POSTPARTUM &

PUERPERAL INFECTIONS

(Current Diagnosis & Treatment Obstetrics & Gynecology,

Tenth Edition 2007)

G.M. Punarbawa

 Infections: most prominent puerperal

complications.
An improved understanding of the natural
history of female genital infections and the
availability of powerful antibiotics
Cost>>: patients & society, serious
disability & death
Puerperal morbidity: temperature > 38 C
on 2 separate occasions at least 24 hours
apart following the first 24 hours after
delivery
Fever: patient with fever assumed: have a
genital infection until proved otherwise

 Incidence
Puerperal infectious: 28% of pregnant
women (>> low socioeconomic status,
operative delivery, PROM, long labors,
multiple pelvic exam)
Morbidity & Mortality
Postpartum infections:
Death (8% of all pregnant women who die
each year) The costs: additional
hospitalization, medications, time lost from
work
Sterility: (periadnexal adhesions)
Hysterectomy (serious postpartum/
postoperative infection)

 Pathogenesis
Birth canal flora: pregnant = nonpregnant
Vaginal flora: pathogenic aerobic &
anaerobic organisms (Table 311).
Mechanisms to prevent overt genital tract
infection:
acidity (normal vagina)
thick, tenacious cervical mucus
maternal antibodies to most vaginal flora

 During labor & rupture of the

membranes: some protective
mechanisms (-)
Examinations & invasive monitoring
apparatus vaginal bacteria uterine
cavity
Contractions during labor: spread
amniotic cavity bacteria adjacent
uterine lymphatics bloodstream
Postpartum uterus (devoid of
mechanisms keep it sterile), &
bacteria recovered from uterus (nearly
all women) in the postpartum period.

 Disease? clinically expressed?:

Depends on: predisposing factors, duration of
uterine contamination, type & amount of
microorganisms involved
Decidua necrosis & intrauterine contents
(lochia) anaerobic bacteria>>, heretofore
limited by lack of suitable nutrients and other
factors necessary for growth.
Endometrial cavity sterility: returns by 3rd 4th
postpartum week
Prevent infection by: Granulocytes (penetrate
endometrial cavity) & drainage of lochia

 Etiology
Almost by normal genitalia bacteria of
pregnant women.
Lochia: excellent culture medium
(ascending vagina organisms)
Cesarean section: >>devitalized tissue,
foreign bodies (sutures) additional fertile
ground contamination & subsequent
infection
+70% puerperal soft-tissue infections:
mixed infections (aerobic & anaerobic
organisms)

 General Evaluation
Source of infection should be identified, the
likely cause determined, and the severity
assessed.
Postpartum period fever: >> endometritis.
Urinary tract infection (UTI): next most
common
Neglected / virulent endomyometritis
serious infection (sepsis, septic pelvic
thrombophlebitis, pelvic abscess)

 Endometritis
Etiology
Risk factors: prolonged rupture of the membranes (>
24 hours), chorioamnionitis, >>VT, prolonged labor
(> 12 hours), toxemia, intrauterine pressure
catheters (> 8 hours), fetal scalp electrode
monitoring, preexisting vaginitis or cervicitis,
operative vaginal deliveries, CS, intra/postpartum
anemia, poor nutrition, obesity, low socioeconomic
status, coitus near term
CS & low socioeconomic class >>puerperal
infection
Series report: 4080% infection rate following CS
Postpartum infection: > serious CS vs vaginal
delivery
Bacterial vaginosis history: higher risk post-CS
endometritis

Clinical Findings
SYMPTOMS AND SIGNS
Endometritis: fever, soft, tender uterus
Lochia: foul odor? (+/-)
Leukocytosis (>10,000/ L)
Severe disease: high fever, malaise,
abdominal tenderness, ileus,
hypotension, & sepsis.

Uterus movement pain

 Fever
Puerperium: high metabolic activity
(should not raise > 37.2 C & only briefly
in 1st 24 hours postpartum
Fever > 38 C at any time (puerperium)
be evaluated.
Endometritis: 38 C - 40 C; depend on
patient, microorganism, extent of
infection
Usually develops on 2nd or 3rd postpartum

Uterine Tenderness
Uterus: soft & tender
Cervix & uterus motion pain
Abdominal tenderness: lower abdomen
Adnexal masses (tubo-ovarian abscess)
Bowel sounds, abdomen distended &
tympanitic
Pelvic examination confirms the findings
disclosed by abdominal examination.

LABORATORY FINDINGS
Hematologic Findings
Leukocytosis: > 20,000/ L
Bacteremia: 510% of women with
uncomplicated endometritis
Mycoplasma :>> blood of patients
with postpartum fever
Bacteroides: >> positive blood
cultures

 Urinalysis
Routinely performed (thought have
endometritis)
Urinary tract infections (UTI) clinical picture
similar to mild endometritis.
If pyuria & bacteria (+): antibiotic & culture
Lochia Cultures
lochia cultures: Bacteria colonizing cervical
canal & ectocervix (may not causing
endometritis)
Accurate cultures: transcervically (vaginal
contamination -)
Transabdominal aspiration uterine contents
(not routine)

 Bacteriologic Findings
Most puerperal infections: anaerobic
streptococci, gram (-) coliforms,
Bacteroides spp., & aerobic streptococci.
Chlamydia & Mycoplasma: clinical
isolates are rare (difficult to culture).
The percentage of microorganisms
recovered from women with endometritis
is given in Table 312
Patterns of bacterial isolates in puerperal
infections (patient's hospital): important
selection antibiotics

 AEROBIC BACTERIA
Group A streptococci (not major cause of
postpartum infection), but still occurs.
Penicillin is highly effective.
In 30% clinically recognized endometritis group
B streptococci
Signs: high fever & hypotension shortly after
delivery.
Group D streptococci (Streptococcus faecalis),
:common isolates in endometritis R/ high doses
Ampicillin & Aminoglycosides.
Staphylococcus aureus <<.
Staphylococcus epidermidis >> postpartum
infections (PPI); R/:nafcillin, cloxacillin, or
cephalosporins

 Gram (-) aerobic organisms recovered in PPI: E

coli (most common)
In PPI: E coli >> (seriously ill patients),
In UTI: >> isolated organism (not in sickest
patients). Hospital-acquired E coli : susceptible
to aminoglycosides & cephalosporins.
Incidence Neisseria gonorrhoeae: 28% in
pregnant women antepartum.
Incidence of asymptomatic endocervical
gonorrhea at delivery: slightly less
Gardnerella vaginalis cause of vaginitis: (+) in
PPI, usually with a polymicrobial cause,
although pure isolates have been reported.
Other gram-negative (Klebsiella pneumoniae,
Enterobacter, Proteus, and Pseudomonas spp.)
>> medical & surgical wards (uncommon
causes of endometritis).

 ANAEROBIC BACTERIA
Anaerobic bacteria: involved in 50%-95% PPI of
uterus. << in UTI.
Anaerobic Peptostreptococci & Peptococci: >>
PPI, particularly with other anaerobic species:
R/: Clindamycin, chloramphenicol, newer
cephalosporins.
Bacteroides spp., (Bacteroides fragilis), >> in
mixed PPI. >>:serious infections (puerperal
pelvic abscess, CS wound infections, septic
pelvic thrombophlebitis).
R/: clindamycin, chloramphenicol, 3rd
generation cephalosporins.
Gram (+) anaerobic organisms (only by
Clostridium perfringens): rare cause of PPI.

 OTHER ORGANISMS
Mycoplasma & Ureaplasma spp.: common
genital pathogens (isolated from genital
tract & blood of postpartum women): with
& without overt infection. The role of
these organisms in PPI is unknown.
Chlamydia trachomatis (thought
leading cause of PID) involved PPI, <<
early postpartum endometritis.
Chlamydia >> (mild late-onset
endometritis), cultures should be
obtained from endometritis patients (Dx:
several days after delivery).
Chlamydia: difficult to culture

 Differential Diagnosis
In the immediate postpartum period,
involuntary chills are common and are not
necessarily an indication of overt infection.
Lower abdominal pain is common (uterus
involution & contractions)
Extragenital infections: less common vs
endometritis & UTI. Most infections can
ruled out by history & examination. Asked
patients: coughing, chest pain, pain at the
insertion site of iv catheters, breast
tenderness, & leg pain.
Examination: breasts, chest, iv catheter
insertion site, leg veins.
Chest x-ray (pulmonary cause of the fever)

 Treatment
Antibiotics: (R/ endometritis) depends on
organisms & disease severity.
Initial therapy: iv antibiotics (high doses): because:
large uterus volume, expanded maternal blood
volume, brisk diuresis (puerperium), & difficulty in
achieving adequate tissue concentrations distal to
the thrombosed myometrial blood vessels.
Clindamycin + aminoglycoside: standard 1st line
regimen.
Good evidence: once-a-day dosing as effective
as thrice-daily regimen.
Single-agent therapy with 2nd atau 3rd generation
cephalosporins: acceptable alternative.
Response: monitored for 2448 hours.
Deterioration or failure to respond (clinically &
laboratory) re-evaluation.

 Ampicillin: added (inadequate response to

usual regimen, particularly if Enterococcus spp.
are suspected).
Iv antibiotics: continued until afebrile for 2448
hours.
Randomized & prospective trials: additional
treatment with oral antibiotics after
intravenous therapy is unnecessary.
Remains febrile (standard regimens)
evaluation: abscess, hematomas, wound
infection, septic pelvic thrombophlebitis?
Patients known infected, high risk infection
(delivery), initial therapy: 2- or 3-drug regimens
(1 agent is clindamycin is prudent). Singleagent iv infusion (broad-spectrum agents):
piperacillin or cefoxitin equally effective.

THANK YOU