Puerperal infection, trichomonas vaginalis, Pelvic inflammatory disease Flashcards
What is a puerperal infection?
Puerperal pyrexia is any febrile condition occurring in a woman in whom a temperature of 38.0 degrees centigrade or more has occurred within 14 days after confinement or miscarriage. It is a result of infection.
What is the definition of the puerperium?
From the delivery of the placenta to six weeks following the birth
6-week period of time beginning immediately after birth, during which the reproductive organs and maternal physiology return toward the pre-pregnant state
What are the features of the puerperium
- Return to pre-pregnant state
- Initiation/suppression of lactation
- Transition to parenthood
Physiology of the puerperium
- Endocrine changes
- Profound decrease in serum levels of placental hormones (human placental lactogen, hcg, oestrogen and progresterone)
- Increase of prolactin
- Involution of the uterus and genital tract
- Muscle - ischaemia, autolysis and phagocytosis
- Decidua – shed as lochia: rubra, serosa and alba
Breast and puerperium
Breast – establishment of lactation
At birth – presence of colostrum
Lactogenesis
Prolactin – milk production
Oxytocin – Milk ejection reflex
Lactation suppression
7-10 days
Prolactin response to breastfeeding
Baby suckles
Sensory impulses pass from nipple to the brain
Prolactin secreted by anterior pituitary gland goes via bloodstream to breasts
Lactocytes produce milk
More secreted at night
Suppresses ovulation
Level peaks after the feed, to produce milk for the next feed
Oxytocin reflex
Baby suckles
Sensory impulses pass from nipple to the brain
Oxytocin secreted by posterior pituitary gland goes via bloodstream to
the breasts
Myo-epithelial (muscle) cells contract and expel milk
Helped by sight,
sound and smell of baby
Becomes conditioned over time
Hindered by anxiety, stress, pain and doubt
Works before or during the feed to make the milk flow
What are the health risks of infant feeding?
Risks of not breastfeeding
Risks of artificial feeding
Risks of not being at the breast
If half of mothers who currently do not breastfeed were to do so for up to 18 months of their lifetime, there would be:
865 fewer cases of breast cancer
With cost savings to the NHS of over £21 million
Improved quality of life equating to more than £10 million
for each annual cohort of first time mothers.
Reduction of four acute conditions in infants: gastrointestinal disease, respiratory disease, otitis media, and necrotising enterocolitis (NEC)
What is lactoferrin
multifunctional protein in milk
Functions:
- Regulates iron absorption in intestines and delivery of iron to the cells
- Protection against bacterial infection, some viruses and fungi
- Involved in regulation of bone marrow function
- Boosts immune system
Minor postnatal problems
Infection
Postpartum haemorrhage (PPH)
Fatigue
Anaemia
Backache
Breast engorgement / mastitis
Urinary stress incontinence
Hemorrhoids/Constipation
The ‘blues’
Major postnatal problems
Sepsis
Severe PPH
Pre-Eclampsia/eclampsia
Thrombosis
Uterine prolapse
Incontinence (urinary or faecal)
Post dural puncture headache
Breast abscess
Depression / psychosis
Who is involved in normal care postnatal
Midwives
breastfeeding support workers
Doulas
Support workers
Nursery nurses
Housekeepers
Domestics
Who is involved in complex postnatal care?
All normal care plus:
Obstetricians and/or GP
Paediatricians
Anaesthetists
Physiotherapists
Substance use specialists
Microbiologists etc
What conditions could this be?
Sudden and profuse blood loss or persistent increased blood loss, Faintness, dizziness or palpitations/tachycardia
PPH, retained placental tissue or endometritis
What conditions could this be?
abdominal, pelvic or perineal pain, fever, shivering, or vaginal discharge with an unpleasant smell
Infection
What conditions could this be?
Persistent or severe headache
hypertension, pre-eclampsia,
postdural-puncture headache, migraine, intracranial pathology or infection
What conditions could this be?
leg swelling and tenderness, or shortness of breath or chest pain
Thromboembolism or cardiac problems (chest pain)
What are the possible causes/ aetiology of puerperal infection/ pyrexia?
genital tract infection - on examination the woman may have a bulky tender uterus. There may be perineal infection without involvement of the upper genital tract
urinary tract infection
deep vein thrombosis
mastitis
respiratory tract infection - this is more common after anaesthesia.
non-puerperal related causes eg appendicitis
anaemia
What are the commonest organisms that cause puerperal pyrexia?
Streptococci - both anaerobic and occasionally the beta-haemolytic streptococcus, e.g. S.agalactiae
staphylococci
coliforms
anaerobes eg bacteroides
chlamydia
mycoplasma
Clostridium welchii - very rare, but can cause a serious genital tract infection
What are the antepartum causes of puerperal infections?
- duration of labour
- duration of membrane rupture before delivery
- the number of cervical examinations
- sexual intercourse Intrapartum factors include:
iatrogenic bacterial contamination during examination, manipulation or instrumentation
trauma, eg caesarian section, lacerations
haemorrhage: consequent haematomas act as a infective focus
Which type of women are more susceptible to infection?
Women of lower socioeconomic class
What are the possible complications of puerperal infections?
- formation of a pelvic abscess
- pelvic thrombophlebitis
- paralytic ileus
- disseminated intravascular coagulation
- septic shock
- subsequent infertility
- salpingitis, pelvic cellulitis and - pelvic peritonitis - very rarely seen today because of early administration of antibiotics.
What does the management of puerperal pyrexia involve?
- detailed history and examination
- isolation of the mother and baby
- investigation of possible cause:
- high vaginal swab
- throat swab
- blood culture
- urine analysis
What is the appropriate treatment of infection for mastitis and endometritis?
mastitis - empirical treatment with flucloxacillin (erythromycin if penicillin-allergic); send a sample of breast milk for culture and sensitivity
endometritis - empirical treatment e.g. amoxycillin 500mg tds IV and metronidazole 400mg IV tds; also uterine curettage
What is endometritis?
inflammation of the endometrium, usually caused by infection. It can occur in the postpartum period, as infection is introduced during or after labour and delivery
process of delivery opens the uterus to allow bacteria from the vagina to travel upwards and infect the endometrium.
When does endometritis occur most commonly?
more commonly after caesarean section compared with vaginal delivery.
What are given to women during a CS to reduce the risk of infection?
Prophylactic antibiotics
What can endometritis be caused by?
Endometritis can be caused by a large variety of gram-negative, gram-positive and anaerobic bacteria. It can also be caused by sexually transmitted infections such as chlamydia and gonorrhoea
What is endometritis when it occurs unrelated to pregnancy?
When endometritis occurs unrelated to pregnancy and delivery, it is usually part of pelvic inflammatory disease, which is covered elsewhere.
What are the S + S of endometritis?
present from shortly after birth to several weeks postpartum
- Foul-smelling discharge or lochia
- Bleeding that gets heavier or does not improve with time
- Lower abdominal or pelvic pain
- Fever
- Sepsis
What are the investigations for endometritis?
Vaginal swabs (including chlamydia and gonorrhoea if there are risk factors)
Urine culture and sensitivities
Ultrasound may be considered to rule out retained products of conception
What do septic patients require with endometritis?
Septic patients will require hospital admission and the septic six, including blood cultures and broad-spectrum IV antibiotics (according to local guidelines). A combination of clindamycin and gentamicin is often recommended. Blood tests will show signs of infection (e.g. raised WBC and CRP).
What do patients presenting with milder symptoms have?
Patients presenting with milder symptoms and no signs of sepsis may be treated in the community with oral antibiotics. A typical choice of broad-spectrum oral antibiotic might be co-amoxiclav, depending on the risk of chlamydia and gonorrhoea.
What are Pelvic inflammatory disease (PID)
inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix. It is a significant cause of tubular infertility and chronic pelvic pain.
What is endometritis, salpingitis and oophoritis?
Endometritis is inflammation of the endometrium
Salpingitis is inflammation of the fallopian tubes
Oophoritis is inflammation of the ovaries
What is parametritis and peritonitis?
Parametritis is inflammation of the parametrium, which is the connective tissue around the uterus
Peritonitis is inflammation of the peritoneal membrane
What are the most causes of PID?
one of the sexually transmitted pelvic infections:
Neisseria gonorrhoeae tends to produce more severe PID
Chlamydia trachomatis
Mycoplasma genitalium
What are the non- sexually transmitted infections?
Gardnerella vaginalis (associated with bacterial vaginosis)
Haemophilus influenzae (a bacteria often associated with respiratory infections)
Escherichia coli (an enteric bacteria commonly associated with urinary tract infections)
What are the RFs for PID?
Not using barrier contraception
Multiple sexual partners
Younger age
Existing sexually transmitted infections
Previous pelvic inflammatory disease
Intrauterine device (e.g. copper coil)
What are the S + S of PID?
Pelvic or lower abdominal pain
Abnormal vaginal discharge
Abnormal bleeding (intermenstrual or postcoital)
Pain during sex (dyspareunia)
Fever
Dysuria
What do examination findings reveal in PID exams?
Pelvic tenderness
Cervical motion tenderness (cervical excitation)
Inflamed cervix (cervicitis)
Purulent discharge
Patients may have a fever and other signs of sepsis.
What are the investigations for PID?
NAAT swabs for gonorrhoea and chlamydia
NAAT swabs for Mycoplasma genitalium if available
HIV test
Syphilis test
A high vaginal swab can be used to look for bacterial vaginosis, candidiasis and trichomoniasis.
A microscope can be used to look for pus cells on swabs from the vagina or endocervix. The absence of pus cells is useful for excluding PID.
A pregnancy test should be performed on sexually active women presenting with lower abdominal pain to exclude an ectopic pregnancy.
Inflammatory markers (CRP and ESR) are raised in PID and can help support the diagnosis.
What should the management be for PID?
- Patients referred to GUM
- Antibiotics started empirically
- BASSH guidelines
One suggested outpatient regime (listed here to help your understanding and not as a guide to treatment) is: - A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea)
- Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) + - Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)
- Ceftriaxone and doxycycline will cover many other bacteria, including H. influenzae and E. coli.
What happens in most severe cases of PID?
particularly where there are signs of sepsis or the patient is pregnant, require admission to hospital for IV antibiotics. Where a pelvic abscess develops, this may need drainage by interventional radiology or surgery.
What are the complications of PID?
Sepsis
Abscess
Infertility
Chronic pelvic pain
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
What is Fitz-Hugh-Curtis Syndrome?
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum
Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
What does Fitz-Hugh-Curtis Syndrome result in?
right upper quadrant pain that can be referred to the right shoulder tip if there is diaphragmatic irritation. Laparoscopy can be used to visualise and also treat the adhesions by adhesiolysis.
What is trichomonas vaginalis?
type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella
What are the characteristics of trichomonas vaginalis
Trichomonas has four flagella at the front and a single flagellum at the back, giving a characteristic appearance to the organism. The flagella are used for movement, attaching to tissues and causing damage.
How is trichomonas spread?
Trichomonas is spread through sexual activity and lives in the urethra of men and women and the vagina of women.
What does trichomonas increase the risk of?
Contracting HIV by damaging the vaginal mucosa
Bacterial vaginosis
Cervical cancer
Pelvic inflammatory disease
Pregnancy-related complications such as preterm delivery.
What are the S + S of trichomonas vaginalis?
50% Asymptomatic
Vaginal discharge
Itching
Dysuria (painful urination)
Dyspareunia (painful sex)
Balanitis (inflammation to the glans penis)
The typical description of the vaginal discharge is frothy and yellow-green, although this can vary significantly. It may have a fishy smell.
What does examination of the cervix show?
Examination of the cervix can reveal a characteristic “strawberry cervix” (also called colpitis macularis). A strawberry cervix is caused by inflammation (cervicitis) relating to the trichomonas infection. There are tiny haemorrhages across the surface of the cervix, giving the appearance of a strawberry.
Testing the vaginal pH will reveal a raised ph (above 4.5), similar to bacterial vaginosis.
What are the investigations for trichomonas?
The diagnosis can be confirmed with a standard charcoal swab with microscopy (examination under a microscope).
Swabs should be taken from the posterior fornix of the vagina (behind the cervix) in women. A self-taken low vaginal swab may be used as an alternative.
A urethral swab or first-catch urine is used in men.
What is the treatment for trichomonas?
Patients should be referred to a genitourinary medicine (GUM) specialist service for diagnosis, treatment and contact tracing.
Treatment is with metronidazole.
What are sepsis, severe sepsis and septic shock?
Sepsis: infection plus systemic manifestations of infection
Severe sepsis: sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion
Septic shock: the persistence of hypoperfusion despite adequate fluid replacement therapy
RFs for sepsis
Obesity
Impaired glucose tolerance / diabetes
Impaired immunity/ immunosuppressant medication
Anaemia
Vaginal discharge
History of pelvic infection
Cervical cerclage
Prolonged SROM
etc
Likely causes of sepsis
Chorioamnionitis
Endometritis/ infected retained products
Genital tract infections
Wound infections (including perineum)
Intra-abdominal collections
Pharyngitis
Pneumonia
Mastitis
Urinary tract infection
Skin and soft-tissue infection
CNS Infections
Gastroenteritis
Acute appendicitis/ pancreatitis/ cholecystitis
Infection related to regional anaesthesia (meningitis/ spinal abscess)
Necrotising Fasciitis
Sepsis 3Ts
Temperature <36 or >38 degrees
Tachycardia -Heart rate > 90bpm (PN)
Tachypnoea - Respiratory rate > 20bpm
WCC >12 or <4 x 109/l
Hyperglycaemia >7.7mmol
The clinical symptoms of sepsis during pregnancy/Intrapartum/Postpartum include one or more of the following:
Fever or rigors
Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)
Rash (generalised streptococcal maculopapular rash or purpura fulminans suggests early toxic shock syndrome)
Abdominal / pelvic pain and tenderness
Offensive vaginal discharge (suggests anaerobes; serosanguinous suggests streptococcal infection)
Productive cough
Urinary symptoms
The clinical signs of sepsis during pregnancy/Intrapartum/Postpartum include one or more of the following:
New onset of confusion or altered mental state
Temperature >38.0oC or <36oC
Heart Rate >130 beats per minute
Respiratory Rate (counted over 60 seconds) >20 breaths per minute
Blood Glucose >7.7mmol/L in the absence of known Diabetes
White cell count >12 or <4x109/L
Hypoxia
Hypotension
Oliguria (urine output <0.5ml/kg/hr for at least 2 hours, despite adequate fluid resuscitation)
Failure to respond to treatment
Red flag markers for severe sepsis
BP <90mmHg systolic or >40mmHg drop norm
HR >130bpm
Resp rate> 25 bpm
O2 saturation <90%
Urine output < 30 ml/hr
Lactate > 2 mmol/L
Lab markers
Creatinine >177umol/L
Platelets <100 x10 to power of 9 /L
APPT > 60s
INR >1.5
Sepsis 6 (BUFALO) plus 2
Bloods cultures
Urine output
Fluid Resuscitation
Antibiotics
Lactate
Oxygen
Plus 2 – Consider delivery (ERPC) & VTE prophylaxis
Sepsis pathway -
Slide 32 disorders of the puerperium
