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Define puerperal morbidity

Morbidity related to the genital tract following childbirth, miscarriage, or pregnancy termination


Define puerperal mortality

Death of pregnant or postpartum woman within 42 days of to childbirth, miscarriage, ectopic pregnancy, or termination from any cause related to pregnancy or its treatment (according to WHO)


Discuss predisposing factors to puerperal infection

Maternal characteristics
- Obesity
- Diabetes
- Severe anemia
- Immunocompromised: HIV infection
- BV
- GBS or Group A strep +
- Co-occurring infection: TB, pneumonia, meningitis
- Smoking
- Poor maternal hygiene, nutrition, oxygenation, tissue perfusion

Pregnancy characteristics
- Preterm birth
- Post-term pregnancy

Labor Characteristics
- C/S
- Chorio
- Internal monitoring
- Manual placenta removal
- Thick mec / meconium staining
- Operative vaginal delivery
- Prolonged labor
- Prolonged ROM
- Frequent vaginal exams
- Foley catheter


What is a puerperal Infection?

Fever of 38C or higher for over 24 hours, from onset of ROM or labor to 42 days after childbirth or abortion with one or more of the following:
- Abnormal vaginal discharge
- Pelvic pain
- Odor
- Delay in uterine involution
- Other s/s: general malaise, chills, pain, inc’d HR, abd pain, malodorous lochia


S/S of external genitalia, vaginal and cervical infection

- Increasing tenderness, erythema, edema
- Malodorous lochia
- Often accompanied by dysuria
- Severe infection: perineal abscess, purulent drainage, systemic symptoms


Pathophys of external genitalia, vaginal, and cervix infection

Laceration or episiotomy becomes infected. Infection generally confined to skin and subcutaneous tissue
Severe complication -- necrotizing fasciitis can develop


Treatment of external genitalia, vaginal, and cervix infection

Localized perineal infection (+heat, redness, erythema, absence of systemic s/s)
- Expectant management and perineal wound care -- frequent sitz baths, meticulous attention to perianal hygiene.
In absence of comorbidities, abx rarely indicated

Serious perineal wound infection -- prompt referral for eval and treatment
- Removal of sutures, plus opening, debriding and cleansing wound to allow area to heal by granulation
- Antibiotics may be administered if cellulitis present
- Most perineal wound infections not repaired again unless a 3rd or 4th degree perineal extension present
- Reduction in incidence of wound infections reported w/ prophylactic abx for 3rd & 4th degree tears


Cause of infections originating in the genital tract

Infections may occur from organisms that normally exist in the lower genital tract or bowel


Pathophys for endometritis

- Usually from GBS, enterococcus, E. coli, Klebsiella pneumoniae, Proteus, Bacteroides, Prevotella
- Endogenous cervicaovaginal flora enter the uterine cavity, contaminating its contents.
- Be more alert to it if there was something extra done to get the placenta or membranes (ie manual removal, etc)

Incidence: most common PP infection
C/S=15-20% * much higher risk for endometritis *


S/S of endometritis

- Classic triad: fever, tachy, uterine tenderness
- Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, purulent/foul smelling lochia, tachycardia, subinvolution
- If Group A or B Strep → scant odorless lochia, no signs except fever
- Lab findings: Leukocytosis
- Complications: Salpingitis, oophoritis, may result in infertility issues


Tx of endometritis

Treat empirically---
- Usually don’t manage this by yourself - comanage, or at least consult
- Clindamycin 900mg + Gentamicin 1.5mg/kg, q8h IV (endometrial infxn usually polymicrobial, so need broad-spectrum abx).
- Administer until woman is afebrile for 24-48 hrs (usually women respond to IV tx within 48-72 hrs)
- Add Ampicillin if suspect sepsis or enterococcal infection
- Gentamicin is poorly excreted in breastmilk, w/Clinda you need to observe infant for GI sx, and Ampicillin is ok w/breastfeeding
- R/o other sources of infection i.e. pneumonia, mastitis, pyelonephritis, or surgical site infection.


What is septic thrombophlebitis?

Venous thrombosis + inflammation + bacteremia

Usually associated with postpartum endometritis/parametritis following C/S in setting of chorio. Can occur in setting of pelvic vein endothelial damage, venous stasis, and hypercoagulability.


S/S septic thrombophlebitis

- fever , erythema, tenderness, a palpable tender cord, purulent drainage at site of involved vessel

- Complications: septic PE, secondary pneumonia

- Should be suspected in patients with persistent fever at least 3-5 days despite abx tx, and no evidence of abscess


Pathophys septic thrombophlebitis

- Postpartum women fulfil virchow’s triad for thrombosis (endothelial damage, venous stasis, hypercoagulability) + presence of infection → septic pelvic thrombophlebitis
- Can occur as extended site of local puerperal infection
- Most commonly caused by staph aureus
- Rare complication of pregnancy (1 in 9000 vag deliveries, 1 in 800 C/S)


Tx septic thrombophlebitis

- R/o more common causes of infection (wound or surgical site infection, resp tract infection, UTI)
- IV Antibiotics, maybe systemic anticoagulation (heparin)--Usually pt’s will already be on abx to empirically treat endometritis

Abx treatment:
Clindamycin 900mg + Gentamicin 1.5mg/kg, q8h IV (same as endometritis)
or ampicillin-sulbactam (unasyn)


What is pelvic cellulitis?

Inflammation of parametrium (connective tissue adjacent to uterus i.e. broad ligaments)


S/S of pelvic cellulitis

same as endometritis --
- Fever, chills, malaise, lethargy, anorexia, abdominal pain and cramping, uterine tenderness, purulent/foul smelling lochia, tachycardia


Pathophys pelvic cellulitis

- Can occur as extended site of local puerperal infection (i.e. deep cervical laceration extending to parametrium)
- Inflammatory process from endometritis may invade the myometrium and parametrium


Tx pelvic cellulitis

IV abx, same as endometritis

(clindamycin 900mg + gentamicin 1.5mg/kg q8, or ampicillin-sulbactam (unasyn)


S/S & Tx Peritonitis

- Abdominal pain, tenderness, guarding, rigidity
- Rebound tenderness
- Fever, tachy

Tx: IV abx


What is peritonitis?

Inflammation of membranes that line the abdomen


Discuss common pathogens in puerperal infection

Gram positive aerobes
- Strep A, B & D * fever >=39.0 C within 24 hrs of C/S may indicate Grp A infection
- Enterococcus, Staph aureus (also common w/ wound infections), Epidermis

Gram negative aerobes
- E-coli, Klebsiella, Enterobacter, Proteus

Gram variable organisms
- Gardnerella vaginallis

- Peptostreptococcus, peptococcus, bacteroides species, clostridium, fusobacterium

Mycoplasma, chlamydia, gonorrhea


Discuss methods of diagnosing puerperal infection and difficulties establishing a diagnosis

Most common causes - endometritis, wound infections, UTI
- Consider possibility of extended infections -- localized infection that extends via path of venous circulation or lymphatics to produce bacterial infection to more distant sites

- UA/UC (r/o UTI, pyelo)
- Phys exam (r/o ddx i.e. appendicitis, mastitis, pyelo)
- CXR as indicated to r/o pneumonia
- Blood cultures not routinely recommended if woman not acutely ill, as most women respond well to empiric therapy


S/S mastitis

- one or more segments of the breast are hot, red, tender, and inflamed.
- s/s may include chills, malaise, fever, flu-like symptoms, WBC < 4,000 or >12,000, and N/V


Pathophys of mastitis

Occurs d/t ineffective and/or obstructed drainage of milk from the breast.
Infectious mastitis results from untreated milk stasis and/or colonization with pathogenic bacteria. bacteria may be introduced from cracked or traumatised nipples.


Plugged ducts vs. mastitis

Plugged ducts
- Lump of localized milk stasis
- can be resolved with frequent feeding to empty breast, positioning infant’s chin toward blocked area, manual massage and warm water soaks
- may occur w/ painful white bleb on the nipple
- no fever or systemic s/s

- erythematous breast, painful, may be accompanied by systemic s/s
- not resolved w/ adequate emptying


Mastitis management

- Breast support-- Complete, frequent emptying of affected breast, assist with nursing technique, warm compresses or warm shower
- Appropriate intake of fluids

Antibiotic Tx
1st line tx:
- Dicloxacillin (dynapen) 500mg 4x/day for 10-14 days
- Cephalexin (keflex) 500mg 4x/day for 10-14 days
OR if PCN allergy -- clindamycin 300mg 4x/day or erythromycin 250mg (or 500mg) 4x/day for 10-14 days

*When to send milk culture & consult
- If s/s don’t resolve within 48 hrs of initiating abx
- s/s worsen despite tx
- maternal acute illness
- high suspicion of MRSA
- bilateral mastitis
- Infant may need to be treated concurrently, particularly if infxn with group A or group B strep suspected.
- Recurrent mastitis - culture and treat as appropriate for 14-30 days
- Rarely, persistent unresolved mastitis may be an early sign of inflammatory carcinoma


What is a breast abscess?

Localized collection of pus in the breast. Infecting organism is most often S. aureus, MRSA is increasingly common


Dx and Tx

Dx: by phys exam & US

- MD referral, may be collaboratively managed by midwife
- Surgical drainage or needed aspiration
- Antibiotics may be recommended (same tx as mastitis)
- Dicloxacillin (dynapen): 500mg PO 4x/day for 10-14 days
Or Cephalexin (keflex): 500mg PO 4x/day for 10-14 days


S/S postpartum UTI

May present with classic symptoms, but postpartum women w/ upper or lower UTIs often present with fever and generalized s/s, w/o dysuria, frequency or urgency.
**therefore any woman w/ fever postpartum should be eval’d for UTI**


Tx postpartum UTI

- Nitrofurantoin (Macrobid) 50-100mg PO q6h x 5d
Ok for lactating mothers of infants > 8d old, but consider other drugs if G6PD
- Sulfa-trimethoprim (Bactrim) 800/160mg PO BID x 3d
Ok to use in lactating mothers w/FT, healthy infants, consider other alternatives if infant is jaundiced or premature, or w/G6PD
- Fosfomycin (Monurol) 3g PO x 1
Low levels in milk, ok for lactating mother


Define subinvolution

Uterus does not return to its pre-pregnant size and position within expected time frame
- 2 wks PP: uterus should no longer be palpated abdominally
- 6 wks PP: involution should be complete


predisposing factors of subinvolution

Retained placental fragments, leiomyomas, infection
May occur from excessive maternal activity


S/S of subinvolution

- New onset bleeding or hemorrhage, often occurs during 2nd wk PP. Can present as increase or return of lochia rubra, or frank hemorrhage * for abnormal PP bleeding US may be useful to detect retained tissue or clot
- During bimanual exam uterus is larger and softer than expected


Management of subinvolution

If abnormal postpartum bleeding, perform US to assess if retained tissue or clot
- if retained tissue/clot -- uterine evacuation and curettage
- if empty uterine cavity -- oxytocin or methergine therapy


Puerperal hematoma

localized collection of extravasated blood that is usually clotted; arises following spontaneous or traumatic rupture of a blood vessel


Etiologies hematomas

Unrepaired torn blood vessels, trauma from instrumental birth, episiotomy


Predisposing factors to puerperal hematomas

Primiparity, multiple gestation, LGA, PEC, coagulopathies, vulvar varicosities, prolonged second stage


S/S vulvar & vaginal hematomas

- Perineal, vaginal, urethral, bladder, or rectal pressure and severe pain; Tense, fluctuant swelling
- Bluish or blue-black discoloration of tissue
- Extreme pain out of proportion to the expected amount of discomfort for that time period
- Usually sudden onset within 2-6 hours of delivery


S/S broad ligament hematomas

- Lateral, uterine pain sensitive to palpation
- Extension of pain to flank
- Painful swelling identified on high rectal examination
- A ridge of tissue just above the pelvic brim extending laterally
- Possible abdominal distension


Subperitoneal Hematoma

Very rare; likely diagnosed when patient begins experiencing hypovolemic shock from unrestricted bleeding


Management for Hematoma

- Frequent VS to monitor for increase in pulse rate and RR, drop in BP, and increase in temperature

If small, likely will absorb → manage expectantly
- Trace borders with pen to observe any change in size
- Pain medication as needed

If large (or growing)…CONSULT a physician
- Consider CBC and IV access if not already in place
- Frequent VS monitoring to observe for signs of shock
- Pain medication as needed

- Vaginal packing for counter pressure (12-24 hours)
- Incision to evacuate blood and blood clots/ensure closure of the cavity
- Involve interventional radiology, blood replacement, or antibiotics
- Require arterial embolization as a first or second line intervention to achieve hemostasis
- Be careful with cold therapy. Use intermittently (10 minutes per hour) and not directly on skin for best practice


Subsequent risks of puerperal hematomas

Subsequent risks include - Hemorrhage, Anemia, Infection, Hypovolemic shock


Why assess for puerperal hematoma w/ perineal/vulva exam during PP rounds?

Some hematomas will act inconspicuously so thorough examination of the vagina and the perineum/vulva (and possibly a rectal exam) may allow for earlier detection of hematomas and decrease risk of subsequent issues


Predisposing factors for VTE

- Pregnancy itself
- previous VTE
- family hx of VTE
- inherited thrombophilia
- diabetes
- autoimmune inflammatory disorders
- age greater than 35
- BMI >30
- varicose veins
- multifetal gestation
- hospitalization


Dx of VTE

venous doppler US


Describe pelvic venous thrombosis & management

- Blood clot in a pelvic vein.
- Often asymptomatic, incidence upwards of 30% in NSVD, and 47% in C/S
- Asymptomatic pelvic venous thrombosis is almost always not an issue, but in rare cases can be life threatening.
- if a thrombus is found incidentally, should be treated with some sort of thromboprophylaxis
- May need MRI to confirm if suspected; difficult to see with U/S during pregnancy


Management of PP venous thrombosis

- IV heparin and oral warfarin simultaneously; larger doses are often necessary in the PP period to achieve target INR of 2-3; will need 6 months of anticoagulation
- Will often need to wear graduated compression stockings for 2 years post treatment to avoid postthrombotic syndrome (chronic leg paresthesias or pain, intractable edema, skin changes, and leg ulcers)
- Therapeutic mgmt that we can encourage:
rest, elastic support, elevation of LE to improve venous return, warm packs, BR then ambulate once s/sx disappear, avoid standing for long periods of time, wear TEDS hose
Avoid pillow behind knees (causes pooling)


Management of PP venous thrombosis

- IV heparin + oral warfarin simultaneously
- Will often need to wear graduated compression stockings for 2 years post tx to avoid postthrombotic syndrome (chronic leg paresthesias or pain, intractable edema, skin changes, and leg ulcers)
- Therapeutic mgmt that we can encourage:
rest, elastic support, elevation of LE to improve venous return, warm packs, BR then ambulate once s/sx disappear, avoid standing for long periods of time, wear TEDS hose
Avoid pillow behind knees (causes pooling)


Risks for septic pelvic thrombophlebitis

- c/s
- chorioamnionitis
- endometritis
- wound complications


Tx and prevention

- Tx: abx
- Prevention: fewer C/S, DVT prophylaxis, abx prophylaxis


Define pulmonary embolism

Blockage of artery in lung by clot that has been dislodged from elsewhere in the body (complication of DVT)


S/S pulmonary embolism

Dyspnea, sudden/sharp chest pain, tachycardia, syncope, tachypnea, pulmonary rales, cough, hemoptysis, low O2 sats, CXR shows atelectasis and pleural effusion


Tx pulmonary embolism

- O2 by tight face mask to decrease hypoxia
- Bed rest w/HOB elevated to reduce dyspnea
- Analgesics for pain
(there were more on her slide….)
- Thrombolytic therapy (IV heparin)


PP thyroiditis (incidence, risk factors, s/s)

Incidence: 1.1-16.7%

Risk factors:
Autoimmune disorders (ie. T1DM, previous thyroid dysfunction, hx of thyroid disorders)
Family hx of thyroid disease
Presence of goiter

Can present as
1. Transient hypothyroidism
(4-8 months PP)
Constipation, depression, dry skin, fatigue, goiter, impaired concentration
*similar to normal PP changes and those with PP mood disorders.
2. Transient hyperthyroidism
(occurs 1-4 months PP)
Anxiety, fatigue, goiter, heat intolerance/sweats, insomnia, irritability, weight loss
3. Hyperthyroidism followed by hypothyroidism, and then recovery.

Associated with PP depression


Postpartum thyroiditis Dx

- Can occur anytime during the 1st year PP
Hyperthyroidism: low TSH, positive for TPO, neg TSHRAb (TSH receptor antibodies)
Hypothyroidism: high TSH, positive for antithyroid peroxidase antibodies


Postpartum thyroiditis TX

- If s/s mild - no treatment needed
- Hyperthyroidism s/s if bothersome -- beta blockers
- Hypothyroidism if s/s - synthroid
- MD consult
- Long term follow up strongly advised -- up to 50% of pts will develop permanent hypothyroidism in 5-10 years


Describe Graves disease and course in the postpartum period

- autoimmune disorder, most common cause of hyperthyroidism
- most common cause of thyrotoxicosis in pregnancy
- Graves hyperthyroidism may recur after delivery with an exacerbation in the 1st 3 months or between 6-12 months PP. S/s in grave’s disease more severe than pt’s with postpartum thyroiditis.
- The late postpartum period is associated with risk of developing graves disease de novo


Graves disease risk factors

Hx of or active grave’s disease during pregnancy or a thyrotoxic phase in early pregnancy at inc’d risk


Graves disease s/s & clinical course

Exacerbation of hyperthyroidism
Visible goiter


Graves disease dx

- Undetected TSH, high T4, TRAb positive
- 4 or 24hr thyroid radioactive iodine uptake (RAIU) (contraindicated w/ breastfeeding) -- will be high normal or elevated with recurrent hyperthyroidism d/t Graves disease


Graves disease Tx

MD consult
Anti-thyroid medications-- PTU, methimazole
Beta blockers help w/ symptoms
May advise ablation therapy


Sheehan's syndrome

- pituitary ischemia and necrosis associated with obstetrical blood loss → hypopituitarism
- rare
- s/s: Persistent hypotension, tachycardia, hypoglycemia, lactation failure, amenorrhea or oligomenorrhea
- dx: check pituitary hormone labs. check for adrenal insufficiency as well, life threatening complication of Sheehan's
- tx: glucocorticoid replacement tx, lifelong hormone replacement tx