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Puerperium. puerperal fever ,and puerperal sepsis for undergraduate

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Undergraduate course lectuers in Obstetrics&Gynecology ,Faculty of medicine ,Zagazig University ,Prepared by DR Manal Behery – PowerPoint PPT presentation

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Title: Puerperium. puerperal fever ,and puerperal sepsis for undergraduate


1
  • Normal
  • puerperium
  • .

DR MANAL BEHERY Assistant Professor Zagazig
University 2013
2
Definition of Normal Puerperium
  • It is the period following delivery of the baby
    and placenta to 6 weeks postpartum.
  • It is the period during it ,the reproductive
  • organs maternal physiology returns towards the
    pre pregnancy state .

3
Divided into
  • First 24 hours
  • Early- up to 7 days
  • Remote- up to 6 weeks

4
Objectives
  • To monitor physiological changes of puerperium
  • To diagnose and treats any postnatal
    complications
  • To establish infant feeding
  • To advise about contraception

5
Physiological changes in Normal Puerperium
  • Changes in Genital Tract
  • Changes in breast and Lactation
  • Changes in other systems

6
Changes in Genital Tract
  • Involution of the Uterus
  • Lochia
  • Involution of Other Pelvic Organs
  • Menstruation

7
  • Uterine involution
  • A. Immediately after delivery
  • fundus palpable at
  • level of umbilicus
  • B. 10-14 days later,
  • At level of the
  • symphysis pubis.
  • C. 6 WKS post partun
  • non pregnant size

8
  • ? Decidua is cast off as a result of
    ischemia ? lochial flow
  • ? Lochia blood, leucocytes, shreds of
    decidua and organisms.
  • ? Initially dusky red3-4 days(rubra), fades
    after one-two week(serosa), clears within 4
    weeks of delivery(alba).
  • ? New endometrium grows from basal layer of
    decidua.

Endometrium Cavity
9
Cervix
  • It has reformed within several hours of
  • delivery
  • it usually admits only one finger by 1 weeks
  • the external os is fish-mouth-shaped
  • it return to its normal state at 4 weeks after
    birth

10
Ovarian function
  • Return of menstruation
  • non-nursing mothers
  • menstruation returns by 6 8 weeks.
  • nursing mothers
  • may develop lactating amenorrhea.
  • time of ovulation is 3 months in non-
  • breast -feeding women

11
Changes in Breast and Lactation
  • Mamogenesis (Mammary duct-gland growth
    dev.)
  • Lactogenesis (Initiation Of milk secretion
    in alveoli)
  • Galactopoiesis (Maintenance of Lactation)

12
Changes in other systems
  • Pulse slow
  • Temp. subnormal
  • Shivering
  • Fever up to first 24 hours
  • Hb. Rises
  • TLC increases
  • Diuresis- 2nd to 5th day post delivery

13
OTHER SYSTEMS
  • OTHER SYSTEMS
  • Bladder Urethra
  • - Within 2-3 weeks
  • Hydroureter and calycial dilatation of
    pregnancy is much less evident.
  • - Complete return to normal ? 6-8 weeks
  • Cardiovascular system
  • cardiac output plasma volume
    gradually returns to normal during the first 2
    weeks.
  • marked weight loss occurs in the
    first week as a result of the decrease of plasma
    volume and the deuresis of the extracellular
    fluid.

14
Management of Normal Puerperium
15
Daily round by physical staff should incluid
  • Uterus palpate uterine funds to evaluate level
    and tone
  • Abdomen examine for distension especially
    postoperative
  • Lochia for quantity ,and unusual odors
  • Perineum inspected for hematoma formation ,signs
    of infections, or wound breakdown.

16
  • Bladder function may be abnormal after traumatic
    delivery or epidural anethesia.
  • (Catheter may be left in place for 24 hr if there
    is marked periurtheral edema or repair).
  • Breasts examined for engorgement or signs of
    infection
  • Lungs evaluated in all post CS patients.
  • Extremities because post partum pt are at
    increased risk of DVT especially post CS.

17
Post partum immunization
  • Adminster a booster dose in Rubella non immune
    wommen or MMR vacine.
  • Adminster 300 ug of RhoGAM within first 72 hours
    after delivery to RH ve mothers .

18
Breast feeding should be Encouraged
  • Help in rapid uterine involution, decreased risk
    of ovarian ,breast cancer,osteprosis.
  • Women shouldn't breastfed if
  • Have infant with galactosemia
  • Are infected with HIV.
  • Have active untreated TB.
  • Are being treated for breast cancer.

19
Contraceptive advice
  • Breast feeding women shouldnt relay on lactation
    amenorrhea as a method of contraception (98
    protection in first 6 months provided that
    feeding every 4 hours daily ,6 hours at nigth
    ,formula supply 10-15)
  • Use a barrier method or hormonal contraception
    .POP 2-3 weeks postpartum
  • DMPA 6 weeks postpartum

20
Health nutrition education
Health nutrition education
  • Calorie need per day-2200700 2900
  • Care of MLE stitches if any
  • Care of nipples and areola
  • Sexual intercourse can be resumed after 6 weeks
    after delivery
  • Immunization of child

21
Puerperal fever
22
Definition
  • Temperatures reach 100.4F(38.0C) or higher on any
    two of the first 10 days postpartum, exclusive of
    the first 24 hours.
  •  

23
Benign single-day fevers following vaginal
delivery
  • Fever in the first 24 hours after delivery
    often resolves spontaneously and cannot be
    explained by an identifiable infection.

24
Significance
Significance
  • Fever is not an automatic indicator of puerperal
    infection.
  • A new mother may have a fever owing to prior
    illness or an illness unconnected to childbirth.
  • However, any fever within 10 days postpartum is
    aggressively investigated.
  • Physical symptoms such as pain, malaise, loss of
    appetite, and others point to infection.

25
Causes
  • Endometritis (most common),
  • Milk engorgment, Mastitis,breast abscess
  • Urinary tract infection
  • pneumonia\atlectasis,
  • CS ,perineal wound infection, fasiaties.
  • Septic pelvic thrombophlebitis.

26
  • uncommon complication usually
    develops after 2 4 weeks.
  • symptoms signs
  • low grade fever , chills , indurated ,red
    and painful segment of the breast.
  • caused by Staphylococcus aureus bacteria
    from the infants oral pharynx.

Mastitis
27
  • Mastitis

28
Treatment
  • Mother should start antibiotics
    immediately,
  • such as dicloxacillin for 7-10 days.
  • Breastfeeding may be discontinued so,
    breast pump can be used to maintain lactation .
  • however , suppression of lactation is
    advisable.
  • if a breast abscess develops , it should be
  • surgically drained.

29
Endometritis
  • 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.

30
Atelectasis
  • Caused by hypoventilation and is best prevented
    by coughing and deep breathing on a fixed
    schedule following surgery

31
Acute pyelonephritis Acute
  • Has a variable clinical picture, and postpartum,
    the first sign of renal infection may be fever,
    followed later by costovertebral angle
    tenderness, nausea, and vomiting.

32
Wound infections
  • Incisional abscesses that develop following
    cesarean delivery usually cause persistent fever
    beginning about the fourth day
  • Perineal infection uncommon , caused by bacterial
    contamination during delivery
  • Antimicrobials and surgical drainage, with
    careful inspection to ensure that the fascia is
    intact.

33
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34
Septic Thrombophlebitis
  • A dignosis of exclusion .
  • Thrombous spread by lymphatic's to the iliac
    vessels or directly via the ovarian vessels.
  • Suspected by intermittent spiky fever which
    fails to response to ordinary antibiotics and
    improved with heparin .

35
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36
Puerpral sepsis


37
  • Incidence
  • 3- 7 of all direct maternal deaths ,
    excluding deaths after abortion.
  • Etiology
  • Puerperal infection is usually poly
    microbial involves contaminants from the bowel
    that colonize the perineum and
    lower genital tract.

38
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39
Clinical course severity of the infection is
determined by
  • clinical course severity of the infection is
    determined by
  • 1. general health and resistance of the
    woman.
  • 2. virulence of the causative organisms.
  • 3. presence of predisposing factors as bl.
    Clots, hematoma or retained products of
    conception.
  • 4. timing of antibiotic therapy.

40
Risk factors
  • Prolonged PROM
  • Prolonged (more than 24 hours) labor
  • Frequent vaginal examinations
  • Retained products of conception
  • Hemorrhage
  • Anemia, poor nutrition during pregnancy.
  • Obesity.
  • Diabetes.

41
Risk factors (CONT ..)
  • Cesarean birth (20-fold increase in risk for
    puerperal infection).
  • Genital or urinary tract infection prior to
    delivery.
  • Urinary catheter
  • Fetal scalp electrode, internal FHR during
    labor.

42
Pathogenesis of puerperal sepsis
43
  • Puerperal infection following vaginal delivery
    primarily involves the placental implantation
    site, decidua and adjacent myometrium, or
    cervicovaginal lacerations.
  • Uterine infection following cesarean delivery is
    that of an infected surgical incision
  • Bacteria that colonize the cervix and vagina gain
    access to amnionic fluid during labor, and
    postpartum, they invade devitalized uterine
    tissue.

44
UTERINE INFECTIONS
  • Postpartum uterine infection has been called
    variously endometritis, endomyometritis, and
    endoparametritis.
  • Because infection involves not only the decidua
    but also the myometrium and parametrial tissues,
    the inclusive term metritis with pelvic
    cellulitis.

45
Predisposing factor
  • The route of delivery is the single most
    significant risk factor for the development of
    uterine infection
  • 1- to 6- incidence of metritis after vaginal
    delivery.
  • If there is intrapartum chorioamnionitis, the
    risk of persistent uterine infection increases to
    13

46
CESAREAN DELIVERY
  • Single-dose perioperative antimicrobial
    prophylaxis is given almost universally at CS
  • 10-50 incidence of metritis after CS
  • Women with CS after labor (risk factors
    factors) who were not given perioperative
    prophylaxis had a 90-percent serious pelvic
    infection rate

47
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48
Diagnosis
  • A. Clinical Picture
  • symptoms
  • fever ,rigors, malaise, headache.
  • vomiting and diarrhoea.
  • abdominal discomfort.
  • offensive lochia.
  • 2ry PP Hge.

49
  • Pyrexia and tachycardia
  • Uterus is large and tender
  • Parametrial tenderness (parametritis)or fullness
    in pelvis due to abscess is elicited on abdominal
    and bimanual examination
  • peritoneum and paralytic ileus (severe cases).

Signs
50
Investigations
  • 1. CBC anaemia, Leukocytosis may
    range from 15,000 to 30,000 cells/L, but recall
    that cesarean delivery itself increases the
    leukocyte count
  • 2. Coagulation Profile DIC.
  • 3 Arterial blood gas acidosis
    hypoxia. ( septiceamic shock)

51
Bacterial cultures
  • 4-Routine pretreatment genital tract
  • cultures are of little clinical use and
  • add significant costs
  • 5-Similarly, routine blood cultures
  • seldom modify care(25 ve in septic
  • Pelvic thrombo phelbities.

52
  • 6.Urine analysis white blood cell casts is
    diagnostic of pyelonephrities.
  • 7-Pelvic US
  • Retained products
  • Adnexal mass in pelvic abscess.
  • CT Occult abscess or thrombous in
    tthrombophelbities.

Investigations
53

Management
54
Prevention
  • Awareness of general hygiene principles
  • Good surgical technique with proper hemostasis.
  • Prophylactic antibiotics especially in
    emergency CS.a single intra operative dose of
    cphalosporin metronidazole.

55
Treatment
  • Begins with I.V. infusion of broad spectrum
    antibiotics and is continued for 48 hours after
    fever is resolved.
  • Surgery may be necessary to remove any remaining
    products of conception or to drain local lesions,
    such as an infected episiotomy .

56
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57
CLINDAMYCIN-GENTAMICIN REGIMEN
  • had a 95-percent response rate still considered
    by most to be the standard by which others are
    measured
  • Because enterococcal infections may persist
    despite this standard therapy, many add
    ampicillin to the clindamycin-gentamicin regimen,
    either initially or if there is no response by 48
    to 72 hours.

58
Patients with persistant fever despite
antibiotics TTT are assessed for
  • Ratained product of conception
  • Wound infection
  • Pelvic abcess
  • Ovarian vein thrombosis
  • Septic pelvic thrombophelbities.

59
Complications
60
  • 1- Metritis and parametitis.
  • 2. Pelvic abscess
  • 3 Pelvic Peritonitis
  • 4. Septic Thrombophlebitis

61
  • Fatal infection of skin ,fascia and muscle. It
    occurs in the perineal tears, episiotomy sites
    CS wounds.
  • caused by a variety of bacteria including
    anaerobes.

Necrotizing Fasciitis
62
  • Necrotizing fasciitis of the episiotomy site may
    involve any of the several superficial or deep
    perineal fascial layers, and thus may extend to
    the thighs, buttocks, and abdominal wall

63
  • in addition to signs of infection ,there is
    extensive necrosis
  • managed by surgical removal of the necrotic
    tissue under general anesthesia and
    split-thickness skin grafts

64
CASE SCENARIO
65
  • 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.

66
  • A diagnosis of postpartum endometritis was made
    and the infection was treated with Mefoxine 1 g
    IV Q8H.

67
  • 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 .
  • On Abdominal exam
  • Soft, flat abdomen
  • Tenderness on the right iliac fossa
  • No rebound-tenderness,
  • Mcburneys point (/-),Murphys sign(-),
  • Kindey region percussion (-).

68
investigation
  • Urinalysis was unremarkable.

69
On postpartum day four
  • The patients condition showed no improvement
    after antibiotic treatment,
  • An abdominal CT scan was obtained.
  • A right ovarian vein thrombosis was noted on the
    imaging.
  • Diagnosis ovarian vein thrombophlebitis

70
  • 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
  • After 6 weeks a CT scan was repeated. The right
    ovarian thrombosis was not present in the images
    and warfarin was discontinued

71
How to prevent ?
  • Avoid the risk factors
  • Keep the episiotomy site clean
  • Careful attention to antiseptic procedures during
    childbirth is the basic key of preventing
    infection.
  • Administer prophylactic antibiotics with
    Cesarean section, PROM, cardiac ,diabetic
    patients and with any uterine manipulation.

72
  • MCQ

73
Which change can be seen in puerperium?
  • A-maternal heart beat is increased 2 days after
    delivery
  • B- endometrium repair is resumed three weeks
    after delivery
  • C- Ureters will return to non pregnant state
    after 8 weeks
  • D- Vaginal rugae appear after 3 months from
    delivery
  • AnsC

74
Which is true about puerpural changes?
  • A- total number of uterine muscular cells is not
    reduced
  • B-vaginal rugae occur in the third month from
    delivery
  • C-uterine connective tissue wont change
  • D-uterine is re-epithelialized totally in the
    first week of pregnancy
  • AnsA

75
Which organism is the least responsible in
puerpural infection?
  • A- peptostreptococcus
  • B-enterococcus
  • C- chlamydia trachomatis
  • D-mycoplasma
  • AnsD

76
A patient comes to the clinic because of fever 4
days after C/S which persists 72 hours from
antibiotic administration. What is the most
likely reason of antibiotic failure?
  • A- wound infection
  • B- pelvic thrombophlebitis
  • C- pyelonephritis
  • D- adenexal infection
  • AnsA

77
What is wrong about puerpural immunization?
  • A- tetanus and diphtheria vaccine before
    discharge from hospital is advocated
  • B-a woman already injected measles vaccine does
    not need a booster dose
  • C- Rh negative women with an Rh positive newborn
    should take RhoGam
  • D- women who have never taken rubella vaccine
    should be vaccinated
  • AnsB

78
Which is wrong about fever after delivery?
  • A-fever more than 39 c in the first 24 hours
    after delivery is a sign of severe infection
  • B-fever in bacterial mastitis usually is late
    and persistent
  • C-pulmonary infection usually occurs in the first
    24 hours mostly after C/S
  • D-pyelonephritis is one of the most common reason
    of infection and is most often mistaken for
    pelvic infection
  • Ans D

79
A woman has gone through C/S 7 days ago . Three
days after the operation chills and fever
(enigmatic fever) occured. She is given
antibiotic with no improvement in her condition.
She doesnt look ill. What is your diagnosis?
  • A-pelvic abscess
  • B-parametrial phlegmon
  • C-pelvic septic thrombophlebitis
  • D-adenexal infection
  • AnsC

80
Who can lactate?
  • A- mother of a galactosemic newborn
  • B- mother with HBV
  • C- mother with active untreated TB
  • D-mother with breast herpetic lesions
  • AnsB

81
An infection after C/S which is not responsive
to clindagenta is because of
  • A-clostridium
  • B-enterococcus
  • C-bacteroid fargilis
  • D-chlamydia trachomatis
  • AnsB

82
What is true about lactation period mastitis?
  • A-It occurs in the last days of the first week
  • B- Most of the time it is bilateral
  • C-nose and throat of the newborn is the source of
    infection
  • D-it is mostly a result of coagulase-negative
    staph
  • AnsC

83
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