any bacterial infection of the genital tract after delivery Most persistent fevers after childbirth are caused by genital tract infection

temperature 38.0 C (100.4 F) or higher at any 2 of the first 10 days postpartum, exclusive of the first 24 hours and to be taken by mouth by a standard technique at least 4 times daily high spiking fever within first 24 hours virulent infection with group A strep Attributable fever rarely exceeds 39C in the

first few postpartum days and usually lasts less than 24 hours. Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. Atelectasis is caused by hypoventilation and is best prevented by coughing and deep

breathing on a fixed schedule following surgery Postpartum uterine infection has been called variously endometritis, endomyometritis, and endoparametritis. Because infection involves not only the decidua but also the myometrium and parametrial tissues, the inclusive term

metritis with pelvic cellulitis. PREDISPOSING FACTOR The route of delivery is the single most significant risk factor for the development of uterine infection

VAGINAL DELIVERY Women at high risk for infection because of membrane rupture, prolonged labor, and multiple cervical examinations have a 5- to 6-percent incidence of metritis after vaginal delivery. If there is intrapartum chorioamnionitis, the risk of persistent uterine infection increases to 13 percent CESAREAN DELIVERY

Single-dose perioperative antimicrobial prophylaxis is given almost universally at cesarean delivery Important risk factors for infection following surgery ARE: 1. prolonged labor 2. membrane rupture,multiple cervical examinations, 3. internal fetal monitoring Women with all of these factors who were not given perioperative prophylaxis had a 90-percent serious pelvic infection rate

Lower socioeconomic status Group B streptococcus, Chlamydia trachomatis, Mycoplasma hominis,Ureaplasma urealyticum, and Gardnerella vaginalis Cesarean delivery for multifetal gestation Young maternal age and nulliparity Prolonged labor induction

Obesity Meconium-stained amnionic fluid group A -hemolytic streptococcus causing toxic shock-like syndrome and life-threatening infection skin and soft-tissue infections due to community-acquired methicillin-resistant

Staphylococcus aureusCA-MRSAhave become common METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS -these strains are not a common agent of puerperal metritis, but they are causative in incisional wound infections Routine pretreatment genital

tract cultures are of little clinical use and add significant costs Similarly, routine blood cultures seldom modify care Fever is the most important criterion for the diagnosis of postpartum metritis. Temperatures commonly are 38 to 39C. Chills that accompany fever suggest bacteremia.

Women usually complain of abdominal pain, and parametrial tenderness is elicited on abdominal and bimanual examination Although an offensive odor may develop, many women have foul-smelling lochia without evidence for infection. Other infections, notably those due to group A -hemolytic streptococci, are frequently associated with scanty, odorless lochia Leukocytosis may range from 15,000 to 30,000 cells/L,

but recall that cesarean delivery itself increases the leukocyte count If mild metritis develops after a woman has been discharged following vaginal delivery, outpatient treatment with an oral antimicrobial agent is usually sufficient. For moderate to severe infections, however, intravenous therapy with a broad-spectrum

antimicrobial regimen is indicated. Improvement follows in 48 to 72 hours in nearly 90 percent of women treated with one of several regimens. The woman may be discharged home after she has been afebrile for at least 24 hours. Further oral antimicrobial therapy is not needed

CLINDAMYCIN-GENTAMICIN REGIMEN had a 95-percent response rate still considered by most to be the standard by which others are measured Because enterococcal infections may persist despite this standard therapy, many add ampicillin to the clindamycin-gentamicin regimen, either initially or if there is no

response by 48 to 72 hours. Because of potential nephrotoxicity and ototoxicity with gentamicin in the event of diminished glomerular filtration, some have recommended a combination of clindamycin and a second-generation cephalosporin to treat such women. Others recommend a combination of

clindamycin and aztreonam, a monobactam compound with activity similar to the aminoglycosides LACTAMASE INHIBITORS (CLAVULANIC ACID, SULBACTAM, AND TAZOBACTAM) combined with ampicillin, amoxicillin, ticarcillin, and piperacillin to extend their spectra.

METRONIDAZOLE superior in vitro activity against most anaerobes. given with ampicillin and an aminoglycoside provides coverage against most organisms encountered in serious pelvic infections IMIPENEM a carbapenem that has broadspectrum coverage against most

organisms associated with metritis used in combination with cilastatin, which inhibits renal metabolism of imipenem it is effective in most cases of metritis Vancomycin is a glycopeptide antimicrobial

active against gram-positive bacteria. It is used in lieu of -lactam therapy for a patient with a type 1 allergic reaction and given for suspected infections due to Staphylococcus aureus s and to treat C difficile colitis. Prenatal treatment of asymptomatic vaginal infections has not been shown to

prevent postpartum pelvic infections No beneficial effects for women treated for asymptomatic bacterial vaginosis. In more than 90 percent of women, metritis responds to treatment within 48 to 72

hours When prophylactic antimicrobials are given as described above, the incidence of abdominal incisional infections following cesarean delivery is less than 2 percent The incidence in some cases averaged 6 percent and ranged from 3 to 15 percent Wound infection is a common cause of

persistent fever in women treated for metritis Risk factors: obesity diabetes corticosteroid therapy immunosuppression

anemia poor hemostasis with hematoma formation Incisional abscesses that develop following cesarean delivery usually cause fever or are responsible for its persistence beginning about the fourth day. Wound erythema and drainage usually

accompany it. Treatment includes antimicrobials and surgical drainage, with careful inspection to ensure that the fascia is intact. With local wound care given two to three times daily, secondary en bloc closure at 4 to 6 days of

tissue involved in superficial wound infection can usually be refers to separation of the fascial layer serious complication and requires secondary closure of the incision in the operating room disruptions manifest about 5th post-op day with serosanguineous discharges TREATMENT

secondary closure of the incision with adequate anesthesia uncommon, severe wound infection is associated with high mortality may involve abdominal incisions, or it may complicate episiotomy or other perineal

lacerations RISK FACTORS:diabetes, obesity, and hypertensionare relatively common in pregnant women caused by a single virulent bacterial species such as group A -hemolytic streptococcus. Occasionally some are caused by rarely encountered pathogens

TREATMENT Treatment consists of broad-spectrum antibiotics along with prompt wide fascial debridement until healthy bleeding tissue is encountered. With extensive resection, synthetic mesh may be required to close the fascial incision Clindamycin given with a beta-lactam antimicrobial - most effective regimen

unusual for peritonitis to develop following cesarean delivery It is almost invariably preceded by metritis and uterine incisional necrosis and dehiscence. Other cases may be due to inadvertent bowel injury at cesarean delivery. Yet another cause is peritonitis following

rupture of a parametrial or adnexal abscess. It may rarely be encountered after vaginal delivery. Ovarian abscess bacterial invasion through a vent in the ovarian capsule usually unilateral and present 1-2 weeks after delivery Rupture is common and peritonitis may be

severe TREATMENT drain and give antibiotics In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of

induration, or phlegmon, within the leaves of the broad ligament These infections should be considered when fever persists longer than 72 hours despite intravenous antimicrobial therapy Phlegmons are usually unilateral, and they frequently are limited to the parametrial area at the base of the broad ligament

The most common form of extension is laterally along the broad ligament, with a tendency to extend to the pelvic sidewall. Occasionally, posterior extension may involve the rectovaginal septum, producing a firm mass posterior to the cervix Because puerperal metritis with cellulitis is typically a retroperitoneal infection, evidence

of peritonitis suggests the possibility of uterine incisional necrosis, or less commonly, a bowel injury In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen. Typically, fever resolves in 5 to 7 days,

but in some cases, it is longer. Absorption of the induration may require several days to weeks. Surgery is reserved for women in whom uterine incisional necrosis is suspected In rare cases, uterine debridement and resuturing of the incision are feasible. For most, hysterectomy and surgical

debridement are needed and are predictably difficult Frequently, the cervix and lower uterine segment are involved with an intensive inflammatory process that extends to the pelvic sidewall to encompass one or both ureters . The adnexa are seldom involved, and one or both ovaries usually can be

conserved A.Pelvic computed tomography scan of dehiscence caused by infection of a vertical cesarean incision. Endometrial fluid (small black arrows) communicates with parametrial fluid (curved white arrows) through the uterine defect (large black arrow). A dilated bowel loop (b) is adjacent to the uterus on the left. B. Supracervical hysterectomy specimen with instrument through uterine dehiscence.

parametrial phlegmon suppurates, forming a fluctuant broad ligament mass that may point above the inguinal ligament Psoas abscess may rarely follow delivery TREATMENT antimicrobial therapy percutaneous drainage

common complication in the preantibotic era With the advent of antimicrobial therapy, the mortality rate and need for surgical therapy for these infections diminished Although there occasionally is pain in one or both lower quadrants, patients are usually asymptomatic except for chills.

Diagnosis can be confirmed by either pelvic CT or MR imaging Routes of extension of septic pelvic thrombophlebitis. Any pelvic vessel and the inferior vena cava may be involved as shown on the left. The clot in the right common iliac vein extends from the uterine and internal iliac veins and into the inferior vena cava.

The addition of heparin to antimicrobial therapy for septic pelvic thrombophlebitis did not hasten recovery or improve outcome. Certainly, there is no evidence for longterm anticoagulation as given for "bland" venous thromboembolism. Most important is that the surgical

wound must be properly cleaned and free of infection once the surface of the episiotomy wound is free of infection and exudate and covered by pink granulation tissue, secondary repair can be accomplished Postoperative care includes local wound care, low-residue diet, stool softeners, and nothing per vagina or rectum until

healed rare but frequently fatal complication of perineal and vaginal wound infections is deep soft-tissue infection involving muscle and fascia Although women with diabetes or women who are immunocompromised

are more vulnerable, these serious infections may develop in otherwise healthy women Necrotizing fasciitis of the episiotomy site may involve any of the several superficial or

deep perineal fascial layers, and thus may extend to the thighs, buttocks, and abdominal wall Although some virulent infections, for example, from group A -hemolytic streptococci, develop early postpartum, these infections typically do not cause symptoms until 3 to 5 days after delivery. Clinical findings vary, and it is frequently difficult

to differentiate more innocuous superficial perineal infections from an ominous deep fascial one. A high index of suspicion, with surgical exploration if the diagnosis is uncertain, may be lifesaving

Early diagnosis, surgical debridement, antimicrobials, and intensive care are of paramount importance in the successful treatment of necrotizing soft-tissue infections Surgery includes extensive debridement of all infected tissue, leaving wide margins of

healthy tissue. Mortality is virtually universal without surgical treatment, and rates approach 50 percent even if extensive debridement is performed.

acute febrile illness with severe multisystem derangement fever, headache, mental confusion, diffuse macular erythematous rash, subcutaneous edema, nausea, vomiting, watery diarrhea, marked hemoconcentration

renal failure hepatic failure, DIC circulatory collapse Staphylococcus aureus toxic shock syndrome toxin 1 first associated with young menstruating women who used tampons

Therapy : SUPPORTIVE, similar treatment with septic shock, anti-staphylococcal antimicrobials, massive fluid replacement, mechanical ventilation with PEEP, renal dialysis

Parenchymal infection of the mammary glands is a rare antepartum complication but is estimated to develop in up to a third of breast-feeding women.

Symptoms of suppurative mastitis seldom appear beforethe end of the first week postpartum and as a rule, not until the third or fourth week. Infection almost invariably is unilateral, and marked engorgement usually precedes inflammation.Symptoms include chills or actual rigors, which are soon followed by fever and tachycardia. There is severe pain, and the breast(s) becomes hard and red (Fig. 37-8). Approximately10 percent

of women with mastitis develop an abscess. Staphylococcus aureus, especially its methicillin-resistant strain, isthe most commonly isolated organism. Other commonly isolated organisms are coagulase-negative staphylococci and viridans streptococci. The infecting organismcan usually be

cultured from milk. Toxic shock syndrome from mastitis caused by S aureuss has been reported . Provided that appropriate therapy for mastitis is started before suppuration begins, the infection usually resolves within48 hours.

As discussed, abscess formation is more common with S aureus infection . Most recommend that milk be expressed from the affected breast onto a swab and cultured before therapy is begun.

Dicloxacillin, 500 mg orally four times daily, may be started empirically. Erythromycin is given to women who are

penicillin sensitive. If the infection is caused by resistant, penicillinase-producing staphylococci or if resistant organisms are suspected while awaiting the culture results, then vancomycin or another anti-MRSA antimicrobial should be given. Even though clinical response may be prompt, treatment should be continued for10 to 14 days.

continued breast feeding is important. When nursing bilaterally, it is best to begin suckling on the uninvolved breast. This allows let-down to commence before moving to the tender breast.

An abscess should be suspected when defervescence does not follow within 48 to 72 hours

of mastitis treatment or when a mass is palpable. Traditional therapy is surgical drainage, which usually requires general anesthesia. A more recently used technique that is less invasive is sono-graphically guided needle aspiration using local analgesia. This has an 80- to 90-percent success rate. aspiration resulted in quicker healing at 8 weeks.

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