00:01
Evidence-based management
00:02
of postpartum infection.
00:03
00:06
This is an outline
00:07
of our presentation today.
00:09
We’ll start off by giving
00:10
a brief introduction
00:12
to postpartum infections.
00:13
In particular, we will discuss
00:15
endomyometritis, wound
00:17
infection, urinary tract
00:19
infections, and mastitis,
00:21
with the focus
00:22
on their etiology,
00:23
associated risk factors, signs
00:26
and symptoms, and management.
00:27
00:30
General risk factors
00:32
for postpartum infection
00:33
include Cesarean delivery,
00:36
prolonged rupture of membranes,
00:38
urinary catheterization,
00:40
diabetes, group B strep
00:42
infection, anemia, and obesity.
00:45
00:48
The first postpartum infection
00:50
we will discuss
00:51
is endomyometritis.
00:53
Endomyometritis is
00:54
a polymicrobial infection
00:56
of the uterine lining
00:57
and underlying wall.
00:59
Risk factors for developing
01:00
endomyometritis
01:02
include lower segment Cesarean
01:04
section, manual removal
01:06
of the placenta,
01:07
retained products of conception,
01:09
chorioamnionitis,
01:11
and premature rupture
01:12
of membranes.
01:14
Patients present with fever
01:16
and uterine tenderness,
01:17
typically five to 10 days
01:18
following delivery.
01:19
01:22
Because retained products
01:24
of conception
01:24
can be the etiology
01:26
of infection, ultrasound
01:27
is often obtained to examine
01:29
the intrauterine contents.
01:31
Full blood count
01:32
and C-reactive protein
01:34
are also routinely done.
01:36
Usually treated
01:37
with broad-spectrum
01:38
intravenous antibiotics,
01:39
such as second-generation
01:40
cephalosporins.
01:42
If products of conception
01:43
are identified on ultrasound,
01:45
dilation and curettage
01:47
is performed.
01:48
Antibiotics are continued
01:50
until the patient is afebrile
01:51
for 48 hours, uterine pain
01:54
and tenderness are absent,
01:56
and white blood cell count
01:57
is normal.
01:58
The routine use of antibiotics
02:00
has proven to be
02:01
beneficial
02:02
in high-risk obstetric patients
02:04
with postpartum endometritis–
02:07
for example,
02:08
patients with prolonged labor
02:09
or prolonged rupture
02:10
of membranes.
02:11
02:14
Postpartum wound infections are
02:16
uncommon.
02:17
They occur in 1% to 5%
02:19
of Cesarean skin incisions
02:21
and 0.1% of perineal lacerations
02:24
or episiotomy sites.
02:26
Most often,
02:27
the etiologic organisms
02:29
associated with wound infections
02:30
are skin flora, including
02:32
staphylococcus or streptococcus
02:35
species,
02:36
and gram-negative organisms as
02:38
in endometritis.
02:38
02:42
Signs and symptoms of wound
02:43
infection usually occur four
02:45
to seven days later.
02:47
These would include fever,
02:48
particularly
02:49
with infected Cesarean section
02:51
incisions, erythema
02:53
around the wound site,
02:54
particularly if it’s associated
02:56
with tenderness, and warmth.
02:58
Purulent discharge
02:59
from the wound site is a telling
03:01
sign.
03:02
If the infection does not
03:03
respond to antibiotics
03:05
and persistent fever
03:06
or there is
03:07
a fluctuant collection
03:08
within the wound site,
03:10
an abscess should be suspected.
03:11
03:15
Treatment entails proper wound
03:16
cleaning and care.
03:18
Abscesses must be incised,
03:20
drained, and properly cleaned
03:22
and dressed as a delay may lead
03:24
to necrotizing fasciitis.
03:27
Patients should be treated
03:28
with broad-spectrum antibiotics
03:30
with the focus
03:31
on covering skin flora.
03:33
Before giving
03:33
broad-spectrum antibiotics,
03:35
a wound culture swab should be
03:37
obtained to determine
03:38
the causative organisms
03:40
and the antibiotic sensitivity
03:41
profile
03:42
so
03:43
that definitive antimicrobial
03:45
therapy can be implemented.
03:47
Finally,
03:48
as a preventive measure,
03:49
prophylactic antibiotics should
03:51
be given for all Cesarean
03:52
sections.
03:52
03:56
Urinary tract infections often
03:58
result
03:58
from urinary catheterization
04:00
during and after labor.
04:02
Catheterizations are required
04:03
for epidural and spinal
04:05
anesthesia
04:06
to avoid urinary retention.
04:08
Urinary tract infections can
04:10
travel up to involve the bladder
04:12
and the kidneys, causing
04:14
cystitis and pyelonephritis
04:15
[INAUDIBLE].
04:17
Symptoms include
04:19
urinary frequency, dysuria,
04:21
flank pain, costovertebral angle
04:24
tenderness,
04:25
suprapubic tenderness,
04:26
and fever.
04:27
Diagnosis is made by urinalysis
04:31
and urine culture.
04:32
Treatment consists
04:33
of
04:34
trimethoprim-sulfamethoxazole,
04:36
nitrofurantoin,
04:38
fluoroquinolones.
04:40
These drugs are safe to use
04:41
in breastfeeding mothers.
04:43
Nevertheless, care should be
04:45
taken to avoid breastfeeding
04:46
the infant within four hours
04:48
of taking the drug to minimize
04:50
exposure.
04:50
04:53
Mastitis is a regional infection
04:55
of the breast which is caused
04:57
by the mother’s skin flora
04:59
or baby’s oral flora.
05:01
These bacteria can penetrate
05:02
through a cracked nipple
05:04
and proliferate causing symptoms
05:06
of infection.
05:08
Commonly, lactating women will
05:10
have warm, diffusely tender,
05:12
and firm breasts,
05:13
especially at the time of breast
05:15
engorgement and milk
05:16
[INAUDIBLE].
05:17
These are the normal signs
05:19
and are not signs of mastitis.
05:21
The infection typically presents
05:23
with focal tenderness, erythema,
05:25
and differences in temperature
05:27
from one region of the breast
05:28
to another.
05:30
Mastitis might also complicated
05:32
by formation of an abscess.
05:34
Mastitis is diagnosed
05:36
by physical examination
05:37
of the breasts.
05:38
Fever and elevated white cell
05:40
count are common.
05:42
Mastitis is treated
05:43
with oral antibiotics.
05:45
It is worth noting
05:46
that a patient should continue
05:48
breastfeeding as it helps
05:49
to remove bacteria
05:50
from the breast.
05:52
If breastfeeding is not
05:53
possible, then the patient
05:55
should pump breasts
05:56
in acute phase of the infection.
05:59
If oral therapy fails,
06:01
then IV antibiotics should be
06:02
started until the patient is
06:04
afebrile for 48 hours.
06:07
If this fails, then an abscess
06:08
should be suspected
06:10
and confirmed by imaging
06:11
studies.
06:12
The abscess is treated
06:14
with incision and drainage.
06:15
06:18
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06:20
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