Infection and Disorders of the Puerperium

CHAPTER 24 INFECTION & DISORDERS OF THE PUERPERIUM


July 5, 1999


1 st Year Resident, Oh Sang-Yun MD

Puerperal Infection


Any bacterial infection of the genital tract after delivery

One of the lethal triad of causes of maternal deaths

About 4 % of maternal deaths (1998 Rochat and colleagues)

About 8 % of maternal deaths (1990 Atrash)

1. Puerperal Fever



Temperature 38.0° or higher, temperature to occur on any 2 of the first 10 days postpartum, exclusive of the first 24 hours, and to be taken by mouth

by a standard technique at least four time daily


2. Differential Diagnosis of Fever



1) Genital tract infection

20 % of febrile women delivered vaginally

70 % of febrile women delivered by cesarean section

                   
A high spiking fever ( > 39 or higher) developing within the first 24 hours after birth  very

                   
virulent pelvic infection caused by either group A or group B streptococcus

2) Respiratory complication

        Include atelectasis, aspiration
pneumonia, bacterial pneumonia

        Most often seen within 24 hours following delivery

        Invariably in women delivered by cesarean section

3) Pyelonephritis

        Bacteriuria, pyuria, CVA tenderness, spiking fever : typical picture

4) Breast engorgement

        About 15 % of all postpartum women

        Rarely exceed 39, no longer than 24 hours

        Complicated bacterial mastitis

5) Thrombophlebitis

        At superficial or deep veins

        Painful, swollen leg, calf tenderness, femoral triangle tenderness : typical symptoms


II Postpartum uterine infection



Called variously endometritis, endomyometritis, endoparametritis - prefer the term metritis with pelvic cellulitis

Relatively uncommon following uncomplicated vaginal delivery

Major problem in women delivered by cesarean section

          The route of delivery is the single most significant risk factor for the development of postpartum uterine infection

1. Vaginal Delivery



The incidence of metritis following vaginal delivery :1.3 ~ 2.6%


1) High risk

 

                 
Prolonged membrane rupture and labor

                 
Multiple cervical examination

                 
Internal fetal monitoring

                 
Adverse fetal outcomes - stillbirth, LBW, preterm delivery, serious neonatal morbidity

2. Cesarean Delivery



The incidence of metritis   various, prior to use of antimicrobial prophylaxis -> about 13~27 %


1) High risk

                 
Duration of labor

                 
Membrane rupture

                 
Multiple cervical examination

                 
Internal fetal monitoring

3. Predisposing causes





                 
Lower socioeconomic status

                 
Racial difference

                 
Anemia -> transferrin, significant antimicrobial action but iron deficient
anemia not predispose   to infection

                 
Nutrition -> although cell mediated immunity is impaired, unclear

                 
Colonization of the lower genital tract

                 
Group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis, Gardnerella
vaginalis

                 
Chorioamnion colonization with Ureaplasma urealyticum with intact membrane
in women

                 
delivered by cesarean section

                 
Abdominal twin delivery

                 
Maternal age :  44 % < 17 years, 15 % > 35 years

4. Bacteriology



Organisms that normally colonize the cervix, vagina, and perineum  invade the placental implantation  site, incisions and laceration site, but these organism

are relatively low virulent.

Exogenous organism more virulent

1) Common pathogen

    Aerobes


                 
Group A, B and D streptococci

                 
Enterococcus

                 
Gram negative bacteria - E.coli, Klebsiella, proteus

                 
S. aureus

    Anaerobes

 

                 
Peptococcus

                 
Peptostreptococcus

                 
B. fragilis, B.disiens

                 
Clostridium

                 
Fusobacterium

    Other

 

                 
Mycoplasma hominis

                 
Chlamydia trachomatis

Relatively low virulence

Become pathogenic as a result of hematoma and devitalized tissue

From cultures of amnionic fluid obtained at cesarean section performed
in women in labor with

membranes ruptured more than 6 hours, amnionic fluid culture results
are likely to be following:

 

          Aerobic and anaerobic
: 63 %

          Anaerobic :
30 %

          Aerobic : 7
% (Gilstrap and Cunningham 1979)

Predominant anaerobic organisms

          Peptostreptococcus
and peptococcus species (gram-positive cocci) : 45 %

          Bacteroides
species : 9 %

          Clostridium
species : 3 %

Gram positive aerobic organisms

          Enterococcus
: 14 %

          Group B streptococcus:
8 %

E. coli 9 %

2) Pathogenesis

Metritis following cesarean section (Glistrap and Cunningham 1979)




5. Clinical course


Fever occurs postpartum -> uterine infection should be suspected

Fever -> proportional to the extent of infection, more commonly, temperature exceeds 38.3

Chills with fever -> suggest bacteremia

Usually complain of abdominal pain

Abdominal tenderness and parametrial tenderness on bimanual examination

Foul-smelling lochia, but group A - hemolytic streptococcus, scanty, odorless lochia

Leukocytosis : 15000 ~ 30000 but DDx physiologic leukocytosis

6. Treatment of Metritis



Mild cases following vaginal delivery - oral agent may suffice

Moderately to severely infected women ( including cesarean section)
- parentral therapy with broad

spectrum antimicrobial regimen

Improvement in 48 to 72 hours in nearly 90 %

Complication of metritis that cause persistent fever despite appropriate therapy

  - parametrial phlegmons, intense cellulitis, surgical incisional and pelvic abscess, infected hematomas, septic pelvic thrombophlebitis



1) principles of antimicrobial treatment

Initial antimicrobial therapy - empirical

Treatment following cesarean delivery - directed against at least most of polymicrobial and mixed flora that typically cause puerperal infections

Infection following vaginal delivery - broad-spectrum coverage responds to regimen such as ampicillin and gentamicin

Post-cesarean section : importance of including anaerobic coverage, only 60~70 % have a satisfactory  response to ampicillin and gentamicinh

The spectra of beta-lactam antimicrobials

Against many anaerobic pathogens

Safe except for allergic reaction

Cost-effective

-cephalosporin (cefoxitin, cefoperazone, cefotetan, cefotaxime, ceftizoxime)

-extended spectrum penicillin (piperacillin, ticarcillin, mezlocillin)

-beta-lactamase inhibitor - clavulanic acid, sulbactam, tazebactam - effective

clindamycin-gentamicin - 95 % response

clindamycin - effective against anaerobes

                   
induce pseudomembranous colitis by overgrowth of resistant enterotoxin-producing clostridium diffcile

enterococcal infection -> higher incidence of wound infection - addition of ampicillin


metronidazole

        against most anaerobes

        combination with either gentamicin or tobramycin

        especially if an abscess is suspected

                   
use of metronidazole plus ampicillin and aminoglycoside   coverage against most organisms

                   
encountered in serious pelvic infection

imipenem

        Broad spectrum coverage

        Reserve for more serious
infection (such as abscess) and for antimicrobial failure


Chloramphenicol

        Combination with one of the beta-lactam antimicrobials -> excellent coverage for severe pelvic sepsis

        Achieving good serum level following oral administration   useful in poor venous access

        Side effect   bone marrow suppression


7. Complication of uterine infection



1) Wound infection

Incidence of abdominal incisional infection : 3~15 %, average 6 %, but prophylactic antibiotics < 2 %

Risk factors


          Obesity

          Diabetes

          Corticosteroid

          Immunosuppression

          Anemia

          poor hemostasis with hematoma formation

          Abdominal twin delivery


Incisional abscesses following cesarean section - fever begin on about the fourth postoperative day - treatment: antimicrobial therapy and surgical

drainage, if fascia is not intact - secondary closure


2) Necrotizing fascitis

Life-threatening infection, rare but high mortality

Commonly isolated bacteria

    Aerobes


                 
Group A, B and D streptococci

                 
Enterococcus

                 
Gram negative bacteria - E.coli, Klebsiella, proteus

                 
S. aureus

    Anaerobes

 

                 
Peptococcus

                 
Peptostreptococcus

                 
B. fragilis, B.disiens

                 
Clostridium

                 
Fusobacterium

    Other

 

                 
Mycoplasma hominis

                 
Chlamydia trachomatis

Risk factors

          DM

          Obesity

          IV drug abuse

          Age over 50
years

          Hypertension

          Malnutrition

          Peripheral vascular
disease

          Malignancy

          Cirrhosis

Treatment: broad-spectrum antibiotics and extensive surgical debridement

3) Peritonitis

Uterine infection may extend by way of the lymphatics to reach the abdominal
cavity and cause peritonitis

Rare, but may be encountered with infection following cesarean section
when there is uterine incisional necrosis and dehiscence

Symptoms: resemble surgical peritonitis except that abdominal rigidity
is less prominent because of abdominal stretching associated with pregnancy

          Severe pain

          Fever with adynamic
ileus

          Marked bowel distension due to paralytic ileus

Course

    Pelvic infection  pelvic cellulitis  parametrial or adnexal abscess, if rupture - catastrophic generalized peritonitis

Treatment

    Principles

                 
Infection began in the uterus and extended into peritoneum -medical treatment

                 
Bowel lesion or uterine incisional necrosis causes peritonitis - surgical
treatment

    Antibiotics : agents most likely effective against
Peptostreptococcus, Peptococcus, Bacteroides, Clostridia, aerobic coliforms

    Fluid and electrolyte balance

    Continuous nasogastric suction -> GI decompression ;

4) Adnexal infections

Perisalpingitis without subsequent tubal occlusion and sterility - most often

Ovarian abscess - rare, usually unilateral, present 1~2 weeks after delivery, if rupture -> peritonitis ->  surgical exploration


5) Parametrial phlegmon
Metritis following cesarean delivery -> parametrial cellulitis -> an area of induration within the leaves of the broad ligament, termed a phlegmon

More often unilateral

Frequently limited to the base of the broad ligament

Clinical findings : peritonitis

Treatment

        One of the intravenous antimicrobial regimens -> usually remain febrile for 5 to 7 days

        Surgery is reserved for uterine incisional necrosis

6) Pelvic abscess

Supurative parametrial phlegmon -> forming a fluctuant broad ligament mass -> abscess rupture into peritoneal cavity -> life threatening peritonitis

CT findings

F24-5

Treatment

        Antibiotics and surgical
drainage

        Dissect anteriorly -> needle drainage directed by CT

        Dissect posteriorly -> colpotomy incision drainage


7) Pelvic hematoma

Following cesarean section, collections of blood -> in the bladder flap or in the broad ligament near the uterine incision

If infected  require drainage, usually aspirated using CT guidance


III Septic Pelvic Thrombophlebitis



1. Pathogenesis



Puerperal infection may extend along venous routes with resultant thrombophlebitis

Bacterial infection of the placental site -> thrombosed myometrial veins -> anaerobic bacterial proliferation -> ovarian veins involved -> Lt renal vein or vena

cava involved

This process is usually unilateral, more frequent on the right side

2. Clinical findings



Usually not ill appearance and be asymptomatic

Hectic fever spikes with chills

Lower abdomen, flank or both pain typically on the second or third postpartum day

Tender mass was palpable just beyond the uterine cornu

3. Diagnosis



CT

MRI

** Heparin challenge test: IV heparin -> lysis of fever -> diagnosis of pelvic phlebitis -> continuous heparin treatment

      But this was disproven by Brown and colleagues (1986)


4. Treatment



Continuous antimicrobial therapy

Complication

        Pul. Embolism, pleural effusions, pul. Infarction

Iv Infections of the Perineum, Vagina, and Cervix



Infection of perineal wound ( episiotomy incision, repaired laceration ) : relatively uncommon

Incidence: 0.05 ~ 0.35 %

1. Pathogenesis



Wound edges become red, brawny, swollen - sutures tear through the edematous tissues - wound edges necrosis - serous, serosanguineous, purulent

exudates - episiotomy breakdown and dehiscence

2. Predisposing factors





          Coagulation disorders

          Cigarette smoking

          HPV infection

          Typical symptoms: local pain, dysuria, urinary retention


3. Treatment




          Broad spectrum antimicrobial regimen and analgesics

          Drainage and sutures are removed and infected wound opened, classically, episiotomy dehiscence repair not be attempt for at least 3 to 4 months

          Once surface is free of infection and exudate, covered by pink granulation tissue repair can be attempt

4. Necrotizing fascitis



Rare but fatal complication

Deep soft tissue infection involving muscle and fascia

Predisposing factors: diabetes, immunosuppression

May extend to the thighs, buttocks and abdominal wall

Treatment: extensive debridement

Mortality: even if aggressive excision, it approaches 50 %


V Toxic shock syndrome



Acute febrile illness with severe multisystem derangement

Case-fatality: 10~15 %

Typical symptoms: fever, headache, mental confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, diarrhea, marked

hemoconcentration - renal and hepatic failure, DIC, circulatory collapse

Pathogen: S. aureus -staphylococcal exotoxin (TSST-1)- profound endothelial
injury
Most common in young women who use tampons

Treatment: supportive, similar to septic shock


          Massive fluid
replacement

          Mechanical ventilation
with PEEP, if severe dyspnea

          Renal dialysis

          Antimicrobial
therapy with specific antistaphylococcal drug