47. Pathologic puerperium. Puerperal sepsis

Question 1

name types of postpartum infections

Answer 1

• Endometritis
• Postpartum sepsis
• Surgical site infection (may present as superficial cellulitis, and up to necrotizing fasciitis)
• Mastitis and breast abscess
• UTI (cystitis, pyelonephritis)

in 5-7% of women

Question 2

postpartum endometritis

Answer 2

Ascending polymicrobial infection, involving the endometrial lining or deeper tissues
(endomyometritis).

Question 3

associated organisms of postpartum endometritis

Answer 3

enterococci, GBS, Gardnerella, aerobic streptococci, E. coli, Bacteroides, Peptostreptococci.

Question 4

risk factors of postpartum endometritis

Answer 4

• Emergency C-section
• Prolonged ROM
• Prolonged labor
• ↑ number of cervical exams
• Group B-strep positive
• HIV positive

Question 5

presentation of postpartum endometritis

Answer 5

Early-onset after delivery with rapid progression.

• Fever (most characteristic finding)
• Foul-smelling lochia
• HR ↑
• Pelvic tenderness

Question 6

diagnosis of postpartum endometritis/ sepsis

Answer 6

clinical
Work-up for differential diagnosis may include: labs, urinalysis and urine culture, blood
culture, CXR, pelvic US to exclude retained POC (endometritis), pelvic CT to exclude pelvic abscess (sepsis) .

Question 7

DD for Postpartum maternal fever

Answer 7

The 7 W’s:
Wind Atelectasis, pneumonia Day 0
Water UTI Day 1
Womb Endometritis Day 2-3
Wound Wound infection Day 4-5
Walking Septic thrombophlebitis, DVT Day 5-6
Weaning Mastitis, breast abscess Day 7-21
Wonder drugs Drug fever At any time

Question 8

most common cause of postpartum maternal fever

Answer 8

endometritis

Question 9

treatment of postpartum endometritis

Answer 9

1. Admission to hospital care.
   2, Antibiotic regimen: Clindamycin + Gentamycin +/- Ampicillin (if GBS positive).
   *Start IV treatment until the fever subsides, continue PO treatment to complete a total of 14-days course.
2. Consider D&C if evidence of retained POC.

Question 10

Antibiotic prophylaxis before cesarean delivery to prevent postpartum endometritis

Answer 10

• Cefazolin 60 min’ before skin incision in all patients.
• plus Azithromycin (if in active labor, ROM, or emergent C-section)

Question 11

postpartum endometritis complications

Answer 11

• Sepsis
• Peritonitis
• Pelvic abscess
• Endometrial scarring (Ashermann syndrome)

Question 12

The major pathogens causing sepsis in the puerperium period?

Answer 12

• Group A strep (S. pyogenes)
• E. coli
• S. aureus
• S. pneumoniae
• Methicillin-resistant S. aureus (MRSA)

Question 13

risk factors for postpartum sepsis

Answer 13

• D.M.
• Obesity
• Immunocompromised state
• Prolonged ROM
• C-section
• Retained POC

Question 14

presentation of postpartum sepsis

Answer 14

• Fever, rigors
• Diarrhea or vomiting – may indicate exotoxin production (early toxic shock)
• Breast engorgement/redness
• Rash (generalized maculopapular rash)
• Abdominal/pelvic pain and tenderness
• Wound infection – spreading cellulitis or discharge
• Offensive vaginal discharge
• Productive cough
• Urinary symptoms

Question 15

treatment for postpartum sepsis

Answer 15

1. Hospital/ICU admission.
2. Antibiotic regimen: Piperacillin/Tazobactam OR Carbapenem + Clindamycin.
   **Add Vancomycin if MRSA infection is suspected or documented.
3. IVIG is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed.
4. Address underlying infectious foci if identified.