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Puerperal infection - Causes, Symptoms and Treatments

A common cause of childbirth-related death, puerperal infection is an infection of the birth canal and other structures during the postpartum period.

It can result in endometritis, parametritis, pelvic and femoral thrombophlebitis, and peritonitis. In the United States, puerperal infection develops in about 6% of maternity patients. The prognosis is good with treatment.

Causes of Puerperal infection:

Microbes that commonly cause puerperal infection include streptococci, coagulase-negative staphylococci, Clostridium pelfringens, Bacteroidesfragilis, and Escherichia coli. Most of these microbes are considered normal vaginal flora. But they may cause puerperal infection in the presence of certain predisposing factors, such as prolonged and premature rupture of the membranes, prolonged (more than 24 hours) or traumatic labor, cesarean section, frequent or unsanitary vaginal examinations or unsanitary delivery, retained products of conception, hemorrhage, and maternal couditions, such as anemia or dehilitation from malnutrition.

Signs and symptoms of Puerperal infection:

A characteristic sign of puerperal infection is fever (at least 100.4 F [38 C]) that occurs on any 2 consecutive days up to the 11th day postpartum (excluding the first 24 hours). This fever can spike as high as 105° F (40.6° C) and is commonly associated with chills, headachc, malaise, restlessness, and anxiety.

Accompanying signs and symptoms depend on the extent and site of infection. With endometritis there is heavy, sometimes foul-smelling lochia; tender, enlarged uterus; backache; severe uterine contractions persisting after childbirth. Parametritis (pelvic cellulitis) symptoms are vaginal tenderness and abdominal pain and tellderness (pain may become more intense as infection spreads).

The inflammation may remain localized, may lead to abscess formation, or may spread through the blood or lymphatic system. Widespread inflammation may cause pelvic thrombophlebitis with severe, repeated chills and dramatic swings in body temperature; lower abdominal or flank pain; and, possibly, a palpable tender mass over the affected area, which usually develops near the second postpartum week. Also, femoral thrombophlebitis may develop with pain, stiffness, or swelling in a leg or the groin; inflammation or shiny, white appearance of the affected leg; malaise; fever; and chills, usually beginning 10 to 20 days postpartum (these signs may precipitate pulmonary embolism). Finally, peritonitis is possible with its associated symptoms of fever with tachycardia (greater than 140 beats per minute), weak pulse, hiccups, nausea, vomiting, and diarrhea, and constant and possibly excruciating abdominal pain.

Diagnosis of Puerperal infection:

Development of the typical clinical features, especially fever within 48 hours after delivery, suggests a diagnosis of puerperal infection.

A culture of lochia, blood, incisional exudate (from cesarean incision or episiotomy), uterine tissue, or material collected from the vaginal cuff that reveals the causative organism may confirm the diagnosis.

Within 36 to 48 hours, white blood cell count usually demonstrates leukocytosis (15,000 to 30,000/ul).

Typical clinical features usually suffice for diagnosis of endometritis and peritonitis. In parametritis, pelvic examination shows induration without purulent discharge; culdoscopy shows pelvic adnexal induration and thickening. Red, swollen abscesses on the broad ligaments are even more serious indications because rupture leads to peritonitis.

Diagnosis of pelvic or femoral thrombophlebitis is suggested by characteristic clinical signs, venography, Doppler ultrasonography, Rielander's sign (palpable veins inside the thigh and calf), Payr's sign (pain in the calf when pressure is applied on the inside of the foot), and Homans' sign (pain on dorsiflexion of the foot with the knee extended). Homan's sign should be elicited passively by asking the patient to dorsiflex her foot because active dorsiflexion could, in theory, lead to embolization of a clot.

Other conditions to consider are pelvic abscess, deep venous thrombophlebitis, pyelonephritis, cystitis, mastitis, atelectasis, and wound infection.

Treatment of Puerperal infection:

Treatment of puerperal infection usually begins with I.V. infusion of broadspectrum antibiotics and is continued for 48 hours after fever is resolved.

Ancillary measures include analgesics for pain; antiseptics for local lesions; and anti emetics for nausea and vomiting from peritonitis. Supportive care includes bed rest, adequate fluid intake, I.V. fluids when necessary, and measures to reduce fever. Sitz baths and heat lamps may relieve discomfort from local lesions.

Surgery may be necessary to remove any remaining products of conception or to drain local lesions, such as an abscess in parametritis.

Management of septic pelvic thrombophlebitis consists of heparinization for approximately 10 days in conjunction with broad-spectrum antibiotic therapy.

Special considerations and prevention tips of Puerperal infection:

1. Monitor vital signs every 4 hours (more frequently if peritonitis has developed), intake, and output. Enforce strict bed rest.

2. Frequently inspect the perineum. Assess the fundus, and palpate for tenderness (subinvolution may indicate endometritis). Note the amount, color, and odor of vaginal drainage, and document your observations.

3. Administer antibiotics and analgesics, as ordered. Assess and document the type. degree, and location of pain as well as the patient's response to analgesics. Give the patient an antiemetic to relieve nausea and vomiting, as necessary.

4. Provide sitz baths and a heat lamp for local lesions. Change bed linen, pcrineal pads, and under pads frequently. Keep the patient warm.

5. Elevate the thrombophlebitic leg about 30 degrees. Don't rub or manipulate it or compress it with bed linen. Provide warm soaks for the leg. Watch for signs of pulmonary embolism, such as cyanosis, dyspnea, and chest pain.

6. Offer reassurance and emotional support. Thoroughly explain all procedures to the patient and family.

7. If the mother is separated from her infant, provide her with frequent reassurance about his progress. Encourage the father to reassure the mother about the infant's condition as well.

8. Maintain aseptic technique when performing a vaginal examination. Limit the number of vaginal examinations performed during labor. Take care to wash your hands thoroughly after each patient contact.

9. Keep the episiotomy site clean.

10. Screen personnel and visitors to keep persons with active infections away from maternity patients.

Instruct all pregnant patients to call the health care provider immediately when their membranes rupture. Warn them to avoid intercourse after rupture or leak of the amniotic sac. Teach the patient how to maintain good perineal hygiene following delivery.

 

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