1. PUERPERAL SEPSIS
Fahad zakwan

2. PUERPERAL INFECTION
any bacterial infection
of the genital tract
after delivery

3. PUERPERAL FEVER
• Most persistent fevers after childbirth are caused by
genital tract infection
temperature – 38.0° C (100.4° F) or higher at 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 4 times daily
high spiking fever within first 24 hours  virulent infection
with group A strep

4. Attributable fever rarely exceeds 39°C in the first few
postpartum days and usually lasts less than 24 hours.
Acute pyelonephritis 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.
Atelectasis is caused by hypoventilation and is best
prevented by coughing and deep breathing on a fixed
schedule following surgery

5. 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.

6. •The route of delivery is the
single most significant risk
factor for the development of
uterine infection
•c/s more risky than SVD
PREDISPOSING FACTOR

7. VAGINAL DELIVERY
 Women at high risk for infection because of membrane rupture, prolonged labor, and
multiple cervical examinations have a 5- to 6-percent incidence of metritis after vaginal
delivery.
 If there is intrapartum chorioamnionitis, the risk of persistent uterine infection increases
to 13 percent
CESAREAN DELIVERY
 Single-dose perioperative antimicrobial prophylaxis is given almost universally at
cesarean delivery
 Important risk factors for infection following surgery ARE:
1. prolonged labor
2. membrane rupture, multiple cervical examinations,
3. internal fetal monitoring
Women with all of these factors who were not given perioperative prophylaxis had a 90-
percent serious pelvic infection rate

8. OTHER RISK FACTORS
• Lower socioeconomic status
• Group B streptococcus, Chlamydia trachomatis, Mycoplasma
hominis, Ureaplasma urealyticum, and Gardnerella vaginalis
• Cesarean delivery for multifetal gestation
• Young maternal age and nulliparity
• Prolonged labor induction
• Obesity
• Meconium-stained amnionic fluid

9. BACTERIOLOGY
group A -hemolytic streptococcus causing toxic shock-like
syndrome and life-threatening infection
skin and soft-tissue infections due to community-acquired
methicillin-resistant Staphylococcus aureus—CA-MRSA—have
become common
METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS
-these strains are not a common agent of puerperal metritis, but
they are causative in incisional wound infections.

12. BACTERIAL CULTURES
Routine pretreatment genital tract
cultures are of little clinical use and
add significant costs
Similarly, routine blood cultures
seldom modify care

13. PATHOGENESIS
 Puerperal infection following vaginal delivery primarily involves the
placental implantation site, decidua and adjacent myometrium, or
cervicovaginal lacerations.
 The pathogenesis of 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.
 With early treatment, infection is contained within the paravaginal
tissue but may extend deeply into the pelvis.

14. CLINICAL COURSE
Fever is the most important criterion for the diagnosis of postpartum
metritis.
Temperatures commonly are 38 to 39°C. Chills that accompany fever suggest
bacteremia.
Women usually complain of abdominal pain, and parametrial tenderness is
elicited on abdominal and bimanual examination
Although an offensive odor may develop, many women have foul-smelling
lochia without evidence for infection. Other infections, notably those due to
group A -hemolytic streptococci, are frequently associated with scanty, odorless
lochia
Leukocytosis may range from 15,000 to 30,000 cells/L, but recall that
cesarean delivery itself increases the leukocyte count

15. TREATMENT
If mild metritis develops after a woman has been
discharged following vaginal delivery, outpatient treatment
with an oral antimicrobial agent is usually sufficient.
 For moderate to severe infections, however, intravenous
therapy with a broad-spectrum antimicrobial regimen is
indicated. Improvement follows in 48 to 72 hours in nearly
90 percent of women treated with one of several regimens.

16. TREATMENT
PARAMETRIAL PHLEGMON—an area of intense
cellulitis; an abdominal incisional or pelvic abscess or
infected hematoma; and septic pelvic
thrombophlebitis.
The woman may be discharged home after she has
been afebrile for at least 24 hours. Further oral
antimicrobial therapy is not needed

18. CHOICE OF ANTIMICROBIALS
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.

19. Because of potential nephrotoxicity and ototoxicity
with gentamicin in the event of diminished glomerular
filtration, some have recommended a combination of
clindamycin and a second-generation cephalosporin
to treat such women.
Others recommend a combination of clindamycin
and aztreonam, a monobactam compound with
activity similar to the aminoglycosides

20. LACTAM ANTIMICROBIALS
( cephalosporins such as cefoxitin, cefotetan, and
cefotaxime, as well as extended-spectrum penicillins
such as piperacillin, ticarcillin, and mezlocillin)
 include activity against many anaerobic
pathogens
 are inherently safe and except for allergic
reactions, are free of major toxicity.

21. LACTAMASE INHIBITORS (CLAVULANIC
ACID, SULBACTAM, AND TAZOBACTAM)
 combined with ampicillin, amoxicillin, ticarcillin,
piperacillin to extend their spectra.
METRONIDAZOLE
 superior in vitro activity against most
 given with ampicillin and an aminoglycoside
provides coverage against most organisms
encountered in serious pelvic infections

22. CHOICE OF ANTIMICROBIALS
IMIPENEM
 a carbapenem that has broad-spectrum coverage
against most organisms associated with metritis
 used in combination with cilastatin, which
inhibits renal metabolism of imipenem
it is effective in most cases of metritis

23. PERIOPERATIVE ANTIMICROBIAL
PROPHYLAXIS
• Numerous studies have shown that prophylactic antimicrobials reduce the rate
of pelvic infection by 70 to 80 percent
• Single-dose prophylaxis with ampicillin or a first-generation cephalosporin is
ideal, and both are as effective as broad-spectrum agents or a multiple-dose
regimen
• Recent report of extended-spectrum prophylaxis with azithromycin added to
standard single-dose prophylaxis showed a significant reduction in
postcesarean metritis

24. TREATMENT OF VAGINITIS
•Prenatal treatment of asymptomatic vaginal
infections has not been shown to prevent
postpartum pelvic infections
•No beneficial effects for women treated for
asymptomatic bacterial vaginosis.

25. OPERATIVE TECHNIQUE TO PREVENT
POSTPARTUM INFECTION
Allowing the placenta to separate spontaneously compared with removing it
manually lowers the risk of infection, but changing gloves by the surgical team after
placental delivery does not .
Exteriorizing the uterus to close the hysterotomy may decrease
febrile morbidity
Similarly, infection rates are not appreciatively affected by closure versus nonclosure of the peritoneum
• Importantly, although closure of subcutaneous tissue in obese women does not lower the rate of wound
infection, it does decrease the incidence of wound separation

26. COMPLICATIONS OF PELVIC INFECTIONS
•In more than 90 percent of
women, metritis responds to
treatment within 48 to 72
hours

27. Clinical Course
• If without treatment  indolent course
 ultimate suppuration
• Fever after exclusion of other causes –
most important criterion for the
diagnosis of postpartum metritis

28. Treatment
• Mild Cases – Oral antibiotics
• Moderate to Severe – Parental therapy with broad spectrum
antimicrobial regimen, improvement within 48-72 hours
Complications that cause persistent fever
• Parametrial incision and pelvic abscesses
• Surgical incisional and pelvic abscesses
• Infected hematoma
• Septic pelvic thrombophlebitis

29. WOUND INFECTIONS
• When prophylactic antimicrobials are given as
described above, the incidence of abdominal
incisional infections following cesarean delivery is less
than 2 percent
• The incidence in some cases averaged 6 percent and
ranged from 3 to 15 percent
• Wound infection is a common cause of persistent
fever in women treated for metritis

30. WOUND INFECTIONS
Risk factors:
obesity
diabetes
corticosteroid therapy
immunosuppression
anemia
 poor hemostasis with hematoma formation

31. WOUND INFECTIONS
•Incisional abscesses that develop following
cesarean delivery usually cause fever or are
responsible for its persistence beginning about
the fourth day.
•Wound erythema and drainage usually
accompany it.
•Treatment includes antimicrobials and surgical
drainage, with careful inspection to ensure that
the fascia is intact.

32. WOUND INFECTIONS
With local wound care given two to three times daily, secondary
en bloc closure at 4 to 6 days of tissue involved in superficial wound
infection can usually be
With this closure, a polypropylene or nylon suture of appropriate
gauge enters 3 cm from one wound edge. It crosses the wound to
incorporate the full wound thickness and emerges 3 cm from the
other wound edge
 These are placed in series to close the opening. In most cases,
sutures may be removed on postprocedural day 10

33. WOUND DEHISCENCE
refers to separation of the fascial layer
serious complication and requires secondary closure of
the incision in the operating room
disruptions manifest about 5th post-op day with
serosanguineous discharges
TREATMENT
secondary closure of the incision with adequate anesthesia

34. Necrotizing Fasciitis
uncommon, severe wound infection is associated with high
mortality
 may involve abdominal incisions, or it may complicate
episiotomy or other perineal lacerations
RISK FACTORS:—diabetes, obesity, and hypertension—are
relatively common in pregnant women
caused by a single virulent bacterial species such as group A -
hemolytic streptococcus. Occasionally some are caused by
rarely encountered pathogens

35. Necrotizing Fasciitis
TREATMENT
Treatment consists of broad-spectrum antibiotics along
with prompt wide fascial debridement until healthy bleeding
tissue is encountered.
 With extensive resection, synthetic mesh may be required
to close the fascial incision
Clindamycin given with a beta-lactam antimicrobial -
most effective regimen

36. PERITONITIS
unusual for peritonitis to develop following cesarean
delivery
 It is almost invariably preceded by metritis and uterine
incisional necrosis and dehiscence.
Other cases may be due to inadvertent bowel injury at
cesarean delivery.
 Yet another cause is peritonitis following rupture of a
parametrial or adnexal abscess.
 It may rarely be encountered after vaginal delivery.

37. Abdominal rigidity may not be prominent with puerperal peritonitis
because of abdominal wall laxity from pregnancy
Pain may be severe, but frequently, the first symptoms of peritonitis are those of adynamic ileus.
Marked bowel distension may develop, and these findings are unusual
after uncomplicated cesarean delivery
If the infection begins in an intact uterus and extends into the
peritoneum, antimicrobial treatment alone usually suffices
Peritonitis caused by uterine incisional necrosis or bowel perforation
must be treated surgically

38. ADNEXAL INFECTIONS
Ovarian abscess  bacterial invasion through a vent in the
ovarian capsule
usually unilateral and present 1-2 weeks after delivery
Rupture is common and peritonitis may be severe
TREATMENT
drain and give antibiotics

39. Parametrial Phlegmon
In some women in whom metritis develops
following cesarean delivery, parametrial cellulitis is
intensive and forms an area of induration, or
phlegmon, within the leaves of the broad ligament
These infections should be considered when fever
persists longer than 72 hours despite intravenous
antimicrobial therapy

40. Parametrial Phlegmon
Phlegmons are usually unilateral, and they frequently
are limited to the parametrial area at the base of the
broad ligament
The most common form of extension is laterally along
the broad ligament, with a tendency to extend to the
pelvic sidewall.
Occasionally, posterior extension may involve the
rectovaginal septum, producing a firm mass posterior to
the cervix

41. Parametrial Phlegmon
Because puerperal metritis with cellulitis is typically a
retroperitoneal infection, evidence of peritonitis
suggests the possibility of uterine incisional necrosis, or
less commonly, a bowel injury

42. Parametrial Phlegmon Treatment
In most women with a phlegmon, clinical
improvement follows continued treatment with a
broad-spectrum antimicrobial regimen.
Typically, fever resolves in 5 to 7 days, but in some
cases, it is longer.
Absorption of the induration may require several
days to weeks.

43. Parametrial Phlegmon Treatment
Surgery is reserved for women in whom uterine
incisional necrosis is suspected
 In rare cases, uterine debridement and resuturing of
the incision are feasible.
For most, hysterectomy and surgical debridement are
needed and are predictably difficult
Frequently, the cervix and lower uterine segment are
involved with an intensive inflammatory process that
extends to the pelvic sidewall to encompass one or both
ureters
. The adnexa are seldom involved, and one or both
ovaries usually can be conserved

44. PARAMETRIAL PHLEGMON
On bimanual pelvic examination, a phlegmon is palpable as a firm,
three-dimensional mass

45. IMAGING TECHNIQUE
A.Pelvic computed tomography scan of dehiscence caused by infection of a vertical cesarean
incision. Endometrial fluid (small black arrows) communicates with parametrial fluid (curved
white arrows) through the uterine defect (large black arrow). A dilated bowel loop (b) is
adjacent to the uterus on the left. B. Supracervical hysterectomy specimen with instrument
through uterine dehiscence.

46. PELVIC ABSCESS
• parametrial phlegmon suppurates, forming a fluctuant broad
ligament mass that may point above the inguinal ligament
• Psoas abscess may rarely follow delivery
TREATMENT
• antimicrobial therapy
• percutaneous drainage

47. SEPTIC PELVIC THROMBOPHLEBITIS
• common complication in the preantibotic era
• With the advent of antimicrobial therapy, the mortality rate and need
for surgical therapy for these infections diminished
• Although there occasionally is pain in one or both lower quadrants,
patients are usually asymptomatic except for chills.
• Diagnosis can be confirmed by either pelvic CT or MR imaging

48. PATHOGENESIS OF SEPTIC PELVIC
THROMBOPHLEBITIS
Routes of extension of septic pelvic thrombophlebitis. Any pelvic vessel and the inferior vena
cava may be involved as shown on the left. The clot in the right common iliac vein extends
from the uterine and internal iliac veins and into the inferior vena cava.

49. TREATMENT OF SEPTIC PELVIC
THROMBOPHLEBITIS
• The addition of heparin to antimicrobial therapy for septic pelvic
thrombophlebitis did not hasten recovery or improve outcome.
• Certainly, there is no evidence for long-term anticoagulation as given
for "bland" venous thromboembolism.

50. Infections of the Perineum, Vagina, and Cervix
Episiotomy infections
are not common
because the operation
is performed much less
frequently now than in
the past.
Infection of a fourth-
degree laceration is
likely to be more
serious

51. Infections of the Perineum, Vagina, and Cervix
Local pain and
dysuria, with or
without urinary
retention, are
common
symptoms
most common
findings were pain
in 65 percent,
purulent
discharge in 65
percent, and fever
in 44 percent
Vaginal lacerations
may become
infected directly or
by extension from
the perineum. The
mucosa becomes
red and swollen
and may then
become necrotic
and slough.
Parametrial
extension may
result in
lymphangitis
• Cervical
lacerations are
common but
seldom are
noticeably
infected and
may manifest as
metritis.

52. TREATMENT
Infected episiotomies are
managed like other infected
surgical wounds. Drainage is
established, and in most
cases, sutures are removed
and the infected wound
debrided.
Cellulitis but no purulence,
broad-spectrum
antimicrobial therapy with
close observation may be
appropriate. With
dehiscence, local wound
care is continued along with
intravenous antimicrobials

53. Technique for Early Repair
• Most important is that the surgical wound must be properly cleaned
and free of infection
• once the surface of the episiotomy wound is free of infection and
exudate and covered by pink granulation tissue, secondary repair can
be accomplished
• Postoperative care includes local wound care, low-residue diet, stool
softeners, and nothing per vagina or rectum until healed

54. Dehiscence of fourth-degree episiotomy. Secondary repair is done when the wound surface
is free of exudate and covered by pink granulation tissue

56. Necrotizing Fasciitis
• rare but frequently fatal complication of perineal and
vaginal wound infections is deep soft-tissue infection
involving muscle and fascia
• Although women with diabetes or women who are
immunocompromised are more vulnerable, these
serious infections may develop in otherwise healthy
women

57. • 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

58. Necrotizing Fasciitis
Although some virulent infections, for example, from group A -
hemolytic streptococci, develop early postpartum, these
infections typically do not cause symptoms until 3 to 5 days after
delivery.
Clinical findings vary, and it is frequently difficult to differentiate
more innocuous superficial perineal infections from an ominous
deep fascial one.
 A high index of suspicion, with surgical exploration if the
diagnosis is uncertain, may be lifesaving

59. TREATMENT
Early diagnosis, surgical debridement, antimicrobials, and
intensive care are of paramount importance in the
successful treatment of necrotizing soft-tissue infections
Surgery includes extensive debridement of all infected
tissue, leaving wide margins of healthy tissue.
Mortality is virtually universal without surgical treatment,
and rates approach 50 percent even if extensive
debridement is performed.

60. TOXIC SHOCK SYNDROME
• acute febrile illness with severe multisystem derangement
• fever, headache, mental confusion, diffuse macular erythematous
rash, subcutaneous edema, nausea, vomiting, watery diarrhea,
marked hemoconcentration
• renal failure  hepatic failure, DIC  circulatory collapse

61. TOXIC SHOCK SYNDROME
• Staphylococcus aureus – toxic shock syndrome toxin – 1
– first associated with young menstruating women who used tampons
• Therapy : SUPPORTIVE, similar treatment with septic shock, anti-
staphylococcal antimicrobials, massive fluid replacement, mechanical
ventilation with PEEP, renal dialysis