P UERPERAL SEPSIS

PUERPERIUM =The time during which: - all the physiological changes of pregnancy is reversed - and the pelvic organs return to their previous state - and endocrine influence of the placenta is removed ~6 wks(+ 40 days) … 1 st two weeks, the changes are rapid & become slower thereafter.  Lactation is established  It is a time of physiological and mental adjustment to the new environment with the arrival of a new baby

COMPLICATIONS OF THE PUERPERIUM SERIOUS AND SOMETIMES FATAL DISORDERS MAY ARISE DURING THE PUERPERIUM I.Thrombosis & Embolism : = One of the main causes of maternal death. II.Puerperal Infection : Puerperial Pyrexia = A clinical sign that merits careful investigation. = A temperature of 38 oC on any occasion in the first 14 days delivery.

CAUSES: 1. Urinary tract infection 2. Genital tract infection 3. Pelvic / intra-uterine infection 4. Breast infection 5. Deep vein thrombosis (DVT) 6. Respiratory infection 7. Other non-obstetrics causes 8. Surgical wounds e.g. C.S.

A ETIOLOGY :- 90% of infections are genital or urinary tract in origin. GTI are commonly due to E.coil, strepto coccus A or B or clostridium, gram-negative bacteria or Chlamydia. UTI are predominantly due to E.coil, proteus or klebsiella 5

A ETIOLOGY :- Uterine infections are more likely following prolonged rupture of the membranes and after instrumental of delivery. Breast engorgement without infection associated with pyrexia. 6

A ETIOLOGY :- Surgical wound infections perineal or C/S wound will present as red, tender area surrounded by in duration. Venous thrombosis may be associated with pyrexia. The legs should be inspected because thrombophlebitis may be present. Early ambulation is a key policy in helping to reduce DVT and thrombophlebitis. 7

A ETIOLOGY :- Respiratory infections:- are occur following general anesthesia and in patient with chronic bronchitis and smoking. Mastitis usually “staphylococcal” and breast abscess and its usually occurs after 14 th post natal day. 8

D IAGNOSIS : - *history:- Check for prolonged rupture of membranes, intra part um pyrexia, prolonged labour, operative delivery, and any difficulty with the delivery of placenta, ask about associated symptoms of offensive. or unusually heavy locia,abdominal,wound pain. Previous UTI, catheterization, hx. Of urgency, frequency dysuria, heamaturia, renal angle pain. 9

D IAGNOSIS : - Ask about any previous treatment and allergies Perineal infection usually present around 2 nd day after delivery Hx. Of productive cough, wheezing, chest pain. Hx. Of lactation,breast pain and engorgment Ask about leg swelling and pain. 10

E XAMINATION :- Check the patients general condition, pulse and blood pressure. Check the breasts for any areas of tenderness and erythematic and listen to the chest. Inspect abdominal wound for swelling or associated cellulites. 11

E XAMINATION :- Check the fundal height and tenderness of the uterus. Perform a gentle pelvic examination and check the appearance of the perineum. 12

E XAMINATION :- Assess for tenderness of uterus on bimanual examinant and look for evidence of swelling in the adnexia. Endometritis is associated with lower abdominal pain, offensive liquor, and a tender uterus. Check the legs for superficial thrombophlebitis or DVT. 13

I NVESTIGATIONS Send amid stream urine sample for culture. Take swabs for bacterial culture and for Chlamydia from cervix and lochia, HVS, urethral swab Take sample of sputum or any discharge from wound or nipples for culture 14

I NVESTIGATIONS Take blood for full blood count (FBC) and culture Chest X-ray and uterine Scan for exclude retained product. 15

T REATMENT :- Initial therapy depends on diagnosis allergies, and weather the patients is breast feeding (avoid tetra cycline if breast feeding). For suspected pelvic infections fever, offensive lochia, lower adnominal pain on examination tender uterus, swelling adnexia Diagnoses : HVS, Cx. Swab, Urethral swab, blood culture, ultra sound. 16

T REATMENT BY COMBINATION ANTIBIOTICS AS : cephalaxin gram + ve micro organism 1 gm / 3 time / day or amoxil 500 mg metronidazol 400 mg 3 time daily an aerobes m.o. Or Augamantine 675 mg 3 time daily 17

III. MASTITIS : i.Acute intramammary mastitis = due to failure of milk withdawal from a lobule Rx  breast feeding, cold compress, antibiotics if no improvement within 24 hrs. ii.Infective mastitis : = May be due to staph. Aureus Rx. Antibiotics according to sensitivity iii.Breast abscess formation : = Rare but preventable Rx.- Surgical drainage if established. - antibiotics, only if early.

T REATMENT BY COMBINATION ANTIBIOTICS AS : Flucloxacillin 250 mg 3 time a day for breast infections. Encourage the patient to continue milk expulssion to prevent blockage of milk ducts and breast engorgement 19

T REATMENT BY COMBINATION ANTIBIOTICS AS : UTI : according to the result of C/S. Start with brood spectrum Antibiotics and then according to C/S and continue for 7 days. 20

T REATMENT BY COMBINATION ANTIBIOTICS AS : Intra venous therapy should be used if the patients is vomiting, systemically un well or suspected pyelonephiritis If patient fails to respond to initial therapy. review the result of cultures, assess her clinically,and arrange pelvic U/S to exclude pelvic collection. 21

TREATMENT BY COMBINATION ANTIBIOTICS AS : If there is a wound, pelvic abscess or breast abscess, it may need draining, otherwise change AB according to C/S, if there are not available,consider adding gentamicin or 3 rd generation cephelosporin 22

THANKS 23