Post-partum (puerperal) sepsis

Notes
  • This is an infection of the genital tract that occurs at any time between the onset of labor and the 42nd day postpartum
  • Most cases of puerperal sepsis involve various types of bacteria and they include the following in order of importance: Streptococcus pyogenes, staphylococci, the anaerobic streptococci, Escherichia coli, Clostridium welchii, and Clostridium tetani.
  • Sepsis is most common in the cavity and wall of uterus but it can spread beyond to cause septicemia and other illnesses
  • Statistics: it contributes to about 8% of maternal death globally

##Factors contributing to puerperal sepsis include:

  • Multiple cervical examinations
  • Prolonged labor
  • Prolonged rupture of membranes
  • Manual removal of placenta
  • Low social economic status
  • Caesarean Section
  • Endometritis
  • Preexisting chronic disease
  • Poor observation of hygiene, disinfection and antisepsis at peri and post-partum period
Symptoms
  • General malaise
  • Lethargy
  • Dehydration
  • Fever (oral temperature 5°C during the first 6 weeks post-delivery)
  • Chills
  • Foul odour of vaginal discharge (lochia)
  • Abnormal vaginal discharge (with pus)
  • Parametrial pain and thickening
  • Lower abdominal tenderness
  • Retained placental membrane
  • Involution - delay in the rate of reduction of the size of the uterus
  • Pelvic pain
Diagnosis
  • Complete blood count (CBC)
  • Blood urea
  • Serum electrolytes
  • Liver function tests (LFT)
  • Blood culture and antibiotic sensitivity
  • Genital swabs (perineal, vaginal, high vaginal, endocervical swabs for culture and antibiotic sensitivity)
  • Blood culture
  • Ultrasound scan of pelvis
  • X-ray chest or abdomen (that can detect perforations)
  • Regular pulse and blood pressure recording
  • Sputum for Gram stain and culture
  • Foley catheter to monitor hourly urine output
Differential
  • Acute pyelonephritis
  • UTIs
  • Mastitis
  • Deep vein thrombosis
  • Respiratory tract infections
  • Atelectasis
  • Breast engorgement
Prevention
  • Adherence to established sanitation, antiseptic and sterilization procedures pre and post-partum
  • Advocating for deliveries to take place in organized health institutions and by the trained personnel
  • Avoiding excessive or unnecessary vaginal examinations in premature and prolonged rupture of membranes
  • Prevention of prolonged labour where possible
  • Preventive dose of antibiotics after C-Section
  • Maintaining a good partograph
Management

##General measures:

  • IV Normal saline 500mL to run over 8 hours (depending on the status of the patient)
  • Blood grouping and cross – matching
  • Blood transfusion (depending on the status of the patient)
  • Evacuating the uterus (if some parts of placenta have been retained)
  • Seek alternative care of the baby (back to nursery or to be with relative)
  • Keeping the patient warm:

##Pharmacotherapy

  • Caps Amoxicillin 500mg TID x 5/7 PLUS Tabs Metronidazole 200mg TID x 5/7 PLUS Tabs Paracetamol 1gm TID x 5/7 OR
  • IV or IM Ceftriaxone BD x 3/7 PLUS IV or IM Gentamycin 80mg TID x 3/7 PLUS IV Metronidazole 500mg TID x 3/7 AND THEN continue with Caps  Amoxicillin 500mg TID x 5/7 PLUS Tabs Metronidazole 200mg TID x 5/7 PLUS Tabs Paracetamol 1gm TID x 5/7

## Surgical measures:

  • Surgical wound debridement to remove hematomata and necrotic materials in case septic Caesarean Section wound
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