PUERPERAL COMPLICATIONS Flashcards
What is the puerperium?
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.
What are the characteristics of puerperal pelvic infection?
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.
What is the main symptom of puerperal fever?
The main symptom of puerperal fever is a temperature of 38.0ºC (100.4ºF) or higher during the puerperium.
What causes most persistent fevers after childbirth?
Most persistent fevers after childbirth are caused by genital tract infections.
What are the 6 W’s for the causes of fever?
- Wind: respiratory issues (e.g., pneumonia, atelectasis).
- Water: UTI (e.g., pyelonephritis).
- Woobies: mastitis, abscess.
- Womb: uterine infections.
- Wound: cellulitis, incision infections.
- Walking: DVT.
(Wi-WaWa-Wo3)
What are the common terms for postpartum uterine infection?
(preferred term)
- Puerperal sepsis
- endometritis
- endomyometritis
- endoparametritis
- metritis with pelvic cellulitis
What is the single most significant risk factor for postpartum uterine infection?
The route of delivery is the single most significant risk factor, with cesarean deliveries posing a higher risk than vaginal deliveries.
What are key infection risk factors following cesarean delivery?
Key factors include
- prolonged labor
- membrane rupture
- multiple cervical exams
- internal fetal monitoring
- intraamniotic infections
Why is prophylactic antibiotic use recommended for cesarean delivery?
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.
What increases the risk of uterine infection during labor?
The length of labor and the number of vaginal exams,
- which increase bacterial contamination
- raise the risk of uterine infection.
What factors increase the risk of postpartum endometritis?
Risk factors include:
- lower socioeconomic status
- anemia
- poor nutrition
- obesity
- prolonged labor
- meconium-stained amniotic fluid
- cesarean delivery
Which bacteria commonly cause female genital infections?
Aerobes:
- Group A, B, D streptococci
- E. coli, Klebsiella
- Gardnerella vaginalis
Anaerobes:
- Peptostreptococcus
- Clostridium
- Bacteroides
Others:
- Mycoplasma
- Chlamydia
- Neisseria gonorrhoeae.
What are the signs and symptoms of endometritis?
Signs include :
- fever (38-39ºC)
- abdominal pain
- chills
- leukocytosis (15,000-30,000/µL)
- foul-smelling lochia (though infection can occur without it).
How does uterine infection develop following a vaginal delivery?
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.
What is the role of prophylactic antibiotics in membrane rupture?
Prophylactic antibiotics are
- given when membranes are ruptured for more than 18 hours
- to prevent ascending infections and postpartum endometritis.
What is the significance of meconium-stained amniotic fluid?
It increases the risk of infection, often requiring an additional antibiotic aside from standard prophylaxis.
How is postpartum uterine atony linked to infection?
Postpartum uterine atony can result from:
- infection delaying uterine involution, often due to retained placenta or devitalized tissue.
What is the preferred treatment for postpartum uterine infections?
Prompt use of antibiotics is essential to contain the infection within the uterine or pelvic tissues and prevent its spread.
What is the utility of microbiological testing in severe endometritis?
It is beneficial for septic patients with severe endometritis and can guide targeted treatment.
When are routine genital tract cultures indicated before treatment?
They may be clinically useful but are not always routine unless high-risk factors like group A streptococci are suspected.
What is the first-line treatment for non-severe metritis following vaginal delivery?
Oral or intramuscular antimicrobial agents.
What is the recommended treatment for moderate to severe infections?
Intravenous therapy with a broad-spectrum antimicrobial regimen.
What is the gold standard antimicrobial regimen for severe pelvic infections?
Clindamycin and Gentamicin.
What precautions should be taken before administering Gentamicin?
Request :(tests to assess renal status due to potential nephrotoxicity and ototoxicity)
- BUN
- Creatinine
What is the alternative regimen if renal insufficiency is present?
Clindamycin plus Aztreonam.
What is the role of Ampicillin in pelvic infection treatment?
It is added for persistent positive enterococcal cultures or if there is no response within 48-72 hours.
What is the preferred prophylaxis for cesarean delivery?
Single-dose perioperative antibiotics such as ;
Ampicillin 2 grams or first-generation cephalosporins like Cefazolin.
Why is abdominal preoperative skin preparation important?
Chlorhexidine-alcohol is superior to iodine alcohol for preventing surgical site infections.
What surgical technique during cesarean delivery reduces infection risk?
Allowing spontaneous placental separation and exteriorizing the uterus to reduce febrile morbidity.
When should parenteral treatment for pelvic infections be discontinued?
After 24-48 hours of the patient being afebrile and asymptomatic.
What are the main complications of untreated uterine and pelvic infections?
- Parametrial phlegmon
- abdominal or pelvic abscess
- infected hematoma
- septic pelvic thrombophlebitis.
What indicates failed therapy for pelvic infections?
Persistent fever after 48-72 hours, which requires further investigation for refractory causes.
What percentage of women with metritis respond to treatment within 48-72 hours?
More than 90% of women respond to antimicrobial treatment within this timeframe.
What are common antimicrobials used for pelvic infections after vaginal delivery?
Ampicillin and Gentamicin, which have a 90% success rate.
What is the additional antibiotic for Clostridium difficile colitis?
Metronidazole, combined with Ampicillin and an Aminoglycoside.
What is the benefit of adding Azithromycin to prophylactic antibiotics?
It further reduces post-cesarean metritis rates.
What surgical closure technique reduces wound separation incidence in obese women?
Closure of subcutaneous tissue reduces wound separation but not infection rates.
What are the diagnostic considerations for refractory pelvic infections?
Careful evaluation for parametrial phlegmon, abscesses, hematoma, or septic thrombophlebitis.
What is a common cause of persistent fever in women treated for metritis?
Abdominal incisional infections.
What are the signs and symptoms of wound infections in abdominal incisions?
Fever (persistent despite medications, begins on the fourth operative day) and wound erythema or drainage.
What are the risk factors for abdominal incisional infections?
- Obesity
- prolonged rupture of membrane
- diabetes
- hypertension
- anemia
- corticosteroid use
- immunosuppression
- poor hemostasis with hematoma formation.
What is wound dehiscence in the context of abdominal incisional infections?
Separation of the wound involving the fascial layer, progressing to a surgical site infection.
What are the treatments for abdominal incisional infections?
- Antimicrobials
- surgical drainage
- debridement of devitalized tissue
- local wound care
What is necrotizing fasciitis?
A rare but potentially fatal complication of perineal and vaginal infections with severe wound infection and high mortality.
What are the risk factors for necrotizing fasciitis?
- Diabetes
- obesity
- hypertension
What is the primary treatment strategy for necrotizing fasciitis?
- Aggressive surgical debridement
- early diagnosis
- antimicrobials
- intensive care.
What is the origin of necrotizing fasciitis infections?
Paravaginal hematoma or polymicrobial infections including Group A ß-hemolytic streptococci.
What are adnexal abscesses and peritonitis?
Ovarian abscesses caused by bacterial invasion through a rent in the ovarian capsule (rare, unilateral) and peritonitis, usually preceded by metritis.
What is the first symptom of peritonitis?
Adynamic ileus.
What causes parametrial phlegmon?
Parametrial cellulitis forming induration within the leaves of the broad ligament, often extending laterally or posteriorly.
What is the typical treatment for parametrial phlegmon?
Continued broad-spectrum antimicrobial therapy; surgery if uterine incisional necrosis is suspected.
What is septic pelvic thrombophlebitis?
A complication involving one or both ovarian plexuses, extending into the inferior vena cava and renal veins.
What are the clinical features of septic pelvic thrombophlebitis?
- Fever of undetermined etiology
- high spiking fever
- chills
- tachycardia
- occasional pain in the lower quadrants.
What is the diagnostic method for ovarian vein thrombosis?
Pelvic CT or MR imaging.
What are the signs of episiotomy dehiscence?
- Local pain
- dysuria with or without urinary retention.
What is the treatment for infected episiotomies?
- Wound drainage
- removal of sutures
- wound debridement
- intravenous antibiotics
- early repair once infection has subsided.
What are the key signs of toxic shock syndrome (TSS)?
- Fever
- headache
- mental confusion
- diffuse macular erythematous rash
- subcutaneous edema
- nausea
- vomiting
- watery diarrhea
What are the causative agents of TSS?
(SB-CC)
- Staphylococcus aureus (Toxic Shock Syndrome Toxin-1)
- B-hemolytic streptococcus
- Clostridium sordellii
- Clostridium perfringens
What is the primary treatment approach for TSS?
- Supportive care
- antimicrobials for staphylococcal and streptococcal coverage
- extensive wound debridement if necessary
What is the fatality rate for TSS?
10-15% case fatality rate.
What is mastitis?
A unilateral parenchymal infection of the mammary glands, commonly occurring in up to 1/3 of breastfeeding women.
What are the risk factors for mastitis?
- Difficulties in nursing
- cracked nipples
- use of oral antibiotics
What is the most common causative agent of mastitis?
Staphylococcus aureus (including MRSA)
How do bacteria typically enter the breast in mastitis?
Through the nipple at the site of a fissure or small abrasion.
When do symptoms of mastitis usually appear postpartum?
Not until the third or fourth week postpartum.
What are the signs and symptoms of mastitis?
- Chills or rigors
- fever
- tachycardia
- severe pain
- unilateral hard
- red-marked breast engorgement
What is the recommended duration of antimicrobial therapy for mastitis?
10-14 days.
What is the first-line antibiotic treatment for mastitis?
Dicloxacillin, 500 mg orally 4x/day.
What antibiotics can be used for penicillin-sensitive women with mastitis?
Erythromycin, 500 mg orally 4x/day.
When should vancomycin or anti-MRSA antibiotics be used for mastitis?
When infection is caused by resistant staphylococci or pending culture results.
Is breastfeeding contraindicated in mastitis?
No, breastfeeding is recommended and acts as a treatment itself.
How should breastfeeding be approached in mastitis?
Begin on the uninvolved breast to allow milk let-down before moving to the tender breast.
What is the treatment for breast engorgement?
Cool packs and oral analgesics for 12-24 hours.
What differentiates breast engorgement from mastitis?
Breast engorgement is bilateral, associated with milk leakage, and fever does not persist beyond 4-16 hours or exceed 39°C.
What should be suspected if a well-defined area of the breast remains hard, red, and tender despite mastitis treatment?
Breast abscess.
What imaging modality is valuable for diagnosing breast abscess?
Sonographic imaging, showing a complex cystic structure with a thick wall.
What are the management options for breast abscess?
Surgical drainage under general anesthesia or sonographically guided needle aspiration with local analgesia.
What are the common signs of breast engorgement?
- Bilateral breast pain
- milk leakage
- fever lasting less than 24 hours
How does breastfeeding help in managing mastitis?
- decreases milk stasis
- reduces edema
- relieves engorgement, aiding in recovery.
When should a breast abscess be suspected in mastitis cases?
If defervescence does not occur within 48-72 hours of mastitis treatment or a mass is palpable.
