Postpartum Infections

1. PostpartumPostpartum
InfectionsInfections
Timokhina E.V

2. Normal postpartum period:Normal postpartum period:
1. Lochia usually lasts for 5-6 weeks:1. Lochia usually lasts for 5-6 weeks:
several days - lochia rubraseveral days - lochia rubra
till the 10th – lochia serosatill the 10th – lochia serosa
then - lochia albathen - lochia alba
2. Diuresis is normalizing to the 2-5th day postpartum.2. Diuresis is normalizing to the 2-5th day postpartum.
Usually the capacity of the bladder is increasing and theUsually the capacity of the bladder is increasing and the
sensitivity is decreasing, that predispose to thesensitivity is decreasing, that predispose to the
postpartum urinary tract infectionpostpartum urinary tract infection
3. Uterus is contracted to the 5-6th week postpartum. The3. Uterus is contracted to the 5-6th week postpartum. The
uterine fundus is decreasing in 1-2 cm/dayuterine fundus is decreasing in 1-2 cm/day
4. Postpartum pains are normal in multipara4. Postpartum pains are normal in multipara

3. Normal postpartum period:Normal postpartum period:
5.In blood formula the leucocytes level is till5.In blood formula the leucocytes level is till
1515*109/l, the level of fibrinogen is increased*109/l, the level of fibrinogen is increased
during the I week postpartumduring the I week postpartum
6.Menses begins in 6-8 weeks in nonlactating6.Menses begins in 6-8 weeks in nonlactating
women, ovulation can happen in 2-4 weeks inwomen, ovulation can happen in 2-4 weeks in
nonlactating women and in 10 weeks in lactatingnonlactating women and in 10 weeks in lactating
womenwomen
7.Postpartum hemorrhage composes 0,5% from7.Postpartum hemorrhage composes 0,5% from
the body weight, and if it is more than 1% it isthe body weight, and if it is more than 1% it is
pathological hemorrhagepathological hemorrhage

4. Postpartum infection (6 weeks)Postpartum infection (6 weeks) - is any- is any
infection of birth canal in postpartuminfection of birth canal in postpartum
period, which is accompanied by highperiod, which is accompanied by high
temperature (more than 38temperature (more than 38 СС) during at) during at
least 2 days from the first 10 daysleast 2 days from the first 10 days
postpartum.postpartum.

5. Postpartum InfectionsPostpartum Infections
Frequency rate –
13,3 – 54,3 %

6. Classification of postpartumClassification of postpartum
infection of Sazonov-Bartelse:infection of Sazonov-Bartelse:
1. The infection is restricted by the labor wound1. The infection is restricted by the labor wound
postpartum endometritispostpartum endometritis
postpartum ulcerpostpartum ulcer
2. The infection is distributed from the labor wound, but is2. The infection is distributed from the labor wound, but is
locatedlocated
vulvitis - metritisvulvitis - metritis
colpitis - parametritiscolpitis - parametritis
paracolpitis - located thrombophlebitisparacolpitis - located thrombophlebitis
- adnecsitis- adnecsitis
- pelvioperetonitis- pelvioperetonitis

7. Classification of postpartumClassification of postpartum
infection of Sazonov-Bartelse:infection of Sazonov-Bartelse:
3. Distributed infection:3. Distributed infection:
Distributed peritonitisDistributed peritonitis
Infectious-toxic shockInfectious-toxic shock
Progressive thrombophlebitisProgressive thrombophlebitis
Anaerobic gas gangreneAnaerobic gas gangrene
4. Generalized infection: sepsis4. Generalized infection: sepsis

8. Postpartum InfectionsPostpartum Infections
Main forms:Main forms:
- endometritis – 13,9%- endometritis – 13,9%
- wound infection - 9,35%- wound infection - 9,35%
- peritonitis – 0,5%- peritonitis – 0,5%

9. Postpartum InfectionsPostpartum Infections
RRisk factorisk factors postpartums postpartum
infectious complications:infectious complications:
1.1. socio-economic statussocio-economic status
(low(low scale of livingscale of living))

10. Postpartum InfectionsPostpartum Infections
2.2. ExtagenitalExtagenital diseasediseasess:ss:
- hypertension,- hypertension,
- diabetes- diabetes
-obesity-obesity
- chronic pyelonephritis,- chronic pyelonephritis,
glomerulonefritisglomerulonefritis
- others infectious focus- others infectious focus
(tonsillitis and etc)(tonsillitis and etc)
- abdominal surgery during- abdominal surgery during
pregnancypregnancy

11. Postpartum InfectionsPostpartum Infections
3.3. Gynecological diseasesGynecological diseases::
- chronic inflammatory,- chronic inflammatory,
- bacterial vaginosis,- bacterial vaginosis,
- recurrence spontaneous and artificial- recurrence spontaneous and artificial
abortions,abortions,
- infertility- infertility
- myoma, endometriosis- myoma, endometriosis

12. Postpartum InfectionsPostpartum Infections
4.4. Pregnancy complications:Pregnancy complications:
Pregnancy – immunodeficiencyPregnancy – immunodeficiency
status (low amount lymphocytes, lowstatus (low amount lymphocytes, low
level Ig A,G)level Ig A,G)
-- impendingimpending early spontaneous abortion,early spontaneous abortion,
- isthmico-cervical unsufficiency, cervical- isthmico-cervical unsufficiency, cervical
cerclage;cerclage;
- i- impendingmpending preterm labor,preterm labor,

13. Postpartum InfectionsPostpartum Infections
- anemia,- anemia,
- intrauterine fetus infections,- intrauterine fetus infections,
- vaginitis, bacterial vaginosis during- vaginitis, bacterial vaginosis during
pregnancypregnancy

14. Postpartum InfectionsPostpartum Infections
- feto-placental insufficiently (intrauterine- feto-placental insufficiently (intrauterine
chronic hypoxia, intrauterine growthchronic hypoxia, intrauterine growth
retardation|),retardation|),
- abruption placentae, placenta previa.- abruption placentae, placenta previa.

15. Postpartum InfectionsPostpartum Infections
5.5. Complications of labour:Complications of labour:
- preterm labour,- preterm labour,
- preterm premature rupture of- preterm premature rupture of
membranes,membranes,
- dysfunctional labour: dystocia,- dysfunctional labour: dystocia,
labourlabour
enhancement,enhancement,
- recurrent vaginal examinations,- recurrent vaginal examinations,
- excess bleeding and postpartum- excess bleeding and postpartum
hemorrhagehemorrhage

16. Postpartum InfectionsPostpartum Infections
6.6. Operative delivery:Operative delivery:
- cesarean section,- cesarean section,
- obstetrician forceps.- obstetrician forceps.
7.7. Postpartum complications:Postpartum complications:
- uterine subinvolution- uterine subinvolution

17. Main infectious agentsMain infectious agents
0 5 10 15 20 25 30 35
others
Enterobacter sp.
Enterococcus
Ps. aeruginosa
Staphylococcus aureus
Proteus sp.
Escherichia coli
0 10 20 30 40 50
Others
Peptostreptococcus sp.
Peptococcus sp.
Bacteroides sp.
aerobicaerobic
anaerobicanaerobic

18. Postpartum InfectionsPostpartum Infections
Main forms of postpartumMain forms of postpartum
infectious complications:infectious complications:
1.1. Endomteritis.Endomteritis.
2.2. Wound infection after cesareanWound infection after cesarean
section (abdomen) or episiotomysection (abdomen) or episiotomy
3. Mastitis3. Mastitis
4. Peritonitis.4. Peritonitis.

19. EndometritisEndometritis
EndometritisEndometritis – inflammatory internal lay of– inflammatory internal lay of
uteri.uteri.
FrequencyFrequency::
–– after vaginal labour – 7-8%,after vaginal labour – 7-8%,
- after cesarean section – 30-35%- after cesarean section – 30-35%

20. EndometritisEndometritis
Clinics (classical variant)Clinics (classical variant)
1.1. Onset first symptoms on 3-5 day afterOnset first symptoms on 3-5 day after
labour;labour;
2.2. Weakness;Weakness;
3.3. Pyrexia, algor (increase tPyrexia, algor (increase t°° to 37,6-38to 37,6-38
CC°)°)

21. EndometritisEndometritis
5.5. Low abdomen painLow abdomen pain
6.6. Illness of external examination of uterusIllness of external examination of uterus
7.7. Subinvolution uteri and cervix of uterusSubinvolution uteri and cervix of uterus
8.8. Abnormal lochia (nonslight)Abnormal lochia (nonslight)
9.9. ↑↑ Leucocytes (granulocytes),Leucocytes (granulocytes), ↑↑
sedimentation erythrocytes ratesedimentation erythrocytes rate

22. EndometritisEndometritis
Today – till 40% - subacute processToday – till 40% - subacute process
((dominancedominance subpathogenicsubpathogenic floraflora ––
association aerobic and anaerobicassociation aerobic and anaerobic
bacteriumbacterium))
1.1. Slight pyrexia;Slight pyrexia;
2.2. NNormal stateormal state
3.3. Main symptoms –abnormal lochia,Main symptoms –abnormal lochia, ↑↑
Leucocytes (granulocytes),Leucocytes (granulocytes), ↑↑
sedimentation erythrocytes rate.sedimentation erythrocytes rate.

23. EndometritisEndometritis
Additional methods:Additional methods:
1. B1. Bacteriacteriological evaluation metroaspirationological evaluation metroaspiration
with sensitivity towardswith sensitivity towards antibioticsantibiotics;;
2. Ultrasonography –2. Ultrasonography – measurementmeasurement of sizeof size
of uterus, cavity,of uterus, cavity, suturesuture (cesaeren(cesaeren
section).section).
3. Hysteroscopy.3. Hysteroscopy.
,

24. Ultrasonography -Ultrasonography - differdiffer 22
forms of endometritisforms of endometritis
First variant -First variant -
DelayDelay in cavity ofin cavity of
uterus necroticuterus necrotic
decidua,decidua, bloodblood
clotclotss,, sometimessometimes
– parts of– parts of
placentae.placentae.
Second variant -Second variant -
basalbasal
endometritisendometritis
(“(“clearclear
endometritis”)endometritis”)

25. EndometritisEndometritis
First form ofFirst form of
endometritisendometritis
((extensionextension ofof
uteruc cavity)uteruc cavity)

26. EndometritisEndometritis
Second form ofSecond form of
endometritis –endometritis –
basal endometritisbasal endometritis
hyperechogenichyperechogenic
impuritiesimpurities in cavityin cavity
of uterusof uterus

27. EndometritisEndometritis
General Therapy
1.Main point - antibacterial therapy
(combination of antibiotic agents);
2. Infusional therapy (desintoxication) –
800-1200 ml i/v.
3.Immunotherapy;
4. Vitaminotherapy;
5. Rheological therapy.

28. Local therapyLocal therapy
First formFirst form
1.Hysteroscopy and instrumental
evaluation cavity of uterus (curetage)-
remove necrotic decidua, placental
parts.
2. Lavage of cavity of uterus with
antiseptic solutions.
3. Application in uterus hydrophilic
ointment

29. Local therapyLocal therapy
Second form – basal endometritisSecond form – basal endometritis
NO hysteroscopy
1. Lavage of cavity of uterus with
antiseptic solutions.
2. Application in uterus hydrophilic
ointment

30. Postpartum ulcer.Postpartum ulcer.
Can be in perineum, in vagina, in cervix.Can be in perineum, in vagina, in cervix.
The wound is covered with yellow spot, isThe wound is covered with yellow spot, is
bleeding, the tissues around are edematous andbleeding, the tissues around are edematous and
red. The fever lasts for 4-5 days and the woundred. The fever lasts for 4-5 days and the wound
is healed till the 10-12th day.is healed till the 10-12th day.
The treatment consists of hypertonic bandageThe treatment consists of hypertonic bandage
on the wound, antibiotics, and remove ofon the wound, antibiotics, and remove of
stitches.stitches.

31. Wound infectionWound infection
EtiologyEtiology
Staphylococcus aureus – 37- 69%;Staphylococcus aureus – 37- 69%;
Enterococcus – 11-28%Enterococcus – 11-28%
Streptococcus – 15%Streptococcus – 15%
Anaerobic bacteria – 9%Anaerobic bacteria – 9%

32. Wound infectionWound infection
Clinics
1.Onset on 3-8 days after cesarean section;
2. Weakness, pyrexia,
algor (increase t° to 37,6-38 C°);
3. Local symptoms: hyperemia, infiltration,
rubor, sickliness

33. Wound infectionWound infection
TreatmentTreatment
General therapy:
Antibacterial therapy;
Infusional therapy (desintoxication)
Immunotherapy;
Vitaminotherapy;
Rheological therapy.

34. Wound infectionWound infection
TreatmentTreatment
Local therapy:
First stage – clean wound
• Drainage, open wound;
• Lavage, drainage irrigation with
hypertonic solutions

35. Wound infectionWound infection
TreatmentTreatment
Local therapy:
Second stage – reparation,
regeneration
• Application ointment or
ointment swab
2. Sometimes – secondary sutures

36. Postpartum thrombophlebitis.Postpartum thrombophlebitis.
MetrothrombophlebitisMetrothrombophlebitis
Thrombophlebitis of pelvic veins. The danger ofThrombophlebitis of pelvic veins. The danger of
embolism is very high in thrombophlebitis ofembolism is very high in thrombophlebitis of
ovarian plexusovarian plexus
Deep venous thrombosisDeep venous thrombosis
Treatment consists of bed regimen with high legTreatment consists of bed regimen with high leg
position, leg bandage, antibiotics, spasmolytics,position, leg bandage, antibiotics, spasmolytics,
heparin, fibrinolysin, reopolyglukin together withheparin, fibrinolysin, reopolyglukin together with
trental.trental.

37. PeritonitisPeritonitis
Extremely seriously
complication
after operative delivery

38. PeritonitisPeritonitis
First form –First form – infectioninfection during cesareanduring cesarean
deliverydelivery
1.1. Risks factorsRisks factors: prolonged delivery,: prolonged delivery,
preterm rupture of membranes and longpreterm rupture of membranes and long
anhydramnion period.anhydramnion period.
2.2. OnsetOnset – on 2-3 days after cesarean– on 2-3 days after cesarean
delivery;delivery;

39. First form –First form – infectioninfection
during cesarean deliveryduring cesarean delivery
3.3. ClinicsClinics::
- intoxcations: hypertermia,tachycardia,- intoxcations: hypertermia,tachycardia,
tachypnoe; dryness skin andtachypnoe; dryness skin and
mucus;mucus;
- peritoneal symptoms;- peritoneal symptoms;
- intestinal paresis.- intestinal paresis.
4.4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑↑
young form neutrophyles)young form neutrophyles)

40. First form –First form – infectioninfection duringduring
cesarean deliverycesarean delivery
Tactics:Tactics:
Complex therapyComplex therapy::
- antibacterial;- antibacterial;
- infusional, desintoxacatinal,- infusional, desintoxacatinal,
- plasma infusional;- plasma infusional;
- rheological;- rheological;
- immunotherapy.- immunotherapy.

41. First form –First form – infectioninfection duringduring
cesarean deliverycesarean delivery
Hysterectomy
Failure therapy
during 18-24 hours

42. Second form of peritonitis –Second form of peritonitis –
peritonitis-paresisperitonitis-paresis
1.1. PatogenesisPatogenesis: failure: failure barrier functionbarrier function
of intestine;of intestine;
2. Onset2. Onset: 3-4 days after operative: 3-4 days after operative
delivery;delivery;

43. Second form of peritonitis –Second form of peritonitis –
peritonitis-paresisperitonitis-paresis
3. Clinics3. Clinics::
-- expressedexpressed intestinal paresis:intestinal paresis: swellingswelling
of abdomen;of abdomen;
- intoxications: hypertermia,- intoxications: hypertermia,
tachycardia, tachypnoe;tachycardia, tachypnoe;
dryness skin and mucus;dryness skin and mucus;
4.4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑↑
young form neutrophyles)young form neutrophyles)

44. Second form of peritonitis –Second form of peritonitis –
peritonitis-paresisperitonitis-paresis
Tactics:
Complex therapy:
- infusional, desintoxicational,
- plasma infusion;
- intestinum stimulation;
- antibacterial;
- rheological;
- immunotherapy.

45. Second form of peritonitis –Second form of peritonitis –
peritonitis-paresisperitonitis-paresis
Failure complex therapy
during 18-24 hours
Extirpation of uterus
with tubes,
Peritoneum drenage

46. Third form of peritonitis – classicalThird form of peritonitis – classical
obstetritional peritonitisobstetritional peritonitis
Patogenesis – failure sutures on uterus

47. Third form of peritonitisThird form of peritonitis
1.1. PatogenesisPatogenesis – failure sutures on uterus;– failure sutures on uterus;
2.2. OnsetOnset: - 5-6 days after cesarean section;: - 5-6 days after cesarean section;
3.3. Clinics:Clinics:
-- EndometritisEndometritis: l: low abdomen pain,ow abdomen pain,
Illness of external examination of uterus,Illness of external examination of uterus,
subinvolution uteri, cervix of uterus,subinvolution uteri, cervix of uterus,

48. Third form of peritonitisThird form of peritonitis
- intoxications: hypertermia,- intoxications: hypertermia,
tachycardia, tachypnoe;tachycardia, tachypnoe;
dryness skin and mucus;dryness skin and mucus;
- peritoneal symptoms;- peritoneal symptoms;
- slight intestinal paresis.- slight intestinal paresis.
4.4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑↑
young form neutrophyles)young form neutrophyles)
5.5. USUS – free fluid in peritoneal cavity– free fluid in peritoneal cavity

49. Third form of peritonitisThird form of peritonitis
Extirpation of uterus
with tubes (hysterectomy),
Peritoneum drenage,
Complex antibacterial,
infusional, desintoxical
(inc. extracorporal detoxycation)
Immunotherapy.

50. Sepsis.Sepsis.
1. Septicemia1. Septicemia
bacteriemiabacteriemia
intoxicationintoxication
on the 2-3 day after laboron the 2-3 day after labor
Etiologic factor: E.coli, Protei and otherEtiologic factor: E.coli, Protei and other
gram-negative floragram-negative flora
Complications: collapse and acuteComplications: collapse and acute
adrenal insufficiencyadrenal insufficiency

51. Sepsis.Sepsis.
2.Septicopyemia2.Septicopyemia
caused by gram-positive flora: St.aureuscaused by gram-positive flora: St.aureus
methastasis in lungs (pulmonary abscess)methastasis in lungs (pulmonary abscess)
and kidneys (renal carbuncle)and kidneys (renal carbuncle)
develops on the 10-17th day postpartumdevelops on the 10-17th day postpartum
Sympthoms: fever, hepatosplenomegaly,Sympthoms: fever, hepatosplenomegaly,
anemia, jaundice, etc.anemia, jaundice, etc.

52. SepsisSepsis
pathogene is revealed in blood only inpathogene is revealed in blood only in
30% of cases30% of cases
in biochemic analysis of blood: hypo- andin biochemic analysis of blood: hypo- and
disproteinemia, hypoglycemia,disproteinemia, hypoglycemia,
hypovolemia, hypoNaemia.hypovolemia, hypoNaemia.
in blood sample: leucocytosis orin blood sample: leucocytosis or
leucopenia, lymphocytopenia,leucopenia, lymphocytopenia,
aneozynophilia, anemia, ESC increase.aneozynophilia, anemia, ESC increase.

53. SepsisSepsis
Treatment: liquidation of infection locusesTreatment: liquidation of infection locuses
(in 1 days of unsuccessful treatment -(in 1 days of unsuccessful treatment -
uterine extirpation with tubes); infusion-uterine extirpation with tubes); infusion-
transfusion treatment; antibiotics;transfusion treatment; antibiotics;
hemosorbtion and lymphosorbtion.hemosorbtion and lymphosorbtion.

54. Postpartum lactation mastitis.Postpartum lactation mastitis.
Frequency is 3-5%Frequency is 3-5%
Usually it is one-sidedUsually it is one-sided
St.aureus is a pathogenSt.aureus is a pathogen
Mamilla fissuras are the inlet of infectionMamilla fissuras are the inlet of infection
lactostasis contributes to infectionlactostasis contributes to infection
distributiondistribution
there are lymphogenic and galactogenicthere are lymphogenic and galactogenic
ways of distributionways of distribution

55. Postpartum lactation mastitis.Postpartum lactation mastitis.
acute start on the 2-4th dayacute start on the 2-4th day
serose, infiltrative and purulent mastitisserose, infiltrative and purulent mastitis
treatment: antibiotics; decrease oftreatment: antibiotics; decrease of
stagnation: draining, no-spa withstagnation: draining, no-spa with
oxytocynum; resorpsion therapy; infusionoxytocynum; resorpsion therapy; infusion
therapy; immunostimulation; surgicaltherapy; immunostimulation; surgical
treatment in purulent mastitis.treatment in purulent mastitis.

56. Anaerobic infection.Anaerobic infection.
Usually it is a consequence of the criminalUsually it is a consequence of the criminal
abortions.abortions.
The pathogen is Clostridia perfringens.The pathogen is Clostridia perfringens.
The disease is characterized by severeThe disease is characterized by severe
intoxication: cyanosis, breathlessness.intoxication: cyanosis, breathlessness.

57. Anaerobic infection.Anaerobic infection.
The triad of symptoms is pathognomonic:The triad of symptoms is pathognomonic:
- jaundice with bronze tint- jaundice with bronze tint
((оттенокоттенок),),
- hypoglobinemia- hypoglobinemia
- hemoglobinuria- hemoglobinuria
Than the nephritis with anuria isThan the nephritis with anuria is
developingdeveloping
Complications:Complications:
- septic shock- septic shock
- renal failure- renal failure

58. Anaerobic infection - treatment.Anaerobic infection - treatment.
hysterectomia or abrasio cavae uterihysterectomia or abrasio cavae uteri
antibiotics in large dosesantibiotics in large doses
blood transfusionblood transfusion
serum with high titer antibodies infusionserum with high titer antibodies infusion

59. Renal infectionRenal infection
The causes:The causes:
trauma of urinary bladdertrauma of urinary bladder
hypotonia of bladder, especially afterhypotonia of bladder, especially after
peridural anesthesiaperidural anesthesia
cateterizationcateterization

60. PostpartumPostpartum
InfectionsInfections