postpartum infections

Postpartum Postpartum InfectionsInfections

Timokhina E.V

Normal postpartum period: Normal postpartum period: 1. Lochia usually lasts for 5-6 weeks: 1. Lochia usually lasts for 5-6 weeks:

several days - lochia rubraseveral days - lochia rubratill the 10th – lochia serosatill the 10th – lochia serosa then - lochia albathen - lochia alba

2. Diuresis is normalizing to the 2-5th day postpartum. 2. Diuresis is normalizing to the 2-5th day postpartum. Usually the capacity of the bladder is increasing and the Usually the capacity of the bladder is increasing and the sensitivity is decreasing, that predispose to the sensitivity is decreasing, that predispose to the postpartum urinary tract infectionpostpartum urinary tract infection

3. Uterus is contracted to the 5-6th week postpartum. The 3. Uterus is contracted to the 5-6th week postpartum. The uterine fundus is decreasing in 1-2 cm/dayuterine fundus is decreasing in 1-2 cm/day

4. Postpartum pains are normal in multipara4. Postpartum pains are normal in multipara

Normal postpartum period:Normal postpartum period:5.In blood formula the leucocytes level is till 5.In blood formula the leucocytes level is till

1515*109/l, the level of fibrinogen is increased *109/l, the level of fibrinogen is increased during the I week postpartumduring the I week postpartum

6.Menses begins in 6-8 weeks in nonlactating 6.Menses begins in 6-8 weeks in nonlactating women, ovulation can happen in 2-4 weeks in women, ovulation can happen in 2-4 weeks in nonlactating women and in 10 weeks in lactating nonlactating women and in 10 weeks in lactating womenwomen

7.Postpartum hemorrhage composes 0,5% from 7.Postpartum hemorrhage composes 0,5% from the body weight, and if it is more than 1% it is the body weight, and if it is more than 1% it is pathological hemorrhage pathological hemorrhage

Postpartum infection (6 weeks)Postpartum infection (6 weeks) - is any - is any infection of birth canal in postpartum infection of birth canal in postpartum period, which is accompanied by high period, which is accompanied by high temperature (more than 38temperature (more than 38 С С) during at ) during at least 2 days from the first 10 days least 2 days from the first 10 days postpartum. postpartum.

Postpartum InfectionsPostpartum Infections

Frequency rate – 13,3 – 54,3 %

Classification of postpartum Classification of postpartum infection of Sazonov-Bartelse: infection of Sazonov-Bartelse:

1. The infection is restricted by the labor wound1. The infection is restricted by the labor woundpostpartum endometritispostpartum endometritispostpartum ulcerpostpartum ulcer

2. The infection is distributed from the labor wound, but is 2. The infection is distributed from the labor wound, but is locatedlocatedvulvitis - metritisvulvitis - metritiscolpitis - parametritis colpitis - parametritis paracolpitis - located thrombophlebitisparacolpitis - located thrombophlebitis

- adnecsitis- adnecsitis - pelvioperetonitis- pelvioperetonitis

Classification of postpartum Classification of postpartum infection of Sazonov-Bartelse:infection of Sazonov-Bartelse:

3. Distributed infection:3. Distributed infection:Distributed peritonitisDistributed peritonitisInfectious-toxic shockInfectious-toxic shockProgressive thrombophlebitisProgressive thrombophlebitisAnaerobic gas gangreneAnaerobic gas gangrene

4. Generalized infection: sepsis4. Generalized infection: sepsis

Postpartum InfectionsPostpartum InfectionsMain forms:Main forms:

- endometritis – 13,9%- endometritis – 13,9% - wound infection - 9,35%- wound infection - 9,35% - peritonitis – 0,5%- peritonitis – 0,5%

Postpartum InfectionsPostpartum Infections RRisk factorisk factors postpartum s postpartum

infectious complications:infectious complications:

1. 1. socio-economic status socio-economic status (low (low scale of livingscale of living))

Postpartum InfectionsPostpartum Infections2. 2. Extagenital Extagenital diseasediseasess: ss: - hypertension, - hypertension, - diabetes- diabetes -obesity-obesity - chronic pyelonephritis, - chronic pyelonephritis, glomerulonefritisglomerulonefritis - others infectious focus - others infectious focus

(tonsillitis and etc) (tonsillitis and etc) - abdominal surgery during - abdominal surgery during pregnancypregnancy

Postpartum InfectionsPostpartum Infections3.3. Gynecological diseasesGynecological diseases: : - chronic inflammatory, - chronic inflammatory, - bacterial vaginosis, - bacterial vaginosis, - recurrence spontaneous and artificial - recurrence spontaneous and artificial

abortions, abortions, - infertility- infertility - myoma, endometriosis- myoma, endometriosis

Postpartum InfectionsPostpartum Infections4.4. Pregnancy complications:Pregnancy complications: Pregnancy – immunodeficiency status Pregnancy – immunodeficiency status

(low amount lymphocytes, low level Ig (low amount lymphocytes, low level Ig A,G)A,G)

- - impendingimpending early spontaneous abortion, early spontaneous abortion, - isthmico-cervical unsufficiency, cervical - isthmico-cervical unsufficiency, cervical cerclage;cerclage; - i- impendingmpending preterm labor, preterm labor,

Postpartum InfectionsPostpartum Infections - anemia,- anemia, - intrauterine fetus infections,- intrauterine fetus infections, - vaginitis, bacterial vaginosis during - vaginitis, bacterial vaginosis during pregnancy pregnancy

Postpartum InfectionsPostpartum Infections - feto-placental insufficiently (intrauterine - feto-placental insufficiently (intrauterine

chronic hypoxia, intrauterine growth chronic hypoxia, intrauterine growth retardation|),retardation|),

- abruption placentae, placenta previa.- abruption placentae, placenta previa.

Postpartum InfectionsPostpartum Infections5.5. Complications of labour:Complications of labour: - preterm labour,- preterm labour, - preterm premature rupture of - preterm premature rupture of membranes,membranes, - dysfunctional labour: dystocia, - dysfunctional labour: dystocia,

labour labour enhancement,enhancement, - recurrent vaginal examinations,- recurrent vaginal examinations, - excess bleeding and postpartum - excess bleeding and postpartum hemorrhagehemorrhage

Postpartum InfectionsPostpartum Infections6.6. Operative delivery:Operative delivery: - cesarean section,- cesarean section, - obstetrician forceps. - obstetrician forceps.

7.7. Postpartum complications:Postpartum complications: - uterine subinvolution - uterine subinvolution

Main infectious agentsMain infectious agents

0 5 10 15 20 25 30 35

others

Enterobacter sp.

Enterococcus

Ps. aeruginosa

Staphylococcus aureus

Proteus sp.

Escherichia coli

0 10 20 30 40 50

Others

Peptostreptococcus sp.

Peptococcus sp.

Bacteroides sp.

aerobicaerobic

anaerobicanaerobic

Postpartum InfectionsPostpartum InfectionsMain forms of postpartumMain forms of postpartuminfectious complications:infectious complications:1.1. Endomteritis.Endomteritis.2.2. Wound infection after cesarean Wound infection after cesarean

section (abdomen) or episiotomy section (abdomen) or episiotomy 3. Mastitis3. Mastitis4. Peritonitis.4. Peritonitis.

EndometritisEndometritisEndometritisEndometritis – inflammatory internal lay of – inflammatory internal lay of

uteri.uteri.FrequencyFrequency::

– – after vaginal labour – 7-8%,after vaginal labour – 7-8%, - after cesarean section – 30-35% - after cesarean section – 30-35%

EndometritisEndometritis Clinics (classical variant)Clinics (classical variant)1.1. Onset first symptoms on 3-5 day after Onset first symptoms on 3-5 day after

labour;labour;2.2. Weakness;Weakness;3.3. Pyrexia, algor (increase tPyrexia, algor (increase t°° to 37,6-38 to 37,6-38

CC°)°)

EndometritisEndometritis5. 5. Low abdomen painLow abdomen pain6.6. Illness of external examination of uterusIllness of external examination of uterus7.7. Subinvolution uteri and cervix of uterusSubinvolution uteri and cervix of uterus8.8. Abnormal lochia (nonslight)Abnormal lochia (nonslight)9.9. ↑↑ Leucocytes (granulocytes), Leucocytes (granulocytes), ↑ ↑

sedimentation erythrocytes ratesedimentation erythrocytes rate

EndometritisEndometritis Today – till 40% - subacute processToday – till 40% - subacute process ((dominancedominance subpathogenic subpathogenic floraflora – –

association aerobic and anaerobic association aerobic and anaerobic bacteriumbacterium) )

1.1. Slight pyrexia;Slight pyrexia;2.2. NNormal stateormal state3.3. Main symptoms –abnormal lochia, Main symptoms –abnormal lochia, ↑↑

Leucocytes (granulocytes), Leucocytes (granulocytes), ↑ ↑ sedimentation erythrocytes rate.sedimentation erythrocytes rate.

EndometritisEndometritisAdditional methods:Additional methods: 1. B1. Bacteriacteriological evaluation metroaspiration ological evaluation metroaspiration

with sensitivity towards with sensitivity towards antibioticsantibiotics;;2. Ultrasonography – 2. Ultrasonography – measurementmeasurement of size of size

of uterus, cavity, of uterus, cavity, suturesuture (cesaeren (cesaeren section).section).

3. Hysteroscopy. 3. Hysteroscopy.

,

Ultrasonography - Ultrasonography - differdiffer 2 2 forms of endometritis forms of endometritis

First variant - First variant - DelayDelay in cavity of in cavity of

uterus necrotic uterus necrotic decidua, decidua, bloodblood clotclotss,, sometimes sometimes – parts of – parts of placentae.placentae.

Second variant - Second variant - basal basal endometritis endometritis (“(“clearclear endometritis”)endometritis”)

EndometritisEndometritis First form of First form of

endometritisendometritis((extensionextension of of

uteruc cavity) uteruc cavity)

EndometritisEndometritis

Second form of Second form of endometritis –endometritis –

basal endometritisbasal endometritis hyperechogenic hyperechogenic

impuritiesimpurities in cavity in cavity of uterusof uterus

EndometritisEndometritisGeneral Therapy

1.Main point - antibacterial therapy (combination of antibiotic agents);

2. Infusional therapy (desintoxication) – 800-1200 ml i/v. 3.Immunotherapy;4. Vitaminotherapy;5. Rheological therapy.

Local therapyLocal therapyFirst formFirst form

1.Hysteroscopy and instrumental evaluation cavity of uterus (curetage)-

remove necrotic decidua, placental parts.

2. Lavage of cavity of uterus with antiseptic solutions.

3. Application in uterus hydrophilic ointment

Local therapyLocal therapySecond form – basal endometritis Second form – basal endometritis

NO hysteroscopy1. Lavage of cavity of uterus with

antiseptic solutions.2. Application in uterus hydrophilic

ointment

Postpartum ulcer.Postpartum ulcer.

Can be in perineum, in vagina, in cervix.Can be in perineum, in vagina, in cervix.The wound is covered with yellow spot, is The wound is covered with yellow spot, is bleeding, the tissues around are edematous and bleeding, the tissues around are edematous and red. The fever lasts for 4-5 days and the wound red. The fever lasts for 4-5 days and the wound is healed till the 10-12th day.is healed till the 10-12th day.The treatment consists of hypertonic bandage The treatment consists of hypertonic bandage on the wound, antibiotics, and remove of on the wound, antibiotics, and remove of stitches.stitches.

Wound infectionWound infectionEtiologyEtiology

Staphylococcus aureus – 37- 69%;Staphylococcus aureus – 37- 69%;Enterococcus – 11-28%Enterococcus – 11-28%Streptococcus – 15%Streptococcus – 15%Anaerobic bacteria – 9% Anaerobic bacteria – 9%

Wound infectionWound infectionClinics

1.Onset on 3-8 days after cesarean section;2. Weakness, pyrexia, algor (increase t° to 37,6-38 C°);3. Local symptoms: hyperemia, infiltration, rubor, sickliness

Wound infectionWound infectionTreatmentTreatment

General therapy:Antibacterial therapy;Infusional therapy (desintoxication) Immunotherapy;Vitaminotherapy;Rheological therapy.


Local therapy: First stage – clean wound• Drainage, open wound;• Lavage, drainage irrigation with hypertonic solutions


Local therapy: Second stage – reparation, regeneration• Application ointment or ointment swab 2. Sometimes – secondary sutures

Postpartum thrombophlebitis.Postpartum thrombophlebitis.MetrothrombophlebitisMetrothrombophlebitisThrombophlebitis of pelvic veins. The danger of Thrombophlebitis of pelvic veins. The danger of embolism is very high in thrombophlebitis of embolism is very high in thrombophlebitis of ovarian plexusovarian plexusDeep venous thrombosisDeep venous thrombosisTreatment consists of bed regimen with high leg Treatment consists of bed regimen with high leg position, leg bandage, antibiotics, spasmolytics, position, leg bandage, antibiotics, spasmolytics, heparin, fibrinolysin, reopolyglukin together with heparin, fibrinolysin, reopolyglukin together with trental.trental.

PeritonitisPeritonitis

Extremely seriously complication

after operative delivery

PeritonitisPeritonitisFirst form – First form – infectioninfection during cesarean during cesarean

delivery delivery 1.1. Risks factorsRisks factors: prolonged delivery, : prolonged delivery,

preterm rupture of membranes and long preterm rupture of membranes and long anhydramnion period.anhydramnion period.

2.2. OnsetOnset – on 2-3 days after cesarean – on 2-3 days after cesarean delivery;delivery;

First form – First form – infectioninfection during cesarean delivery during cesarean delivery

3.3. ClinicsClinics: : - intoxcations: hypertermia,tachycardia,- intoxcations: hypertermia,tachycardia, tachypnoe; dryness skin and tachypnoe; dryness skin and mucus; mucus; - peritoneal symptoms;- peritoneal symptoms; - intestinal paresis.- intestinal paresis.4.4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑ ↑

young form neutrophyles)young form neutrophyles)

First form – First form – infectioninfection during during cesarean delivery cesarean delivery

Tactics:Tactics:Complex therapyComplex therapy: : - antibacterial;- antibacterial; - infusional, desintoxacatinal,- infusional, desintoxacatinal, - plasma infusional;- plasma infusional; - rheological;- rheological; - immunotherapy.- immunotherapy.

First form – First form – infectioninfection during during cesarean deliverycesarean delivery

Hysterectomy

Failure therapy during 18-24 hours

Second form of peritonitis – Second form of peritonitis – peritonitis-paresisperitonitis-paresis

1.1. PatogenesisPatogenesis: failure : failure barrier functionbarrier function of intestine;of intestine;

2. Onset2. Onset: 3-4 days after operative : 3-4 days after operative delivery;delivery;


3. Clinics3. Clinics: : - - expressedexpressed intestinal paresis: intestinal paresis: swellingswelling

of abdomen;of abdomen; - intoxications: hypertermia, - intoxications: hypertermia, tachycardia, tachypnoe; tachycardia, tachypnoe; dryness skin and mucus; dryness skin and mucus; 4. 4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑ ↑

young form neutrophyles)young form neutrophyles)


Tactics:Complex therapy: - infusional, desintoxicational, - plasma infusion; - intestinum stimulation; - antibacterial; - rheological; - immunotherapy.

Second form of peritonitis – Second form of peritonitis – peritonitis-paresisperitonitis-paresisFailure complex therapy

during 18-24 hours

Extirpation of uterus with tubes,

Peritoneum drenage

Third form of peritonitis – classical Third form of peritonitis – classical obstetritional peritonitisobstetritional peritonitis

Patogenesis – failure sutures on uterus

Third form of peritonitisThird form of peritonitis

1.1. PatogenesisPatogenesis – failure sutures on uterus; – failure sutures on uterus;2.2. OnsetOnset: - 5-6 days after cesarean section;: - 5-6 days after cesarean section;3.3. Clinics:Clinics: -- Endometritis Endometritis: l: low abdomen pain, ow abdomen pain,

Illness of external examination of uterus, Illness of external examination of uterus, subinvolution uteri, cervix of uterus,subinvolution uteri, cervix of uterus,

Third form of peritonitis Third form of peritonitis - intoxications: hypertermia, - intoxications: hypertermia, tachycardia, tachypnoe; tachycardia, tachypnoe; dryness skin and mucus; dryness skin and mucus; - peritoneal symptoms;- peritoneal symptoms; - slight intestinal paresis.- slight intestinal paresis.4. 4. Laboratory methodsLaboratory methods: leucocytosis (: leucocytosis (↑ ↑

young form neutrophyles)young form neutrophyles)5. 5. USUS – free fluid in peritoneal cavity – free fluid in peritoneal cavity

Third form of peritonitisThird form of peritonitis

Extirpation of uterus with tubes (hysterectomy),

Peritoneum drenage,Complex antibacterial, infusional, desintoxical

(inc. extracorporal detoxycation)Immunotherapy.

Sepsis.Sepsis.

1. Septicemia 1. Septicemia bacteriemiabacteriemiaintoxicationintoxicationon the 2-3 day after laboron the 2-3 day after laborEtiologic factor: E.coli, Protei and other Etiologic factor: E.coli, Protei and other gram-negative floragram-negative floraComplications: collapse and acute Complications: collapse and acute adrenal insufficiencyadrenal insufficiency

Sepsis.Sepsis.

2.Septicopyemia2.Septicopyemia

caused by gram-positive flora: St.aureuscaused by gram-positive flora: St.aureusmethastasis in lungs (pulmonary abscess) methastasis in lungs (pulmonary abscess) and kidneys (renal carbuncle)and kidneys (renal carbuncle)develops on the 10-17th day postpartumdevelops on the 10-17th day postpartumSympthoms: fever, hepatosplenomegaly, Sympthoms: fever, hepatosplenomegaly, anemia, jaundice, etc.anemia, jaundice, etc.

SepsisSepsis

pathogene is revealed in blood only in pathogene is revealed in blood only in 30% of cases30% of casesin biochemic analysis of blood: hypo- and in biochemic analysis of blood: hypo- and disproteinemia, hypoglycemia, disproteinemia, hypoglycemia, hypovolemia, hypoNaemia.hypovolemia, hypoNaemia.in blood sample: leucocytosis or in blood sample: leucocytosis or leucopenia, lymphocytopenia, leucopenia, lymphocytopenia, aneozynophilia, anemia, ESC increase.aneozynophilia, anemia, ESC increase.

SepsisSepsis

Treatment: liquidation of infection locuses Treatment: liquidation of infection locuses (in 1 days of unsuccessful treatment - (in 1 days of unsuccessful treatment - uterine extirpation with tubes); infusion-uterine extirpation with tubes); infusion-transfusion treatment; antibiotics; transfusion treatment; antibiotics; hemosorbtion and lymphosorbtion.hemosorbtion and lymphosorbtion.

Postpartum lactation mastitis.Postpartum lactation mastitis.

Frequency is 3-5%Frequency is 3-5%Usually it is one-sidedUsually it is one-sidedSt.aureus is a pathogenSt.aureus is a pathogenMamilla fissuras are the inlet of infectionMamilla fissuras are the inlet of infectionlactostasis contributes to infection lactostasis contributes to infection distributiondistributionthere are lymphogenic and galactogenic there are lymphogenic and galactogenic ways of distributionways of distribution

Postpartum lactation mastitis.Postpartum lactation mastitis.

acute start on the 2-4th dayacute start on the 2-4th day

serose, infiltrative and purulent mastitisserose, infiltrative and purulent mastitis

treatment: antibiotics; decrease of treatment: antibiotics; decrease of stagnation: draining, no-spa with stagnation: draining, no-spa with oxytocynum; resorpsion therapy; infusion oxytocynum; resorpsion therapy; infusion therapy; immunostimulation; surgical therapy; immunostimulation; surgical treatment in purulent mastitis.treatment in purulent mastitis.

Anaerobic infection.Anaerobic infection.

Usually it is a consequence of the criminal Usually it is a consequence of the criminal abortions.abortions.

The pathogen is Clostridia perfringens.The pathogen is Clostridia perfringens.

The disease is characterized by severe The disease is characterized by severe intoxication: cyanosis, breathlessness.intoxication: cyanosis, breathlessness.

Anaerobic infection.Anaerobic infection.The triad of symptoms is pathognomonic: The triad of symptoms is pathognomonic:

- jaundice with bronze tint - jaundice with bronze tint ((оттенокоттенок), ),

- hypoglobinemia- hypoglobinemia - hemoglobinuria- hemoglobinuria

Than the nephritis with anuria is developingThan the nephritis with anuria is developingComplications: Complications:

- septic shock- septic shock - renal failure- renal failure

Anaerobic infection - treatment.Anaerobic infection - treatment.

hysterectomia or abrasio cavae uterihysterectomia or abrasio cavae uteriantibiotics in large dosesantibiotics in large dosesblood transfusionblood transfusionserum with high titer antibodies infusionserum with high titer antibodies infusion

Renal infectionRenal infection

The causes: The causes: trauma of urinary bladdertrauma of urinary bladderhypotonia of bladder, especially after hypotonia of bladder, especially after peridural anesthesiaperidural anesthesiacateterizationcateterization

Postpartum Postpartum InfectionsInfections

postpartum infections

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