ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD PUERPERAL INFECTION ASSOCIATE PROFESSOR IOLANDA ELENA BLIDARU MD, PhD

PUERPERAL INFECTION Definition Incidence A rise in temperature to 38° C (100,4°F) or over, maintained for 24 hours occurring in the puerperium infection without pyrexia Extragenital causes: respiratory complications, pyelonephritis, breast engorgement, bacterial mastitis, thrombophlebitis, incisional wound abscess. Incidence 1 to 3%.

PUERPERAL INFECTION Facts IGNAZ SEMMELWEIS (1818–1865) initiated a mandatory hand washing policy for medical students and physicians using a chloride of lime solution LOUIS PASTEUR (1822–1895) - the germ theory of disease, reduced mortality from puerperal fever, and created the first vaccines for rabies and anthrax JOSEPH LISTER, 1st Baron Lister (1827–1912) - a pioneer of antiseptic surgery

PUERPERAL INFECTION Diagnosis History: antepartum infection, the obstetric record Physical examination: throat, heart, breasts, abdomen, legs (to exclude venous thrombosis) Local investigations (vaginal speculum examination + vaginal smear, bimanual examination) Laboratory investigations (swabs to determine the predominant bacteria and sensitivity to antibiotics, urine for microscopic examination and culture, hemoglobin, leukocyte count).

PUERPERAL INFECTION Bacteriology aerobes: Group A, B and D streptococci, Enterococus, staphylococcus aureus, Escherichia coli, Klebsiella, Proteus; anaerobes: peptococcus, Peptostreptococous, B.fragilis, Clostridium, Fusobacterium; other: Mycoplasma hominis, Chlamydia trachomatis.

PUERPERAL INFECTION Mode of infection bacteria, particularly anaerobes (60%), normal inhabitant of the vagina become pathogenic when reduced maternal resistance damaged vaginal tissues (proteolytic action on devitalized tissue) placental remnants in the uterus staphylococcal infections (40%), introduced by the patient → autogenous transmission, by the attendants, or the environment → exogenous transmission.

Site and spread of infection PUERPERAL INFECTION Site and spread of infection depend upon their virulence and the resistance of the patient to invasion (anemia, PE, diabetes, malnutrition, dehydration, shock, instrumental or operative deliveries) the placental site → a large wound

PUERPERAL INFECTION Infection of vulva, vagina and cervix Infection of an episiotomy wound → perineal pain, discharge, the wound edges are swollen and red. Treatment: antibiotics the sutures have to be removed, secondary repair.

PUERPERAL INFECTION Endometritis and myometritis the most frequent puerperal infection. In most cases, the infection is limited to the endometrium (protective mechanisms). onset – day 3-6 after delivery, the clinical evolution depends upon the virulence of the organisms. the lochia becomes darker, increases in quantity and has a bad smell; pyrexia, shivering, headaches, malaise, tachycardia. physical examinations - tender and large painful uterus. Treatment: good drainage from the uterus (utero-tonics) antibiotics.

PUERPERAL INFECTION Salpingitis - the uterine tube becomes swollen and tender. Pelvic cellulitis - Spread may be lateral to involve the connective tissues of the cardinal ligaments. in the 2 nd week of the puerperium - lower abdominal pain, tender abdomen vaginal examination → tenderness in the vaginal fornix, with relative fixation of the cervix.

PUERPERAL INFECTION Pelvic peritonitis Generally unwell patient, pyrexia, disproportionate tachycardia, vomiting and paralytic ileus, low abdominal pain and tenderness, tenderness in the vaginal fornices, pain on manipulating the uterus. Suppuration → local abcess, in Douglas pouch (vaginal / rectal examination). Diarrhea - inflammation and irritation of the adjacent rectum. A pelvic abscess may burst spontaneously into the rectum or posterior vaginal fornix, or can be drained by posterior colpotomy.

PUERPERAL INFECTION Generalized peritonitis Treatment after abdominal delivery (unrecognized uterine rupture, bowel trauma), or as continuation of localized infection. absent classic signs of pain, tenderness and rigidity, clear illness, toxic, often dehydrated, high fever, rapid pulse, vomiting, ileus. Treatment Intravenous fluid and electrolytis, gastric aspiration laparotomy (unless rapid improvement) for diagnostic, drainage and repair or removal of damaged organs.

PUERPERAL INFECTION Septicemia virulent organisms (group A hemolitic streptococci) + low resistance acute illness, swinging pyrexia, rapid pulse, mental confusion thrombophlebitis of the uterine veins → infected clots may be carried to distant organs, particularly the lungs to produce further symptoms.

PUERPERAL INFECTION Prophylaxis General measures: septic foci → treated in antenatal period; surgical asepsis during labor; vaginal examinations in labor must only be performed after the hands have been scrubbed and sterile gloves worn.

PUERPERAL INFECTION Treatment Antibiotic therapy The type of antibiotic, combination of antibiotics depend on the severity of the infection. In early severe sepsis → intravenous administration of Penicillins 4-6g/24 hours every 12 hours intravenously) or cefotaxim (2 g every 12 hours) + Gentamycin (80 mg per dose, in 3 divided doses; 240 mg/day + Metronidazole (500 mg every 8 hours). Surgical treatment – in generalized peritonitis → laparotomy and large drainage with or without hysterectomy and adnexectomy.