Tutorial 11: Puerperal Sepsis

Question 1

What is sepsis?

Answer 1

infection + systemic manifestations of infection.

Question 2

What is puerperal sepsis?

Answer 2

sepsis developing after birth until 6 weeks postnatally

Question 3

What are some facts about puerperal sepsis?

Answer 3

The most common site of sepsis in the puerperium is the genital tract and in particular the uterus, resulting in endometritis.

Puerperal sepsis causes at least 75,000 maternal deaths every year, most in developing countries.

If it does not cause death, puerperal sepsis can cause long term health problems such as chronic pelvic inflammatory disease and infertility.

Question 4

DDx for postpartum fever?

Answer 4

1. Genital Tract Infection
2. Atelectasis/pneumonia
3. UTI
4. Endometritis
5. Wound Infection
6. Septic Pelvic Thrombophlebitis
7. Mastitis

Question 5

What are features of Genital Tract Infection?

Answer 5

Cardinal signs area tender, bulky uterus and offensive lochia (vaginal discharge for 1st fortnight of puerperium containing blood, mucus, and placental tissue. It is often associated with retained placental tissue.

Question 6

What are features of atelectasis/pneumonia?

Answer 6

(PPD 0): mild to moderate fever, no changes or mild rales on chest auscultation.

• Risk factors: general anesthesia, cigarette smoking, and obstructive lung disease.
• Management: pulmonary exercises, ambulation.

Question 7

What are features of a UTI?

Answer 7

(PPD 1-2): high fever, malaise, costovertebral tenderness, positive urine culture.

• Risk factors: multiple catheterization during labor, multiple vaginal
• examinations during labour, and untreated bacteriuria.
• Management: antibiotics as per culture sensitivity (cephalosporine 1-2 g parentral q6hr).

Question 8

What are some features of Endometritis?

Answer 8

PPD 2-3): moderate fever, exquisite uterine tenderness, minimal abdominal findings.

• Risk factors: emergency C section, prolonged membrane rupture, prolonged labour, multiple vaginal deliveries in labour.
• Management: multiple agent IV antibiotics to cover polymicrobial organisms: clindamycin 900 mg q8hr, gentamicin 500 mg everyday, addition of ampicillin 1–2 g IV q6hr if no response, no cultures are necessary.

Question 9

What are features of wound infection?

Answer 9

(PPD 4-5): persistent spiking fever despite antibiotics, wound erythema or flactuance, wound drainage.

• Management: antibiotics for cellulitis, open and drain wound, saline-soaked packing twice a day, secondary closure.
• Risk factors: Emergency C-section, prolonged membrane rupture, prolonged labour, and multiple vaginal examination during labour.

Question 10

What are features of septic pelvic thrombophlebitis?

Answer 10

(PPD 5-6): persistent wide fever swings despite antibiotics, usually normal abdominal or pelvic exams.

• Risk factors: Emergency C-section, prolonged membrane rupture, prolonged labour, and diffuse difficult vaginal delivery.
• Management: IV heparin for 7–10 days at rates sufficient to prolong the PTT to double the baseline values.

Question 11

What are features of mastitis?

Answer 11

(PPD 7-21): unilateral, localized erythema, edema, tenderness. Pathogen is usually staph aureus.
o Risk factors: nipple trauma from breast feeding, diabetes, obesity.
o Management: antibiotics for cellulitis, open and drain abscess if present.

Question 12

What are important parts of the hx and ex for puerperal sepsis?

Answer 12

• Fever +/- rigors
• Diarrhoea or vomiting – may indicate exotoxin production
• Breast engorgement/redness
• Rash – generalised maculopapular rash
• Abdominal/pelvic pain and tenderness
• Wound infection – spreading cellulitis or discharge
• Offensive vaginal discharge
• Productive cough
• Urinary symptoms
• Delay in uterine involution, heavy lochia
• General – non-specific signs such as lethargy, reduced appetite

Question 13

What organisms are commonly involved in puerperal sepsis?

Answer 13

• Streptococcus pyogenes
• Escherichia coli
• Staphylococcus aureus
• Streptococcus pneumoniae
• Other - Clostridium spp., Chlamydia, Gonococci

Question 14

What investigations do you do for puerperal sepsis?

Answer 14

• Routine bloods – FBC, creatinine
• Blood cultures – should be obtained prior to antibiotic administration
• Serum lactate – should be measured within 6 hours of suspicion of severe sepsis.
• Serum lactate ≥ 4 mmol/L is indicative of tissue hypoperfusion.
• Relevant imaging (chest X-ray, pelvic USS, pelvic CT scan) – to confirm source of infection and rule out retained placental products
• Other samples (MSU, throat swab, high vaginal swab, sputum, CSF, epidural site swab, wound swabs, expressed breast milk) – guided by clinical suspicion of focus of infection

Question 15

What is the management of puerperal sepsis?

Answer 15

• ABC’s
• IV broad spectrum antibiotics – within 1 hour of suspicion of severe sepsis (sepsis plus organ dysfunction or tissue hypoperfusion), with or without septic shock. Note that breastfeeding limits the use of some antimicrobials, hence the advice of an infectious diseases consultant should be sought at an early stage.
• Seek focus of infection and deal with it - this may be by uterine evacuation or by drainage of a breast, wound or pelvic abscess.
• Admission to ICU – the presence of shock or other organ dysfunction are indications for admission to ICU.