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Normal
puerperium
.
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 .
Divided into

        –First 24 hours
        –Early- up to 7 days
        –Remote- up to 6 weeks
Objectives
        To monitor physiological changes of
      puerperium
       To diagnose and treats any       postnatal
      complications
        To establish infant feeding

        To advise about contraception
Physiological changes in Normal
Puerperium
    Changes in Genital Tract
    Changes in breast and Lactation
    Changes in other systems
Changes in Genital Tract

 Involution of the Uterus
 Lochia
 Involution of Other Pelvic Organs
 Menstruation
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
Endometrium Cavity
 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.
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
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
Changes in Breast and Lactation

 Mamogenesis       (Mammary duct-
  gland growth & dev.)
 Lactogenesis      (Initiation Of
  milk secretion in alveoli)
 Galactopoiesis     (Maintenance of
  Lactation)
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
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.
Puerprium ,peurpral fever and peurpral sepsis (1)
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.
 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.
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 .
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.
Contraceptive advice
 Breast feeding women shouldn’t 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
Health& nutrition education
      Health & nutrition education
 Calorie need per day-2200+700 =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
Puerperal fever
Definition
Temperatures reach 100.4F(38.0C) or
 higher on any two of the first 10 days
 postpartum, exclusive of the first 24
 hours.

 
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.
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.
Causes
Endometritis (most common),
Milk engorgment, Mastitis,breast abscess
Urinary tract infection
pneumoniaatlectasis,
CS ,perineal wound infection, fasiaties.
Septic pelvic thrombophlebitis.
Mastitis :
    = 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 infant’s oral pharynx.
Mastitis
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.
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.
Atelectasis
 Caused by hypoventilation and is
 best prevented by coughing and deep
 breathing on a fixed schedule
 following surgery
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.
Wound infections
 Incisional abscesses that develop following
 cesarean delivery usually cause persistent
 fever beginning about the fourth day

 Perinealinfection uncommon , caused by
 bacterial contamination during delivery

 Antimicrobials and surgical drainage, with
 careful inspection to ensure that the fascia
 is intact.
Puerprium ,peurpral fever and peurpral sepsis (1)
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
 .
Puerprium ,peurpral fever and peurpral sepsis (1)
Puerpral sepsis
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.
Puerprium ,peurpral fever and peurpral sepsis (1)
Clinical course & severity of theisinfection is
 clinical course & severity of the infection determined by
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.
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.
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.
Pathogenesis
of puerperal sepsis
 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.
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.
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 %
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
Puerprium ,peurpral fever and peurpral sepsis (1)
Diagnosis
A. Clinical Picture

  symptoms:
     • fever ,rigors, malaise, headache.
     • vomiting and diarrhoea.
     • abdominal discomfort.
     • offensive lochia.
     • 2ry PP Hge.
Signs
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).
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)
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.
Investigations
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.
Management
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.
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 .

Puerprium ,peurpral fever and peurpral sepsis (1)
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.
Patients with persistant fever despite
antibiotics TTT are assessed for

   Ratained product of conception
   Wound infection
   Pelvic abcess
   Ovarian vein thrombosis
   Septic pelvic thrombophelbities.
Complications
1- Metritis and parametitis.

2. Pelvic abscess

3 Pelvic Peritonitis

4. Septic Thrombophlebitis
*   Necrotizing Fasciitis

  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 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
    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
CASE SCENARIO
 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.
 A diagnosis of postpartum
 endometritis was made and the
 infection was treated with Mefoxine
 1 g IV Q8H.
 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,
 Mcburney’s point (+/-),Murphy’s sign(-),
 Kindey region percussion (-).
investigation
 Urinalysis was unremarkable.
On postpartum day four

  The patient’s 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
 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
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.
MCQ
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
   Ans:C
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 won’t change
  D-uterine is re-epithelialized totally in the
    first week of pregnancy
  Ans:A
                     med-ed-online
Which organism is the least responsible in
puerpural infection?
  A- peptostreptococcus
  B-enterococcus
  C- chlamydia trachomatis
  D-mycoplasma

  Ans:D
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

   Ans:A
                        med-ed-online
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
   Ans:B
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
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 doesn’t look ill. What is your diagnosis?

    A-pelvic abscess
    B-parametrial phlegmon
    C-pelvic septic thrombophlebitis
    D-adenexal infection

    Ans:C
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

Ans:B
An infection after C/S which is not
responsive to clinda+genta is because of:

   A-clostridium
   B-enterococcus
   C-bacteroid fargilis
   D-chlamydia trachomatis



   Ans:B
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

Ans:C
THANK YOU
  Thank
     you

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Puerprium ,peurpral fever and peurpral sepsis (1)

  • 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. Endometrium Cavity  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.
  • 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.
  • 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 shouldn’t 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-2200+700 =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
  • 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 pneumoniaatlectasis, CS ,perineal wound infection, fasiaties. Septic pelvic thrombophlebitis.
  • 26. Mastitis : = 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 infant’s oral pharynx.
  • 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  Perinealinfection uncommon , caused by bacterial contamination during delivery  Antimicrobials and surgical drainage, with careful inspection to ensure that the fascia is intact.
  • 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 .
  • 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.
  • 39. Clinical course & severity of theisinfection is clinical course & severity of the infection determined by 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.
  • 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
  • 48. Diagnosis A. Clinical Picture symptoms: • fever ,rigors, malaise, headache. • vomiting and diarrhoea. • abdominal discomfort. • offensive lochia. • 2ry PP Hge.
  • 49. Signs 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).
  • 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. Investigations 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.
  • 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 . 
  • 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.
  • 60. 1- Metritis and parametitis. 2. Pelvic abscess 3 Pelvic Peritonitis 4. Septic Thrombophlebitis
  • 61. * Necrotizing Fasciitis  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. *
  • 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
  • 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,  Mcburney’s point (+/-),Murphy’s sign(-),  Kindey region percussion (-).
  • 69. On postpartum day four  The patient’s 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 Ans:C
  • 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 won’t change D-uterine is re-epithelialized totally in the first week of pregnancy Ans:A med-ed-online
  • 75. Which organism is the least responsible in puerpural infection? A- peptostreptococcus B-enterococcus C- chlamydia trachomatis D-mycoplasma Ans:D
  • 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 Ans:A med-ed-online
  • 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 Ans:B
  • 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 doesn’t look ill. What is your diagnosis? A-pelvic abscess B-parametrial phlegmon C-pelvic septic thrombophlebitis D-adenexal infection Ans:C
  • 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 Ans:B
  • 81. An infection after C/S which is not responsive to clinda+genta is because of: A-clostridium B-enterococcus C-bacteroid fargilis D-chlamydia trachomatis Ans:B
  • 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 Ans:C
  • 83. THANK YOU Thank you