PUERPERAL SEPSIS-GENITAL TRACT INFECTION

 

GENITAL TRACT INFECTION:

 PUERPERAL SEPSIS

INTRODUCTION

Genital tract infection following delivery is referred to as Peuperal Sepsis and is synonymous with older descriptions of peuperal fever, milk fever and child bed fever. It can also be deemed as infection of the birth canal in the first six weeks following labour or abortion with the temperature reaching 38 °C or more for 24 hours, or for at least two days of the first 14 days post delivery due to entry, growth and multiplication of pathogenic organisms (Sallers, 2010).

Peuperal Sepsis was not realized until the mid 19^th century that the high maternal mortality and morbidity was due to poor hygiene of birth attendants; the establishment of lying in hospitals and overcrowding perpetuated the condition to epidemic proportions. Until 1937, peuperal sepsis was the major cause of maternal mortality. The discovery of the sulphonamides in 1935 and the simultaneous reduction in the virulence of the hemolytic streptococcus resulted in a dramatic fall in maternal mortality. As by the year 2000, the incidence of peuperal sepsis was approximately at 3%.

CAUSES OF PEUPERAL SEPSIS

a)     Microorganisms

The causative organisms are either aerobic or anaerobic. These could be endogenous or exogenous. Endogenous organisms inhabit the bowel, the anus, the vagina, and the perineum. E. coli is such an example. Exogenous organisms come from outside of the body. They may be introduced through procedures from the attendants, in-patients and the environment.

Ø  Aerobes

Gram Positive

-        Beta-haemolytic streptococcus, group A, B and D

-        Staphylococcus epidermis and aureus

-        Enterococci – streptococci

Gram Positive

-        Escherichia coli

-        Haemophilus influenza

-        Pseudomonous aeruginosa

-        Proteus mirabilis

Gram variable

-        Gardnerella pneumonea

 

Ø  Anaerobes

-        Peptococcus species

-        Peptostreptococcus sp

-        Bacteroides – B fragilis, B Bivius, B diseus

-        Fusobacterium species

 

Ø  Miscellaneous

-        Mycoplasma hominis

-        Chlamidia trachomatis

-        Mycoplasma urealyticum

 

b)     SOURCES OF INFECTION

The sources of infection are classified as autogenous, endogenous and exogenous.

§  Autogenous sources

The infection is from the patient herself. This may be from the nose, skin, valve, throat, feaces or any infectious foci.

§  Endogenous sources

The organisms are readily present in the patient’s vagina. They may gain entry through tears and bruises in the vagina, cervix and the uterus.

§  Exogenous sources

These are from the attendants’ noses, nails, clothes, linen and the environment. Haemolytic staphylococcus Lance field Group A and Staphylococci aureus are two exogenous organisms that can cause peuperal sepsis. The two have been associated with major epidemics and fatalities in the past.

 

PREDISPOSING FACTORS

a)     OBSTETRIC FACTORS

v Antenatal intrauterine infections

v Bruises and lacerations

v Caesarian section

v Internal version

v Cervical sealage for cervical incompetence

v Prolonged rapture of membranes

v Untreated local infections such as Pelvic Inflammatory Diseases

v Multiple vaginal examinations

v Internal fetal monitoring

v Instrumental deliveries

v Prolonged labour

v Manual removal of the placenta

v Retained products of conception

b)     NON-OBSTETRIC FACTORS

v Obesity

v Diabetes

v Anaemia

v HIV

v      Mulnutrition

v Exhaustion (stress)

v Use of unsterile instruments

v Dirty environment

SIGNS AND SYMPTOMS

-        Fever which occurs within 24 hours is the first sign

-        Tachycardia

-        Pelvic thrombophlebitis indicated by a persistent spiking fever for 7 to 10 days after delivery, despite antibiotic therapy

-        Uterus – sub-involuted, boggy, tender and larger

-        Infected wounds – caesarian/perineal

-        Local pain and swelling of the infected suture line

-        Indurated adnaxea (parametritis)

-        Bogginess in the pelvis (absces)

-        Malaise, headache, chills, rigors and insomnia

-        Lower abdominal tenderness and discomfort,

-        Anorexia

-        Diarrheoa

-        Foul smelling lochia (brownish in colour)

-        Secondary post-partum haemorrhage

-        Severe sepsis

Constant pelvic pain

Rise in temperature with increased pulse rate

Lower abdominal pain

Intense pain which worsens the condition of the patient

Severe infection of the fallopian tubes

Collection of pus in the pouch of douglas

DIAGNOSIS

§  Careful history and physical examination to exclude the causes of fever

-        General condition during pregenancy

-        Number of vaginal examinations

-        Time of rapture of membranes

-        Place of delivery (Hospital or home delivery)

-        Type of labour and delivery whether prolonged or instrumental

§  Pelvic ultra-sonogram (reveals retained products of conception)

§  Laboratory investigations

-        Mid-stream urine

-        High vaginal swab

-        Blood culture

-        Throat swab full blood count

-        Bleeding and clotting time for disseminated intravascular coagulation or arterial blood gas