6b puerp sepsis 13sept2011

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Puerperal Sepsis

Maternal Health DivisionMinistry of Health & Family

WelfareGovernment of India

BEMoC - Presentation 6 (b)

Session 6b

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Objectives

Define puerperal sepsis Acquire skills to diagnose , manage and refer

cases of puerperal sepsis

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Puerperal Sepsis

Definition:

Puerperal sepsis is an infection of the genital tract at any time between the onset of rupture of membranes or labour and the 42nd day following delivery or abortion in which any two or more of the following signs and symptoms are present: Fever of >100.4 Fahrenheit (>38.5 ºC) Abnormal, Foul smelling vaginal discharge Lower abdominal pain Subinvoluted uterus which is tender

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How Puerperal Sepsis Occurs ?

Occurs due to colonization of the genital tract by microorganisms

Organisms can be introduced from within (infection of endogenous origin), or from outside (infection of exogenous origin).

• Endogenous Infections: bacteria living within vagina brought into uterus by pelvic examination, instruments, dead tissue. Microorganisms ascend into the uterus during premature & PROM.

• Exogenous Infections: introduced from outside by unclean hands, unsterile instruments, Foreign substances & sexual activity

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How Puerperal Sepsis Occurs ?

Intrapartum:

• due to PROM & can cause Chorioamnionitis

Extrapartum:

• may be localized or

• can spread and lead to parametritis, peritonitis, septicaemia & DIC

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Risk Factors for Puerperal Sepsis

Patient-related Poor patient hygiene Pre-existing anaemia &

malnutrition Pre-existing sexually

transmitted infections (STIs)/RTIs

Not immunized against tetanus

Pre-existing diabetes

Related to delivery Failure to follow Asepsis Frequent vaginal examinations Manipulations high in the birth

canal Dead tissue in the birth canal PROM Prolonged/obstructed labour C- section/ Instrumental delivery Unrepaired vaginal/cervical

lacerations PPH

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Risk Factors For Puerperal Sepsis – Contd...

Related to health service delivery Delivery by untrained persons Lack of asepsis during delivery Lack of routine postpartum care Inadequate monitoring of the temperature during

prolonged labour and after delivery Non-availability of proper antibiotics Inadequate management with appropriate antibiotics in a

case in whom puerperal sepsis has set in Further operative intervention in a case where puerperal

sepsis has set in

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Causes of Fever in Puerperium

Infectious Localized infection of vaginal/cervical laceration or

episiotomy Infection of a laceration or episiotomy which has spread

to the underlying soft tissue Ischiorectal abscess Endometritis Salpingitis Parametritis Generalized peritonitis Septic thrombophlebitis Cystitis Acute Pyelonephritis

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Causes of Fever in Puerperium: Infectious – Contd...

Tubo-ovarian abscess; Broad ligament abscess; Abscess in the pouch of Douglas Abscesses at other sites in the abdomen or chest Septicaemia Septic shock Breast infection such as mastitis or, at a later stage, breast

abscess UTI Malaria Wound infection Thromboembolic disorders (superficial thrombophlebitis &

DVT)

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Non – Infectious Dehydration Tissue trauma Reaction to foetal proteins Breast engorgement

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Most common causes are Endometritis Breast engorgement, mastitis, breast abscess Urinary tract infection Leg vein thrombosis Non obstetric causes

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Features of Puerperal Sepsis

High grade fever Tachycardia, hypotension Excessive or foul smelling discharge Persistent lower abdominal pain On abdominal examination, uterus feels soft,

tender and subinvoluted On per speculum examination, foul smelling

purulent discharge is seen which may be blood stained.

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Management of Puerperal Fever

Detailed history regarding onset, severity and associated symptoms

Complete physical examination including general, systemic and local examination

Manage according to the underlying cause Blood & urine for routine & microscopic investigation Encourage increased oral fluid intake Cold sponging to help decrease temperature Antibiotics Treat the cause Refer if required

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Management of Puerperal Sepsis

If the general condition of the woman is non toxic i.e., low grade fever & pulse not rapid, give her a combination of oral antibiotics

• Ampicillin 500 mg. QDS PLUS

• Tab Metronidazole 400mg. TDS PLUS

• Inj Gentamicin 80 mg. TDS Rule out presence of retained placental bits Monitor vitals every 2 hrly. Watch for 24 hrs If vital signs improving, then complete the course of Antibiotic

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Management of puerperal sepsis

If fever persists after 72 hours of initiating antibiotics:

Re-evaluate and consider other causes of fever Consider if antibiotic cover sufficient; and REFER to FRU

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If the general condition of the woman is toxic i.e.,

with high grade fever & rapid pulse Start her on intravenous fluids and Give her the first dose of IV antibiotics:

• Ampicillin 1 gm IV PLUS

• Tab Metronidazole 500mg PLUS

• Inj Gentamicin 80 mg IM Rule out presence of retained placental bits Refer the woman to FRU immediately

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Prevention

Puerperal sepsis is to a great extent preventable; Measures to be taken in

• Antenatal Period: Improve Hb level to > 11 gms % Treat any septic focus (skin, throat etc.)

• Intranatal Period: Asepsis during delivery

• Postpartum Period: Maintain perineal hygiene Use of clean sanitary pad

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Key Messages

Puerperal sepsis is important cause of maternal mortality and morbidity

It is, to a great extent, preventable Early detection and treatment helps complete

recovery Serious cases require referral

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Thank you

6b puerp sepsis 13sept2011

Health & Medicine

Transcript of 6b puerp sepsis 13sept2011