactiae, S. viridans, Staphylococcus aureus, E. coli, Klebsiella sp., Proteus sp., Gardnerella vaginalis
- Anaerobic isolates in 80% - Peptococcus sp., Peptostreptococcus sp., Clostridium sp., Bacteroides bivius, B. fragilis, Fusobacterium sp.
- Other - genital mycoplasmas - role in endometritis is unclear
- Chlamydia trachomatis - responsible for some late (7-10 days) post-partum endometritis
- Range of number of isolates is 1-8

RISK FACTORS

Cesarean section
Pre-existing chorioamnionitis
Multiple vaginal examinations
Indigent status
Bacterial vaginosis or group B strep colonization of genital tract
Prolonged rupture of membranes, prolonged labor and the use of internal fetal monitoring have been shown to be significant factors in univariate but not multivariate analysis

LABORATORY

CBC - interpret with care as physiologic leukocytosis may be as high as 20,000
Blood cultures - if sepsis is suspected
Amniotic fluid gram stain - usually polymicrobial
Uterine tissue cultures - difficult to obtain without contamination
Genital tract cultures and rapid test for group B strep - usually done when patient is in labor
Note: Diagnosis is usually made clinically

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Microscopic sections of uterine lining show superficial layer of infected necrotic tissue
Thrombosis of any of the pelvic veins including the vena cava
Phlegmon on leaves of the broad ligament
Abscess

SPECIAL TESTS

N/A

IMAGING

If patient is not responsive to antibiotics
- CT or MRI for pelvic thrombophlebitis
- U/S, CT or MRI for abscess, pelvic masses or deep-seated wound infections

DIAGNOSTIC PROCEDURES

Paracentesis or culdocentesis with culture - rarely necessary

APPROPRIATE HEALTH CARE

Inpatient for severe infection
Low grade endometritis may respond to outpatient treatment with oral antibiotics

GENERAL MEASURES

IV antibiotics and close observation for severe infections
Open and drain infected wounds
Normalize fluid status
Note: Amnioinfusion during labor may decrease infections when membranes have been ruptured for more than 6 hours.

SURGICAL MEASURES

Curettage of retained products of conception
Surgery to establish drainage of abscess
Surgery to decompress the bowel
Surgical drainage of a phlegmon is not advised unless suppurative

ACTIVITY

As tolerated

DIET

As tolerated although may be limited by ileus.

PATIENT EDUCATION

Call doctor if fever >38°C (100.4°F) post-partum or other symptoms of infection (see Signs and Symptoms)

PREVENTION/AVOIDANCE

Treat chorioamnionitis during labor
Treat prophylactically with cefazolin for C/S deliveries after the cord is clamped
Avoid unnecessary vaginal exams
Avoid retained placental fragments or membranes

POSSIBLE COMPLICATIONS

Resistant organisms
Pelvic abscess
Septic pelvic vein thrombosis
Septic shock
Death

EXPECTED COURSE AND PROGNOSIS

With supportive therapy and appropriate antibiotics most patients improve within a few days
If no improvement on antibiotics, consider retained placental fragments or membranes, abscess, would infection, hematoma, cellulitis, phlegmon or septic pelvic vein thrombosis.

ASSOCIATED CONDITIONS

Chorioamnionitis

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric:N/A
Others: N/A

PREGNANCY

A complication of pregnancy

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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