1. Infections in Pregnancy

2. Objectives of lecture To describe the main infectious complications during and after pregnancy To describe principles for prevention of infections To describe principles of treating infections

3. Magnitude of the problem Infections in pregnancy is a main cause of maternal deaths. Early pregnancy complications (septic abortion) Infections during pregnancy Infection after delivery

4. Types of infection Womb: septic abortion/chorioamnionitis/endometritis Wound: perineum, vagina, cesarean section Weaning: breast engorgement, mastitis or absces Water: Urine Tract Infection Wind: pneumonia (Walk:) Venous Tromboembolism Malaria Meningitis

5. Preventing infection Complications to abortion: Prevent adolescent pregnancies Prevent unwanted pregnancies Prevent unsafe abortions

6. Effects of the introduction in Romania in November 1966 of an anti abortion law, and legalization of abortion in December 1989

7. Preventing infections At the antenatal clinic Treat anaemia Treat worms Treat malaria and distribute bednets Screen for HIV Discuss good nutrition and maybe micronutrients Discuss hygiene

8. Preventing bacterial infections Clean procedures: Don’t wear watches or rings at work Cut you nails short Clean your hands before and after touching a patient - always Do not share soap and towel! Alcohol is the best desinfecter Keep the labour room clean and tidy

10. Preventing bacterial infections Good obstetric and surgical procedures Use sterile techniques Prevent and stop bleeding: Anaemia is a major risk factor for infection and a hematoma is likely to become infected Avoid unnecessary episiotomies Do not perform cesarean section at a stilbirth unless on a vital indication

11. Preventing bacterial infection PPROM Treat with Ampicillin IV 2 g. STAT followed by 1 g/6 hrs until delivery At PROM >18-24 hrs: Treat with antibiotics as above Induce labour

12. Induction of labour If cervix is ripe: soft, short, open 2-3 cm: 10 IU oxytocin in one liter N/S or R/L Start dose: 12 drops/minute Each 15-20 minutes Increase by: 2-12 drops/minute Until desired effect Maximum dose: 80-84 drops/minute

13. Induction of labour If cervix is unripe: firm, long, closed: Induce with misoprostol: 25 mikrogram vaginally If no effect after 4 hours: 50 mikrogram vaginally Contraindication: previous c. section

14. Treating infections AT SEPSIS IV antibiotics – as per WHO guidance: AMPICILLIN 2g/6 hrs (streptococcal infections) GENTAMYCIN 5mg/kg/24hrs (gram negatives) FLAGYL 500mg/8 hrs (clostridium and anaerobes) If in a malaria risk area treat with QUININE 10 mg/kg in 5% dextrose IV over 4 hours/8 hrs At septic shock: DEXAMETAZONE 4 mg/kg IV/6 hrs

15. Treating infections A number of infections need surgical interventions because... Dead products of pregnancy, haematomas and abscesses are not reached by antibiotics In certain conditions Surgery should be performed immediately and not await ”antibiotic cover” becase... Some antibiotics like ampicillin are only in therapeutic levels for 15-30 minutes so a cover is not possible.

16. Treating bacterial infections Septic abortion: Surgical abortion must be performed immediately! Endometritis (puerperal sepsis): If no effect of antibiotics after 24-48 hrs D&C - or MVA. If no effect after further 24 hrs - Laparotomy Absces or infected hematoma: Drainage and revision when diagnosed All surgical procedures should be performed under ”antibiotic cover” that means giving antibiotics as surgery starts

17. Questions?