Puerperal Infection | Definition | Description | Causes and symptoms | Treatment

Definition

Puerperal infection is a bacterial infection that occurs following childbirth. The diagnostic criteria require that the childbearing woman have a temperature over 100.4°F (38°C) on any two of the first 10 postpartum days after day one, or over 101.5°F (38.6°C) during the first 24 hours.

Description

The incidence of puerperal infection is 1-8% of the postpartum female population in the United States. The incidence is five to 10 times higher when a woman delivers by cesarean section. As most births in the United States occur in hospitals, the majority of puerperal infections are considered nosocomial, or hospital-acquired. With antibiotics readily available in industrialized countries, death related to puerperal infection is very rare, at 0.3 in 100,000. In developing nations, the death rate due to puerperal infection is estimated to be 100 times higher. Puerperal infection may occur in the genital tract, breast, urinary tract, lungs, blood vessel, or wound.

Causes and symptoms

The usual cause of puerperal infection is a bacterial infection in the genital tract, primarily the uterus. This infection, called endometritis, is associated with prolonged rupture of membranes; difficult vaginal birth which involved the use of forceps or vacuum extractor; multiple vaginal examinations; low socioeconomic status; and the primary predisposing factor of cesarean section delivery, with an incidence of postoperative infection reported at 29-85%.

Symptoms of endometritis include elevated temperature, low abdominal pain or tenderness, vaginal discharge, or a heavy, malodorous lochia usually in the first two to seven days postpartum. Endometritis is usually polymicrobial, that is, more than one bacterial species is found upon culture. The mixed species tend to multiply their negative effects. Other symptoms in puerperal infection are dependent on the infected site. Mastitis or breast infection can be caused by bacterial contamination from the breastfeeding infant's mouth. Symptoms include elevated temperature, localized inflammation, breast tenderness, general malaise, and muscle aching. Symptoms of a urinary tract infection include elevated temperature, frequent voiding, urgency to void, and pain upon voiding. Back pain, as well as nausea and vomiting, are common with pyelonephritis. Lung infection, or pneumonia, may be seen especially in the patient who has received general anesthesia. Symptoms include decreased or abnormal breath sounds, cough, and chest wall discomfort. An infection in a blood vessel, phlebitis, may be caused by the introduction of bacteriaby a contaminated intravenous needle or at the site of a blood clot, thrombophlebitis. Wound sites in the postpartum woman may include episiotomy or cesarean section incision. These sites, if infected, would have inflammation, swelling, and drainage, and the patient would have an elevated temperature. It is interesting to note that while vaginal secretions contain up to 10 billion organisms per gram of fluid, only 1% of postpartum women develop infection in perineal tears or episiotomies.

Diagnosis

Diagnosis of puerperal infection is made on the basis of the presenting symptoms, which must be thoroughly investigated. In addition, diagnostic testing may include a complete blood count, chest x ray, urinalysis, or wound culture. High vaginal or endocervical cultures are not helpful in identifying a uterine pathogen, and transabdominal uterine aspiration is not recommended, as it may only serve to spread the infection. Blood cultures may be done, but they are only positive 8% of the time. Radiologic testing is helpful if symptoms are resistant to initial treatment or if pneumonia is suspected. Ultrasound or computed tomography scan (CT scan) may identify a potential abdominal abscess or blood clot. Magnetic resonance imaging (MRI) may also be used if symptoms of a blood clot are present.

Treatment

Antibiotic therapy is the mainstay of treatment in puerperal infection. Hospitalization may or may not be necessary. Clindamycin and gentamicin may be used as initial therapy, as they are broad-spectrum antibiotics, that is, covering more than one organism. Ampicillin may be added if symptoms persist. If an abscess has been diagnosed, surgical drainage may be required. In the presence of thrombophlebitis, heparin therapy will be needed to provide anticoagulation.

Prognosis

With access to appropriate antibiotics, the prognosis of rapid recovery from puerperal infection is excellent.

Health care team roles

Physicians and nurses are involved in the prevention, diagnosis, and treatment of puerpera linfection. Good prenatal care is essential for avoiding the risk of infection after childbirth. Postpartum nurses assess patients for signs and symptoms of infection and educate patients about these signs and symptoms prior to discharge. Home health nurses making follow-up visits assess patients for signs and symptoms of infection. Emergency physicians are seeing an increasing number of postpartum patients presenting with a fever or evidence of infection due to earlier discharge from the hospital after childbirth.

Prevention

Identification of risk factors such as premature rupture of membranes or the use of prophylactic antibiotics at the time of an emergent cesarean section will lower the incidence of puerperal infection. The fundamental practice of strict aseptic technique is the first line of prevention.

KEY TERMS

Endometritis— Inflammation of the mucous membrane lining the inner surface of the uterus.

Lochia— Discharge from the uterus of blood, mucus, and tissue during the puerperal peiord.

Mastitis— Inflammation of the breast.

Nosocomial— Pertaining to a hospital or infirmary.

Postpartum— After childbirth.

Puerperal— Period immediately following childbirth.

Resources

BOOKS

Charles, Jonathan, and David Charles. "Postpartum Infection." In Obstetric and Perinatal Infections, edited by David Charles. St. Louis: Mosby-Year Book, Inc., 1993.

Rivlin, Michel E. "Puerperal Infections." In Manual of Clinical Problems in Obstetrics and Gynecology, 4th edition. Edited by Michel E. Rivlin and Rick W. Martin. Boston: Little, Brown and Company, 1994.

OTHER

Kennedy, Elicia. "Pregnancy, Postpartum Infections." eMedicine Journal, 2, no. 5, 12 May, 2001. 〈http://www.emedicine.com/emerg.topic482.htm〉.

Todar, Kenneth. "Bacteriology 330 Lecture Topics: Streptococcus pyogenes." Bacteriology at University of Wisconsin Home Page, 1998. 〈http://www.bact.wisc.edu/Bact330/lecturespyo〉.

"Puerperal Infection." The Merck Manual, 2001.〈http://www.merck.com/pubs/mmanual/section18/chapter254/254b.htm〉.

University of Pennsylvania. "Puerperal infection."〈http://www.obgyn.upenn.edu/History/puerp.html〉.