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OBSTETRICS > PUERPERAL COMPLICATIONS > Flashcards

PUERPERAL COMPLICATIONS Flashcards

1
Q

What is the puerperium?

A

Puerperium, also known as the postpartum period or fourth trimester,
- time following delivery when maternal anatomical and physiological changes return to the non-pregnant state over 4-6 weeks.

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2
Q

What are the characteristics of puerperal pelvic infection?

A

Puerperal pelvic infection is a bacterial infection of the genital tract after delivery,
- part of the maternal death triad alongside preeclampsia and hemorrhage.
- Effective antimicrobials have decreased its mortality.

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3
Q

What is the main symptom of puerperal fever?

A

The main symptom of puerperal fever is a temperature of 38.0ºC (100.4ºF) or higher during the puerperium.

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4
Q

What causes most persistent fevers after childbirth?

A

Most persistent fevers after childbirth are caused by genital tract infections.

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5
Q

What are the 6 W’s for the causes of fever?

A
  1. Wind: respiratory issues (e.g., pneumonia, atelectasis).
  2. Water: UTI (e.g., pyelonephritis).
  3. Woobies: mastitis, abscess.
  4. Womb: uterine infections.
  5. Wound: cellulitis, incision infections.
  6. Walking: DVT.

(Wi-WaWa-Wo3)

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6
Q

What are the common terms for postpartum uterine infection?

A

(preferred term)
- Puerperal sepsis
- endometritis
- endomyometritis
- endoparametritis
- metritis with pelvic cellulitis

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7
Q

What is the single most significant risk factor for postpartum uterine infection?

A

The route of delivery is the single most significant risk factor, with cesarean deliveries posing a higher risk than vaginal deliveries.

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8
Q

What are key infection risk factors following cesarean delivery?

A

Key factors include
- prolonged labor
- membrane rupture
- multiple cervical exams
- internal fetal monitoring
- intraamniotic infections

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9
Q

Why is prophylactic antibiotic use recommended for cesarean delivery?

A

To reduce infection risks
- a single dose of perioperative antibiotics is recommended:
15 minutes to 1 hour before surgery, followed by additional doses post-op.

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10
Q

What increases the risk of uterine infection during labor?

A

The length of labor and the number of vaginal exams,
- which increase bacterial contamination
- raise the risk of uterine infection.

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11
Q

What factors increase the risk of postpartum endometritis?

A

Risk factors include:
- lower socioeconomic status
- anemia
- poor nutrition
- obesity
- prolonged labor
- meconium-stained amniotic fluid
- cesarean delivery

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12
Q

Which bacteria commonly cause female genital infections?

A

Aerobes:
- Group A, B, D streptococci
- E. coli, Klebsiella
- Gardnerella vaginalis

Anaerobes:
- Peptostreptococcus
- Clostridium
- Bacteroides

Others:
- Mycoplasma
- Chlamydia
- Neisseria gonorrhoeae.

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13
Q

What are the signs and symptoms of endometritis?

A

Signs include :
- fever (38-39ºC)
- abdominal pain
- chills
- leukocytosis (15,000-30,000/µL)
- foul-smelling lochia (though infection can occur without it).

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14
Q

How does uterine infection develop following a vaginal delivery?

A

Infection often begins at the:
1. placental implantation site
2. spreads due to bacteria from the cervix accessing amniotic fluid
3. necrotic material in the uterus.

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15
Q

What is the role of prophylactic antibiotics in membrane rupture?

A

Prophylactic antibiotics are
- given when membranes are ruptured for more than 18 hours
- to prevent ascending infections and postpartum endometritis.

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16
Q

What is the significance of meconium-stained amniotic fluid?

A

It increases the risk of infection, often requiring an additional antibiotic aside from standard prophylaxis.

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17
Q

How is postpartum uterine atony linked to infection?

A

Postpartum uterine atony can result from:
- infection delaying uterine involution, often due to retained placenta or devitalized tissue.

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18
Q

What is the preferred treatment for postpartum uterine infections?

A

Prompt use of antibiotics is essential to contain the infection within the uterine or pelvic tissues and prevent its spread.

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19
Q

What is the utility of microbiological testing in severe endometritis?

A

It is beneficial for septic patients with severe endometritis and can guide targeted treatment.

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20
Q

When are routine genital tract cultures indicated before treatment?

A

They may be clinically useful but are not always routine unless high-risk factors like group A streptococci are suspected.

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21
Q

What is the first-line treatment for non-severe metritis following vaginal delivery?

A

Oral or intramuscular antimicrobial agents.

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22
Q

What is the recommended treatment for moderate to severe infections?

A

Intravenous therapy with a broad-spectrum antimicrobial regimen.

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23
Q

What is the gold standard antimicrobial regimen for severe pelvic infections?

A

Clindamycin and Gentamicin.

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24
Q

What precautions should be taken before administering Gentamicin?

A

Request :(tests to assess renal status due to potential nephrotoxicity and ototoxicity)
- BUN
- Creatinine

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25
Q

What is the alternative regimen if renal insufficiency is present?

A

Clindamycin plus Aztreonam.

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26
Q

What is the role of Ampicillin in pelvic infection treatment?

A

It is added for persistent positive enterococcal cultures or if there is no response within 48-72 hours.

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27
Q

What is the preferred prophylaxis for cesarean delivery?

A

Single-dose perioperative antibiotics such as ;
Ampicillin 2 grams or first-generation cephalosporins like Cefazolin.

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28
Q

Why is abdominal preoperative skin preparation important?

A

Chlorhexidine-alcohol is superior to iodine alcohol for preventing surgical site infections.

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29
Q

What surgical technique during cesarean delivery reduces infection risk?

A

Allowing spontaneous placental separation and exteriorizing the uterus to reduce febrile morbidity.

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30
Q

When should parenteral treatment for pelvic infections be discontinued?

A

After 24-48 hours of the patient being afebrile and asymptomatic.

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31
Q

What are the main complications of untreated uterine and pelvic infections?

A
  • Parametrial phlegmon
  • abdominal or pelvic abscess
  • infected hematoma
  • septic pelvic thrombophlebitis.
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32
Q

What indicates failed therapy for pelvic infections?

A

Persistent fever after 48-72 hours, which requires further investigation for refractory causes.

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33
Q

What percentage of women with metritis respond to treatment within 48-72 hours?

A

More than 90% of women respond to antimicrobial treatment within this timeframe.

34
Q

What are common antimicrobials used for pelvic infections after vaginal delivery?

A

Ampicillin and Gentamicin, which have a 90% success rate.

35
Q

What is the additional antibiotic for Clostridium difficile colitis?

A

Metronidazole, combined with Ampicillin and an Aminoglycoside.

36
Q

What is the benefit of adding Azithromycin to prophylactic antibiotics?

A

It further reduces post-cesarean metritis rates.

37
Q

What surgical closure technique reduces wound separation incidence in obese women?

A

Closure of subcutaneous tissue reduces wound separation but not infection rates.

38
Q

What are the diagnostic considerations for refractory pelvic infections?

A

Careful evaluation for parametrial phlegmon, abscesses, hematoma, or septic thrombophlebitis.

39
Q

What is a common cause of persistent fever in women treated for metritis?

A

Abdominal incisional infections.

40
Q

What are the signs and symptoms of wound infections in abdominal incisions?

A

Fever (persistent despite medications, begins on the fourth operative day) and wound erythema or drainage.

41
Q

What are the risk factors for abdominal incisional infections?

A
  • Obesity
  • prolonged rupture of membrane
  • diabetes
  • hypertension
  • anemia
  • corticosteroid use
  • immunosuppression
  • poor hemostasis with hematoma formation.
42
Q

What is wound dehiscence in the context of abdominal incisional infections?

A

Separation of the wound involving the fascial layer, progressing to a surgical site infection.

43
Q

What are the treatments for abdominal incisional infections?

A
  • Antimicrobials
  • surgical drainage
  • debridement of devitalized tissue
  • local wound care
44
Q

What is necrotizing fasciitis?

A

A rare but potentially fatal complication of perineal and vaginal infections with severe wound infection and high mortality.

45
Q

What are the risk factors for necrotizing fasciitis?

A
  • Diabetes
  • obesity
  • hypertension
46
Q

What is the primary treatment strategy for necrotizing fasciitis?

A
  • Aggressive surgical debridement
  • early diagnosis
  • antimicrobials
  • intensive care.
47
Q

What is the origin of necrotizing fasciitis infections?

A

Paravaginal hematoma or polymicrobial infections including Group A ß-hemolytic streptococci.

48
Q

What are adnexal abscesses and peritonitis?

A

Ovarian abscesses caused by bacterial invasion through a rent in the ovarian capsule (rare, unilateral) and peritonitis, usually preceded by metritis.

49
Q

What is the first symptom of peritonitis?

A

Adynamic ileus.

50
Q

What causes parametrial phlegmon?

A

Parametrial cellulitis forming induration within the leaves of the broad ligament, often extending laterally or posteriorly.

51
Q

What is the typical treatment for parametrial phlegmon?

A

Continued broad-spectrum antimicrobial therapy; surgery if uterine incisional necrosis is suspected.

52
Q

What is septic pelvic thrombophlebitis?

A

A complication involving one or both ovarian plexuses, extending into the inferior vena cava and renal veins.

53
Q

What are the clinical features of septic pelvic thrombophlebitis?

A
  • Fever of undetermined etiology
  • high spiking fever
  • chills
  • tachycardia
  • occasional pain in the lower quadrants.
54
Q

What is the diagnostic method for ovarian vein thrombosis?

A

Pelvic CT or MR imaging.

55
Q

What are the signs of episiotomy dehiscence?

A
  • Local pain
  • dysuria with or without urinary retention.
56
Q

What is the treatment for infected episiotomies?

A
  • Wound drainage
  • removal of sutures
  • wound debridement
  • intravenous antibiotics
  • early repair once infection has subsided.
57
Q

What are the key signs of toxic shock syndrome (TSS)?

A
  • Fever
  • headache
  • mental confusion
  • diffuse macular erythematous rash
  • subcutaneous edema
  • nausea
  • vomiting
  • watery diarrhea
58
Q

What are the causative agents of TSS?

A

(SB-CC)
- Staphylococcus aureus (Toxic Shock Syndrome Toxin-1)
- B-hemolytic streptococcus
- Clostridium sordellii
- Clostridium perfringens

59
Q

What is the primary treatment approach for TSS?

A
  • Supportive care
  • antimicrobials for staphylococcal and streptococcal coverage
  • extensive wound debridement if necessary
60
Q

What is the fatality rate for TSS?

A

10-15% case fatality rate.

61
Q

What is mastitis?

A

A unilateral parenchymal infection of the mammary glands, commonly occurring in up to 1/3 of breastfeeding women.

62
Q

What are the risk factors for mastitis?

A
  • Difficulties in nursing
  • cracked nipples
  • use of oral antibiotics
63
Q

What is the most common causative agent of mastitis?

A

Staphylococcus aureus (including MRSA)

64
Q

How do bacteria typically enter the breast in mastitis?

A

Through the nipple at the site of a fissure or small abrasion.

65
Q

When do symptoms of mastitis usually appear postpartum?

A

Not until the third or fourth week postpartum.

66
Q

What are the signs and symptoms of mastitis?

A
  • Chills or rigors
  • fever
  • tachycardia
  • severe pain
  • unilateral hard
  • red-marked breast engorgement
67
Q

What is the recommended duration of antimicrobial therapy for mastitis?

A

10-14 days.

68
Q

What is the first-line antibiotic treatment for mastitis?

A

Dicloxacillin, 500 mg orally 4x/day.

69
Q

What antibiotics can be used for penicillin-sensitive women with mastitis?

A

Erythromycin, 500 mg orally 4x/day.

70
Q

When should vancomycin or anti-MRSA antibiotics be used for mastitis?

A

When infection is caused by resistant staphylococci or pending culture results.

71
Q

Is breastfeeding contraindicated in mastitis?

A

No, breastfeeding is recommended and acts as a treatment itself.

72
Q

How should breastfeeding be approached in mastitis?

A

Begin on the uninvolved breast to allow milk let-down before moving to the tender breast.

73
Q

What is the treatment for breast engorgement?

A

Cool packs and oral analgesics for 12-24 hours.

74
Q

What differentiates breast engorgement from mastitis?

A

Breast engorgement is bilateral, associated with milk leakage, and fever does not persist beyond 4-16 hours or exceed 39°C.

75
Q

What should be suspected if a well-defined area of the breast remains hard, red, and tender despite mastitis treatment?

A

Breast abscess.

76
Q

What imaging modality is valuable for diagnosing breast abscess?

A

Sonographic imaging, showing a complex cystic structure with a thick wall.

77
Q

What are the management options for breast abscess?

A

Surgical drainage under general anesthesia or sonographically guided needle aspiration with local analgesia.

78
Q

What are the common signs of breast engorgement?

A
  • Bilateral breast pain
  • milk leakage
  • fever lasting less than 24 hours
79
Q

How does breastfeeding help in managing mastitis?

A
  • decreases milk stasis
  • reduces edema
  • relieves engorgement, aiding in recovery.
80
Q

When should a breast abscess be suspected in mastitis cases?

A

If defervescence does not occur within 48-72 hours of mastitis treatment or a mass is palpable.

OBSTETRICS (13 decks)

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