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Puerperal Infection

Infections Puerperal

A puerperal infection is defined as an infection in the mother during the first six weeks after delivery which is the period known as puerperium. A range of pathogens have been identified as potential causative agents, and various risk factors have been reported. Early recognition through a detailed clinical workup is mandatory, as sepsis and shock can develop and be fatal in the absence of proper therapy.


Presentation

Puerperal infection (also referred to as postpartum infection in the literature) represents maternal infection within six weeks after delivery, a period also known as the puerperium. Several risk factors have been established - prolonged rupture of membranes, postpartum hemorrhage (PPH), preexisting chorioamnionitis, the need for a cesarean section, anemia, primiparity and giving birth in unhygienic conditions (for example, home birth) [1] [2] [3]. A majority of the risk factors are related to birth-related events with most of the infections developing within 24 hours after labor [1]. However, one of the main factors in the pathogenesis of puerperal infections is the lack of adequate postnatal follow-up, which leads to delayed recognition and increased risk for complications [1]. The presence of a high fever (> 38°) is one of the most important signs of a puerperal infection, while additional symptoms are related to the type of infection [3] [4] [5]:

  • Endometritis - In the case of infection of the upper genital tract, fever is accompanied by bleeding, foul smelling lochia (uterine discharge after birth) and uterine tenderness [5]. Enterobacteriaceae such as Escherichia coli, Klebsiella pneumoniae, Proteus spp., staphylococci, enterococci, and streptococci, as well as Bacteroides and Prevotella spp. have been identified as causative agents [5]
  • Surgical site infections - Cesarean delivery unequivocally predisposes women to a puerperal infection, which is why prophylactic antibiotic therapy is always necessary. Unfortunately, between 3-15% of women suffer from an infection at the site of the surgical incision, and localized pain is the main symptom [5]. Recognized risk factors are diabetes mellitus, obesity, previous use of corticosteroids and preexisting infections [3] [4]. Enterococci, anaerobic bacteria, and group B streptococcus are described as causes [5].
  • Urinary tract infections (UTIs) - Important for their propensity to progress to disseminated infections and even sepsis, UTIs are important to recognize early on, although only a quarter of women with a UTI will complain of dysuria and UTI-specific symptoms [5].
  • Mastitis - Depending on the severity of infection, puerperal mastitis can present as unilateral breast tenderness with swelling in milder cases, or diffuse bilateral discomfort, pain and the formation of abscesses in severe forms, causing fever and malaise [5]. Staphylococcus aureus and coagulase-negative staphylococci are documented causes [5].
  • Sepsis - Responsible for about 15% of all maternal deaths and considered to be one of the most important causes of maternal death, puerperal sepsis is a life-threatening systemic infection predominantly caused by group A streptococcus [2] [4] [6] [7]. Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints [1].
  • Septic pelvic thrombophlebitis (SPT) and episiotomy infections - SPT denotes the infection of the pelvic veins with a significant risk for systemic dissemination, and symptoms such as pain and fever in spite of antibiotic therapy [5]. Episiotomy infections are quite rare, but still important causes of infections in the puerperium, with symptoms of local swelling, purulent discharge, pain, and fever in most severe cases [5].
  • Respiratory infections - Influenza virus, particularly in the developing countries, remains an important cause of maternal death, and the appearance of symptoms suggestive of a respiratory tract infection must be taken seriously [4] [5].
Fever
  • Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints.[symptoma.com]
  • 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.[medical-dictionary.thefreedictionary.com]
  • Streptococci: Sore throat; Scarlet fever, Impetigo, Bacterial endocarditis, Rheumatic fever, Acute glomerulonephritis.[biologydiscussion.com]
  • While the vast majority of these are due to infection of the genital tract, fever has many other potential causes, as described below.[sharinginhealth.ca]
  • Compared with the non-carriers, the carrier patients without prophylaxis had a significant increase in the mild puerperal infective morbidity, when defined as the proportion of women with an index fever greater than or equal to 10 (10.6% vs. 25%).[ncbi.nlm.nih.gov]
Chills
  • The ovarian veins may then become involved because they drain the upper uterus CLINICAL FINDINGS - display some clinical improvement of their pelvic infection following antimicrobial treatment, however continue to have fever - asymptomatic except for chills[wattpad.com]
  • Note presence of chills or reports of anorexia or malaise. Rationale: Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status.[freenursingcareplan.blogspot.com]
  • Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6 C (102 to 104 F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy.[rnpedia.com]
  • […] parametritis: an infection of the areas around the uterus Symptoms and signs may include: fever pain in the lower abdomen or pelvis caused by a swollen uterus foul-smelling vaginal discharge pale skin, which can be a sign of large volume blood loss chills[healthline.com]
  • Note presence of chills or reports of anorexia or malaise. Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status.[nurseslabs.com]
Malaise
  • Mastitis, or breast infection, is indicated by fever, malaise, achy muscles, and reddened skin on the affected breast. It is usually caused by a clogged milk duct that becomes infected.[medical-dictionary.thefreedictionary.com]
  • Mastitis - Depending on the severity of infection, puerperal mastitis can present as unilateral breast tenderness with swelling in milder cases, or diffuse bilateral discomfort, pain and the formation of abscesses in severe forms, causing fever and malaise[symptoma.com]
  • Note presence of chills or reports of anorexia or malaise. Rationale: Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status.[freenursingcareplan.blogspot.com]
  • Note presence of chills or reports of anorexia or malaise. Elevations in vital signs accompany infection; fluctuations, or changes in symptoms, suggest alterations in client status.[rnpedia.com]
High Fever
  • The presence of a high fever ( 38 ) is one of the most important signs of a puerperal infection, while additional symptoms are related to the type of infection: Endometritis - In the case of infection of the upper genital tract, fever is accompanied by[symptoma.com]
  • The DHS collected information on four obstetrical complications: prolonged labour, excessive bleeding, convulsions and high fever with foul smelling discharge.[journals.plos.org]
  • Signs and symptoms of peritonitis include high fever, rapid pulse, abdominal pains, nausea, vomiting, and restlessness. Nursing Management 1. Promote resolution of the infectious process.[rnpedia.com]
  • There is high fever, rapid pulse, vomiting and absent intestinal sounds due to paralytic ileus. Thrombophlebitis Extension of infection to the pelvic veins leads to high fever, rapid pulse and deep seated pelvic pain.[gfmer.ch]
  • Foul smelling secretion from the uterus, sometimes it may be consisting of pus High fever greater than 38 degree centigrade or 100.4 degree Fahrenheit Chills Abdominal cramps Tenderness and pain in the uterus Failure of uterus to resume to the normal[beingtheparent.com]
Puerperal Pyrexia
  • Puerperal pyrexia: a review. Part I. Obstetrical and Gynecological Survey 62: 393-399. Maharaj, Dushyant. 2007. Puerperal pyrexia: a review. Part II. Obstetrical and Gynecological Survey 62: 400-406. Mitchell R. 1937. Puerperal Infection.[sharinginhealth.ca]
  • Results: During this period, there were 122 cases of puerperal pyrexia. Puerperal pyrexia accounted for 6.28% of 1945 admissions. Most of the women were aged between 20-29 years, primiparous and booked cases with absent membranes.[nepjol.info]
  • However, the possibility of septicaemia and lasting sequelae or even death mean it is important to treat all cases of puerperal pyrexia early and aggressively.[patient.info]
  • Diagnosis of the Cause of Puerperal Pyrexia History Pre-existing infection before labour as chest or urinary tract infection. Symptoms of infection else where as cough, dysuria, breast pain or sore throat.[gfmer.ch]
  • Dushyant M, Teach DT (2007) Puerperal pyrexia: A Review. Part 1. Obstetrical and Gynaecological Survey 62: 393-399. Wold Health Organisation (1995) The prevention and management of puerperal Infection, report of a technical working group. Geneva.[omicsonline.org]
Abdominal Pain
  • Parametritis (pelvic cellulitis) commonly produces elevated temperature of more than 38.6 C (102 to 104 F), chills, abdominal pain, subinvolution of uterus, tachycardia, and lethargy.[rnpedia.com]
  • The major symptoms of a genital tract infection include fever, malaise, abdominal pain , uterine tenderness, and abnormal vaginal discharge. If these symptoms do not respond to antibiotic therapy, an abscess or blood clot may be suspected.[medical-dictionary.thefreedictionary.com]
  • pain fever with chills occasionally blood stained urine If it is due to thrombophlebitis the patient may complain of pain in the limb engorged veins deep vein thrombosis symptoms may not be found Physical Exam Possible physical findings (depending on[sharinginhealth.ca]
  • If a participant was readmitted to the hospital during the follow-up period with a fever (≠38 C) and one or more of the following: abnormal malodorous vaginal discharge, abdominal pain or bleeding, she was classified as having puerperal sepsis.[sajog.org.za]
  • Patients with low-grade fever and no abdominal pain are evaluated for other occult causes, such as atelectasis , breast engorgement , breast infection , UTI, and leg thrombophlebitis . Fever due to breast engorgement tends to remain 39 C.[merckmanuals.com]
Uterine Tenderness
  • At the time of uterine tenderness (Day 2, postpartum), 4 of 5 patients had gram-stained lochial smears showing a predominance of gram-positive cocci.[ncbi.nlm.nih.gov]
  • Note subinvolution of uterus, extreme uterine tenderness. Rationale: Allows early identification and treatment; promotes resolution of infection.[freenursingcareplan.blogspot.com]
  • Note subinvolution of uterus, extreme uterine tenderness. Allows early identification and treatment; promotes resolution of infection.[nurseslabs.com]
  • The major symptoms of a genital tract infection include fever, malaise, abdominal pain , uterine tenderness, and abnormal vaginal discharge. If these symptoms do not respond to antibiotic therapy, an abscess or blood clot may be suspected.[medical-dictionary.thefreedictionary.com]
Pelvic Pain
  • Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints.[symptoma.com]
  • One of pelvic pain, abnormal vaginal discharge, abnormal odour or discharge, or a delay in the reduction of uterine size must also be present.[sharinginhealth.ca]
  • Symptoms are uterine tenderness, abdominal or pelvic pain, fever, malaise, and sometimes discharge. Diagnosis is clinical, rarely aided by culture. Treatment is with broad-spectrum antibiotics (eg, clindamycin plus gentamicin ).[msdmanuals.com]
  • It commonly presents with fever, pelvic pain and foul-smelling vaginal discharge [ 9 ], and has been associated with neonatal sepsis [ 10 , 11 ].[journals.plos.org]
Foul Smelling Vaginal Discharge
  • A 25 year old woman (G1P1) presents to your clinic eight days postpartum, complaining of a temperature of at least 38.5 degrees Celsius over the past 3 days, and a foul-smelling vaginal discharge.[sharinginhealth.ca]
  • vaginal discharge pale skin, which can be a sign of large volume blood loss chills feelings of discomfort or illness headache loss of appetite increased heart rate Symptoms may take several days to appear.[healthline.com]
  • It commonly presents with fever, pelvic pain and foul-smelling vaginal discharge [ 9 ], and has been associated with neonatal sepsis [ 10 , 11 ].[journals.plos.org]

Workup

Because life-threatening sepsis and shock may develop from puerperal infections, an early diagnosis is pivotal in reducing maternal morbidity and mortality [1]. For this reason, the appearance of fever during the puerperium must raise suspicion about an infectious etiology. Firstly, a thorough patient history should be obtained, including information about the delivery (particularly if a cesarean section was performed), preexisting comorbidities and risk factors, as well as evaluation of additional symptoms, if present. A detailed physical exam could potentially determine the focus of the infection by observing localized pain, tenderness, swelling or other organ-specific symptoms [5], after which a complete laboratory workup is advised. A complete blood count (CBC), serum inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, or CRP and ESR, respectively), a full coagulation panel, urinalysis, and kidney function tests must be included in the initial workup [8]. In addition, microbiological testing for blood, urine, or breast milk cultures, and wound and genital swabs, is recommended [5] [8]. Besides bacterial organisms, influenza and human immunodeficiency (HIV) viruses have been established as important causes of maternal mortality, suggesting that the clinical workup should also assess lung function, and appropriate serological or molecular testing should be performed in the presence of a suspicion of HIV or influenza infection [4].

Treatment

  • The treatment in this study was both medical and surgical, blood transfusion was given in some cases with low hematocrit level.[ncbi.nlm.nih.gov]
  • Obstetricians should be alert to the importance of early diagnosis and treatment of this potentially lethal infection.[ncbi.nlm.nih.gov]
  • Developments in etiology and treatment of puerperal infection in the last 20 years are reviewed.[ncbi.nlm.nih.gov]
  • […] limited to the base of the broad ligament  The most common form of extension is laterally, along the base of the broad ligament, with tendency to extend to the lateral pelvic wall  In most women with a phlegmon, clinical improvement follows continued treatment[wattpad.com]
  • […] to top Treatments If the woman is unwell, she should be admitted and agressively treated.[sharinginhealth.ca]

Prognosis

  • Prognosis Antibiotic therapy and other treatment measures are virtually always successful in curing puerperal infections. Prevention Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection.[medical-dictionary.thefreedictionary.com]
  • Prognosis The majority of patients will make a full recovery with no lasting effects if treated speedily with appropriate antibiotic therapy and fluids.[patient.info]

Etiology

  • Developments in etiology and treatment of puerperal infection in the last 20 years are reviewed.[ncbi.nlm.nih.gov]
  • […] due to the underlying etiology.[icd10data.com]
  • For this reason, the appearance of fever during the puerperium must raise suspicion about an infectious etiology.[symptoma.com]
  • Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [] 3. Van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [] 4.[sajog.org.za]
  • “An Investigation into the Etiology of Puerperal Fever.” April 25, 1925. Available from: . Accessed March 5, 2008. ANON. “Haemolytic Streptococci.” October 3, 2005. Available from: . Accessed March 5, 2008. Ignaz Semmelweis.[austincc.edu]

Epidemiology

  • This is an epidemiological, prospective and non-concurrent study of the cohort type about puerperal infection from the perspective of humanized delivery care, based on information from 5,178 records of patients who went through the experience of humanized[ncbi.nlm.nih.gov]
  • Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [] 3. Van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: Epidemiology, etiology, and outcome. Curr Opin Infect Dis 2010;23:249-254. [] 4.[sajog.org.za]
  • Dillen JV, Zwart J, Schutte J, Roosmalen JV (2010) Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis 23: 249-254.[omicsonline.org]
  • Methods Statistics Trigonometry Medical & Nursing Anatomy Anesthesiology Audiology Bacteriology Biochemistry Bioethics Biomedical Science Cardiology Cardiovascular Childbirth Chiropractic Dentistry Dermatology Diagnostic Imaging Drugs Endocrinology Epidemiology[brainscape.com]
  • Maternal Mortality at Twelve Teaching Hospitals in Indonesia: An Epidemiological Analysis , p. 23. (New Delhi: New Roxy Press) Google Scholar Chow, A. M., Leake, R. D. (1974).[link.springer.com]
Sex distribution
Age distribution

Pathophysiology

  • PIP: This comprehensive review on puerperal infections covers risk factors, causative bacteria, pathophysiology, diagnosis, therapy of specific entities, and prevention.[ncbi.nlm.nih.gov]
  • The story according to James Pathophysiology Danielle's Story (Day 8) Severe Puerperal Sepsis- The pathophysiology. The body's immune response to an infection (bacterial or fungal) following the invasion of the body by microorganisms.[prezi.com]
  • […] socioeconomic status poor nutrition, anemia first birth prolonged membrane rupture, or prolonged labour multiple pelvic exams during labour instrumentation during delivery retention of placental fragments in the uterus postpartum hemorrhage return to top Pathophysiology[sharinginhealth.ca]
  • Pathophysiology 1. Causative organisms Aerobic organisms include beta-hemolytic streptococci, Escherichia coli, Klebsiella, Proteus mirabilis, Pseudomonas, Staphylococcus aureus, and Neisseria.[rnpedia.com]

Prevention

  • It is concluded that the use of chemoprophylaxis to prevent neonatal sepsis would probably be followed by a reduction in infectious puerperal morbidity.[ncbi.nlm.nih.gov]
  • Each of these is discussed in terms of contributing factors, microbiology, clinical findings, diagnosis, treatment, prevention and complications.[ncbi.nlm.nih.gov]
  • Methods Secondary analysis of low-risk nulliparas enrolled in a multicenter preeclampsia prevention trial. HOMA:IR was measured on fasting plasma glucose and insulin concentrations among low-risk nulliparas between 22 and 26 weeks' gestation.[ncbi.nlm.nih.gov]
  • Helps prevent cross-contamination. Instruct the proper disposal of contaminated linens, dressings, and peripads. Maintain isolation, if indicated. Prevents spread of infection.[nurseslabs.com]
  • Prevention Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection.[medical-dictionary.thefreedictionary.com]

References

Article

  1. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62(6):393-399.
  2. Zainur RZ, Loh KY. "Postpartum morbidity--what we can do". Med J Malaysia. 2006;61(5):651-656.
  3. Tita ATN, Andrews WW. Diagnosis and Management of Clinical Chorioamnionitis. Clin Perinatol. 2010;37(2):339-354.
  4. Buddeberg BS, Aveling W. Puerperal sepsis in the 21st century: progress, new challenges and the situation worldwide. Postgrad Med J. 2015;91(1080):572-578.
  5. Dalton E, Castillo E. Post partum infections: A review for the non-OBGYN. Obstet Med. 2014;7(3):98-102.
  6. Aronoff DM, Mulla ZD. Postpartum Invasive Group A Streptococcal Disease in the Modern Era. Infect Dis Obstet Gynecol. 2008;2008:796892.
  7. Mason KL, Aronoff DM. Postpartum Group A Streptococcus Sepsis and Maternal Immunology. Am J Reprod Immunol. 2012;67(2):91-100.
  8. Hamilton SM, Stevens DL, Bryant AE. Pregnancy-Related Group A Streptococcal Infections: Temporal Relationships Between Bacterial Acquisition, Infection Onset, Clinical Findings, and Outcome. Goldstein EJC, ed. Clin Infect Dis. 2013;57(6):870-876.

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Last updated: 2018-06-22 04:04