PUERPERAL INFECTIONS ASSOC. PROF. OLUŞ APİ, Yeditepe University Hospital, Department of Obstetrics & Gynecology

PUERPERIUM DEFINITION: DEFINITION: 6 to 8 weeks following delivery of the placenta in which the uterus returns to its normal state. Following delivery of the placenta, the uterus rapidly contracts to half of its predelivery size. Following delivery of the placenta, the uterus rapidly contracts to half of its predelivery size. The involution that then occurs over the next several weeks is most rapid in nursing women. The involution that then occurs over the next several weeks is most rapid in nursing women.

Postpartum vaginal discharge is called LOCHIA. Postpartum vaginal discharge is called LOCHIA. It contains blood, mucus and placental tissue. It contains blood, mucus and placental tissue. Lochia changes as the uterus involutes. Lochia changes as the uterus involutes.

TYPES OF LOCHIA 1) LOCHIA RUBRA: Initially, the discharge is grossly bloody, persisting for 3 to 4 days. It contains large amount of blood. 1) LOCHIA RUBRA: Initially, the discharge is grossly bloody, persisting for 3 to 4 days. It contains large amount of blood. 2) LOCHIA SEROSA: It then decreases in volume and changes to pale brown and becomes thinner, persisting for 10 to 12 days. It contains serous exudate, erythrocytes, leukocytes and cervical mucus. 2) LOCHIA SEROSA: It then decreases in volume and changes to pale brown and becomes thinner, persisting for 10 to 12 days. It contains serous exudate, erythrocytes, leukocytes and cervical mucus. 3) LOCHI ALBA: Finally, the discharge becomes yellowish white, occasionally tinged with blood, and may persist for several weeks. It contains leukocytes, epithelial cells, cholesterol, fat and mucus. 3) LOCHI ALBA: Finally, the discharge becomes yellowish white, occasionally tinged with blood, and may persist for several weeks. It contains leukocytes, epithelial cells, cholesterol, fat and mucus.

After 1 week, the uterus is firm and nontender and extends to about midway between the symphysis and the umbilicus. After 1 week, the uterus is firm and nontender and extends to about midway between the symphysis and the umbilicus. By 2 weeks postpartum, the uterus is no longer palpable abdominally. By 2 weeks postpartum, the uterus is no longer palpable abdominally.

Puerperal complications include: Puerperal complications include: Postpartum hemorrhage Postpartum hemorrhage Postpartum infection Postpartum infection Postpartum depression Postpartum depression

Puerperal fever Puerperal fever, also known as postpartum fever or puerperal infection Puerperal fever, also known as postpartum fever or puerperal infection Definition: temperatures in the postpartum fever reach 100.4F(38.0C) or higher. The fevers occur on any two of the first 10 days postpartum, exclusive of the first 24 hours. Definition: temperatures in the postpartum fever reach 100.4F(38.0C) or higher. The fevers occur on any two of the first 10 days postpartum, exclusive of the first 24 hours. Abortion or miscarriage isn ’ t usually associated with this infection and fever. Abortion or miscarriage isn ’ t usually associated with this infection and fever.

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

Causes ( listed in order of decreasing frequency ) endometritis (most common) Causes ( listed in order of decreasing frequency ) endometritis (most common) urinary tract infection pneumonia\atelectasis wound infection septic pelvic thrombophlebitis. Septic risk factors for each etiologic condition are listed in order of the postpartum day(PPD) on which the condition generally occurs. Septic risk factors for each etiologic condition are listed in order of the postpartum day(PPD) on which the condition generally occurs. Puerperal fever

risk increases with ❑ prolonged and premature rupture of the membranes ❑ prolonged and premature rupture of the membranes ❑ prolonged (more than 24 hours) labor ❑ prolonged (more than 24 hours) labor ❑ frequent or unsanitary vaginal examinations or unsanitary delivery ❑ frequent or unsanitary vaginal examinations or unsanitary delivery ❑ retained products of conception ❑ retained products of conception ❑ hemorrhage ❑ hemorrhage ❑ maternal conditions, such as anemia, poor nutrition during pregnancy. ❑ maternal conditions, such as anemia, poor nutrition during pregnancy. ❑ cesarean birth (20-fold increase in risk for puerperal infection). ❑ cesarean birth (20-fold increase in risk for puerperal infection). ❑ genital or urinary tract infection prior to delivery. ❑ genital or urinary tract infection prior to delivery. ❑ use of a fetal scalp electrode during labor. ❑ use of a fetal scalp electrode during labor. ❑ obesity. ❑ obesity. ❑ diabetes. ❑ diabetes. ❑ urinary catheter ❑ urinary catheter ❑ nipple trauma from breastfeeding ❑ nipple trauma from breastfeeding

The associated symptoms depend on the site and nature of the infection. The associated symptoms depend on the site and nature of the infection. The most typical site of infection is the genital tract. Endometritis, which affects the uterus, is the most prominent of these infections. 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. (REST PLACENTA) Endometritis is much more common if a small part of the placenta has been retained in the uterus. (REST PLACENTA)

Physical examination A pelvic examination is done and samples are taken from the genital tract to identify the bacteria involved in the infection. A pelvic examination is done and samples are taken from the genital tract to identify the bacteria involved in the infection. The pelvic examination can reveal the extent of infection and possibly the cause.

Laboratory  Blood samples may also be taken for blood counts, CRP, or blood culture.  A urinalysis may also be ordered, especially if the symptoms are indicative of a urinary tract infection.  Chest x-ray  Wound culture

Treatment Treatment of puerperal infection usually begins with I.V. infusion of broadspectrum antibiotics and is continued for 48 hours after fever is resolved. Treatment of puerperal infection usually begins with I.V. infusion of broadspectrum antibiotics and is continued for 48 hours after fever is resolved. Supportive care Supportive care Symptomatic treatment Symptomatic treatment Surgery may be necessary to remove any remaining products of conception or to drain local lesions, such as An infected episiotomy (incision made during delivery) may need to be opened and drained. Surgery may be necessary to remove any remaining products of conception or to drain local lesions, such as An infected episiotomy (incision made during delivery) may need to be opened and drained. In the presence of thrombophlebitis, heparin therapy will be needed to provide anticoagulation. In the presence of thrombophlebitis, heparin therapy will be needed to provide anticoagulation.

Prevention Avoid the risk factors Avoid the risk factors Keep the episiotomy site clean Keep the episiotomy site clean Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection.

Infection

Endometritis Ascending polymicrobial infection Ascending polymicrobial infection Usually normal vaginal flora or enteric bacteria Usually normal vaginal flora or enteric bacteria Primary cause of postpartum infection Primary cause of postpartum infection 1-3% vaginal births 1-3% vaginal births 5-15% scheduled C-sections 5-15% scheduled C-sections 30-35% C-section after extended period of labor 30-35% C-section after extended period of labor May receive prophylactic antibiotics May receive prophylactic antibiotics <2% develop life-threatening complications <2% develop life-threatening complications

ETIOLOGY Endometritis is an ascending polymicrobial infection Endometritis is an ascending polymicrobial infection The most common organisms are divided into 4 groups: The most common organisms are divided into 4 groups: aerobic gram-negative bacilli aerobic gram-negative bacilli anaerobic gram-negative bacilli anaerobic gram-negative bacilli aerobic streptococci aerobic streptococci anaerobic gram-positive cocci. anaerobic gram-positive cocci. Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species are the most frequently identified organisms. Specifically, Escherichia coli, Klebsiella pneumoniae, and Proteus species are the most frequently identified organisms.

The infection is variously known as endometritis; endoparametritis; or simply, metritis. The infection is variously known as endometritis; endoparametritis; or simply, metritis. Endometritis complicates 1-3% of all vaginal deliveries and 5- 15% of scheduled cesarean deliveries. Endometritis complicates 1-3% of all vaginal deliveries and 5- 15% of scheduled cesarean deliveries. The incidence of endometritis in patients who undergo cesarean delivery after an extended period of labor is 30-35% and falls to 15-20% if the patient receives prophylactic antibiotics.

Endometritis Risk factors: C-section C-section Young age Young age Low SES Low SES Prolonged labor Prolonged labor Prolonged rupture of membranes Prolonged rupture of membranes Multiple vaginal exams Placement of intrauterine catheter Preexisting infection Twin delivery Manual removal of the placenta

Endometritis Clinical presentation Fever Fever Chills Chills Lower abdominal pain Lower abdominal pain Malodorous lochia Malodorous lochia Increased vaginal bleeding Increased vaginal bleeding Anorexia Anorexia Malaise Malaise Exam findings Fever Tachycardia Fundal tenderness Treatment Antibiotics

Urinary Tract Infection Bacterial inflammation of the bladder or urethra Bacterial inflammation of the bladder or urethra 3-34% of patients 3-34% of patients Symptomatic infection in ~2% Symptomatic infection in ~2%

Urinary Tract Infection Risk factors C-section C-section Forceps delivery Forceps delivery Vacuum delivery Vacuum delivery Tocolysis Tocolysis Induction of labor Induction of labor Maternal renal disease Maternal renal disease Preeclampsia Eclampsia Epidural anesthesia Bladder catheterization Length of hospital stay Previous UTI during pregnancy

Urinary Tract Infection Clinical Presentation Urinary frequency/urgency Urinary frequency/urgency Dysuria Dysuria Hematuria Hematuria Suprapubic or lower abdominal pain Suprapubic or lower abdominal painOR… No symptoms at all No symptoms at all Exam Findings Stable vitals Afebrile Suprapubic tenderness Treatment antibiotics

Mastitis Inflammation of the mammary gland Inflammation of the mammary gland Milk stasis & cracked nipples contribute to the influx of skin flora Milk stasis & cracked nipples contribute to the influx of skin flora 2.5-3% in the USA 2.5-3% in the USA Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%) Neglected, resistant or recurrent infections can lead to the development of an abscess (5-11%)

Mastitis Clinical Presentation Fever Fever Chills Chills Myalgias Myalgias Warmth, swelling and breast tenderness Warmth, swelling and breast tenderness Exam Findings Area of the breast that is warm, red, and tender Area of the breast that is warm, red, and tender Treatment Moist heat Massage Fluids Rest Proper positioning of the infant during nursing Nursing or manual expression of milk Analgesics Antibiotics stasis

Wound Infection Perineum (episiotomy or laceration) 3-4 days postpartum 3-4 days postpartum rare rare Abdominal incision (C-section) Postoperative day % prophylactic antibiotics 2%

Wound Infection Perineum Risk Factors: Infected lochia Infected lochia Fecal contamination Fecal contamination Poor hygiene Poor hygiene Abdominal incision Risk factors: Diabetes Hypertension Obesity Corticosteroid treatment Immunosuppression Anemia Prolonged labor Prolonged rupture of membranes Prolonged operating time Abdominal twin delivery Excessive blood loss

Wound Infection Clinical Presentation Perineal Infection: Pain Pain Malodorous discharge Malodorous discharge Vulvar edema Vulvar edema Abdominal Infection Persistent fever Persistent fever (despite antibiotics) Diagnosis Erythema Induration Warmth Tenderness Purulent drainage With or without fever

POST-CESAREAN WOUND INFECTION

Differential diagnosis Perineal infection Perineal infection Hematoma Hematoma Hemorrhoids Hemorrhoids Perineal cellulitis Perineal cellulitis Necrotizing fasciitis Necrotizing fasciitis Abdominal wound infection Abdominal wound infection Cellulitis Cellulitis Wound dehiscence Wound dehiscence

TREATMENT: Perineal infections Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated. Treatment of perineal infections includes symptomatic relief with NSAIDs, local anesthetic spray, and sitz baths. Identified abscesses must be drained, and broad-spectrum antibiotics may be initiated.

TREATMENT: Abdominal wound infections These infections are treated with drainage and inspection of the fascia to ensure that it is intact. These infections are treated with drainage and inspection of the fascia to ensure that it is intact. Antibiotics may be used if the patient is afebrile. Antibiotics may be used if the patient is afebrile. Most patients respond quickly to the antibiotic once the wound is drained. Antibiotics are generally continued until the patient has been afebrile for hours. Most patients respond quickly to the antibiotic once the wound is drained. Antibiotics are generally continued until the patient has been afebrile for hours. Patients do not require long-term antibiotics unless cellulitis has developed. Patients do not require long-term antibiotics unless cellulitis has developed. Studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth Studies have shown that closed suction drainage or suturing of the subcutaneous fat decreases the incidence of wound infection when the subcutaneous tissue is greater than 2 cm in depth

In emergency cesarean deliveries, use of prophylactic cefazolin has been shown to reduce the rate of postpartum endometritis and wound infection. In emergency cesarean deliveries, use of prophylactic cefazolin has been shown to reduce the rate of postpartum endometritis and wound infection. Other studies have demonstrated that ampicillin/sulbactam, cefazolin, and cefotetan are all acceptable choices for single- dose antibiotic prophylaxis. Other studies have demonstrated that ampicillin/sulbactam, cefazolin, and cefotetan are all acceptable choices for single- dose antibiotic prophylaxis. Controversy still exists with regard to the need for prophylactic antibiotics during elective deliveries Controversy still exists with regard to the need for prophylactic antibiotics during elective deliveries

Other Puerperal Infections Urinary tract infections (UTI’s) Urinary tract infections (UTI’s) Mastitis Mastitis Wound infection Wound infection Septic pelvic trombophlebitis Septic pelvic trombophlebitis

MASTITIS Mastitis is defined as inflammation of the mammary gland. Mastitis is defined as inflammation of the mammary gland. Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. Milk stasis and cracked nipples, which contribute to the influx of skin flora, are the underlying factors associated with the development of mastitis. Mastitis is also associated with primiparity, incomplete emptying of the breast, and improper nursing technique. Mastitis is also associated with primiparity, incomplete emptying of the breast, and improper nursing technique. The most common causative organism, isolated in approximately half of all cases, is Staphylococcus aureus. The most common causative organism, isolated in approximately half of all cases, is Staphylococcus aureus. Other common pathogens include Staphylococcus epidermidis, S saprophyticus, Streptococcus viridans, and E coli. Other common pathogens include Staphylococcus epidermidis, S saprophyticus, Streptococcus viridans, and E coli.

Incidence Incidence In the United States, the incidence of postpartum mastitis is 2.5-3%. In the United States, the incidence of postpartum mastitis is 2.5-3%. Mastitis typically develops during the first 3 months postpartum, with the highest incidence in the first few weeks after delivery. Mastitis typically develops during the first 3 months postpartum, with the highest incidence in the first few weeks after delivery. Morbidity and mortality Morbidity and mortality Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. Neglected, resistant, or recurrent infections can lead to the development of an abscess, requiring parenteral antibiotics and surgical drainage. Abscess development complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails. Abscess development complicates 5-11% of the cases of postpartum mastitis and should be suspected when antibiotic therapy fails.

History History Fever, chills, myalgias, erythema, warmth, swelling, and breast tenderness characterize mastitis. Fever, chills, myalgias, erythema, warmth, swelling, and breast tenderness characterize mastitis. Physical Physical Typical findings include an area of the breast that is warm, red, and tender. Typical findings include an area of the breast that is warm, red, and tender. When the exam reveals a tender, hard, possibly fluctuant mass with overlying erythema, a breast abscess should be considered. When the exam reveals a tender, hard, possibly fluctuant mass with overlying erythema, a breast abscess should be considered.

Differential diagnosis Differential diagnosis Mastitis Mastitis Breast abscess Breast abscess Cellulitis Cellulitis Workup Workup No laboratory tests are required. No laboratory tests are required. Expressed milk can be sent for analysis, but the accuracy and reliability of these results are controversial and aid little in the diagnosis and treatment of mastitis Expressed milk can be sent for analysis, but the accuracy and reliability of these results are controversial and aid little in the diagnosis and treatment of mastitis

TREATMENT Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics. Milk stasis sets the stage for the development of mastitis, which can be treated with moist heat, massage, fluids, rest, proper positioning of the infant during nursing, nursing or manual expression of milk, and analgesics. When mastitis develops, penicillinase-resistant penicillins and cephalosporins. When mastitis develops, penicillinase-resistant penicillins and cephalosporins. Erythromycin, clindamycin, and vancomycin may be used for infections that are resistant to penicillin. Erythromycin, clindamycin, and vancomycin may be used for infections that are resistant to penicillin. Resolution usually occurs 48 hours after the onset of antimicrobial therapy. Resolution usually occurs 48 hours after the onset of antimicrobial therapy.

SEPTIC PELVIC TROMBOPHLEBITIS Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy. Septic pelvic thrombophlebitis is defined as venous inflammation with thrombus formation in association with fevers unresponsive to antibiotic therapy.

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

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. 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. Abd:soft,flat, tenderness on the right abdomen,no rebound-tenderness, Mcburney ’ s point (+/-),Murphy ’ s sign(-), kindey region percussion (-). Abd:soft,flat, tenderness on the right abdomen,no rebound-tenderness, Mcburney ’ s point (+/-),Murphy ’ s sign(-), kindey region percussion (-). Urinalysis was unremarkable. Urinalysis was unremarkable.

On postpartum day four, the patient ’ s condition was no improvement after antibiotic treatment, and an abdominal CT scan was obtained. A right ovarian vein thrombosis was noted on the imaging. On postpartum day four, the patient ’ s condition was no improvement after antibiotic treatment, and an abdominal CT scan was obtained. A right ovarian vein thrombosis was noted on the imaging. IMP: ovarian vein thrombophlebitis IMP: ovarian vein thrombophlebitis

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 and after 6 weeks a CT scan was repeated. The right ovarian thrombosis was not present in the images and warfarin was discontinued 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 and after 6 weeks a CT scan was repeated. The right ovarian thrombosis was not present in the images and warfarin was discontinued

ETIOLOGY Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. Bacterial infection of the endometrium seeds organisms into the venous circulation, which damages the vascular endothelium and in turn results in thrombus formation. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. The thrombus acts as a suitable medium for proliferation of anaerobic bacteria. Ovarian veins are often involved because they drain the upper half of the uterus. Ovarian veins are often involved because they drain the upper half of the uterus. Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss. Risk factors include low socioeconomic status, cesarean birth, prolonged rupture of membranes, and excessive blood loss.

Incidence Incidence Septic pelvic thrombophlebitis occurs in 1 of every pregnancies and is 10 times more common after cesarean birth (1 per 800) than after vaginal delivery (1 per 9000). Septic pelvic thrombophlebitis occurs in 1 of every pregnancies and is 10 times more common after cesarean birth (1 per 800) than after vaginal delivery (1 per 9000). The condition affects less than 1% of patients with endometritis. The condition affects less than 1% of patients with endometritis. Morbidity and mortality Morbidity and mortality Septic thrombophlebitis may result in the migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. Septic thrombophlebitis may result in the migration of small septic thrombi into the pulmonary circulation, resulting in effusions, infections, and abscesses. Only rarely is a thrombus large enough to cause death. Only rarely is a thrombus large enough to cause death.

HISTORY Septic pelvic thrombophlebitis usually accompanies endometritis. Septic pelvic thrombophlebitis usually accompanies endometritis. Patients report initial improvement after an intravenous antibiotic is initiated for treatment of the endometritis. Patients report initial improvement after an intravenous antibiotic is initiated for treatment of the endometritis. The patient does not appear ill. Patients with ovarian vein thrombosis may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen. The patient does not appear ill. Patients with ovarian vein thrombosis may describe lower abdominal pain, with or without radiation to the flank, groin, or upper abdomen.

PHYSICAL SIGNS Vital signs demonstrate fever greater than 38°C and resting tachycardia. Vital signs demonstrate fever greater than 38°C and resting tachycardia. If pulmonary involvement is significant, the patient may be tachypneic. If pulmonary involvement is significant, the patient may be tachypneic. On abdominal examination, 50-70% of patients with ovarian vein thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the uterine cornu. On abdominal examination, 50-70% of patients with ovarian vein thrombosis have a tender, palpable, ropelike mass extending cephalad beyond the uterine cornu.

WORK-UP Urinalysis, urine culture, and CBC count with differential. Urinalysis, urine culture, and CBC count with differential. Imaging: CT scan and MRI are the studies of choice for the diagnosis of septic pelvic thrombophlebitis. Imaging: CT scan and MRI are the studies of choice for the diagnosis of septic pelvic thrombophlebitis. MRI has 92% sensitivity and 100% specificity, and CT imaging has a 100% sensitivity and specificity for identifying ovarian vein thrombosis. MRI has 92% sensitivity and 100% specificity, and CT imaging has a 100% sensitivity and specificity for identifying ovarian vein thrombosis.

TREATMENT The standard therapy after diagnosis of septic pelvic thrombophlebitis includes anticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy. The standard therapy after diagnosis of septic pelvic thrombophlebitis includes anticoagulation with intravenous heparin to an aPTT that is twice normal and continued antibiotic therapy. A therapeutic aPTT is usually reached within 24 hours, and heparin is continued for 7-10 days. A therapeutic aPTT is usually reached within 24 hours, and heparin is continued for 7-10 days. Antibiotic therapy is most commonly with gentamicin and clindamycin. Antibiotic therapy is most commonly with gentamicin and clindamycin. Other choices include a second- or third-generation cephalosporin, imipenem, cilastin, or ampicillin and sulbactam. Other choices include a second- or third-generation cephalosporin, imipenem, cilastin, or ampicillin and sulbactam. All of these antibiotics have a cure rate of greater than 90%. All of these antibiotics have a cure rate of greater than 90%.