Postpartum sepsis, also referred to as puerperal sepsis, is a type of bacterial infection that is often experienced by women in the postnatal period, or after they have had a miscarriage or an abortion. It is a major source of maternal mortality and morbidity, especially in developing countries where health facilities may be limited.
19th Century: Puerperal sepsis was also common among women and was a major cause of maternal mortality. The use of antiseptic measures by Ignaz Semmelweis and Joseph Lister saw a drastic drop in the infection rate.
20th Century: Continued advances in public health measures and the discovery and utilization of antibiotics also contributed to reducing death rates from puerperal sepsis.
Epidemiology
It is challenging to estimate the global puerperal sepsis rate mainly because of the under-reporting and variation of criterion measurement. Nonetheless, it is believed that between 4 to 10 percent of adolescent motherly mortality is a result of puerperal sepsis globally.
The mortality rate for pregnant women is higher in developing countries than in developed nations. Patients in high-income countries have a lesser mortality rate than those from low and medium economies because of better infrastructures such as medical and healthcare, sanitation, among others and antibiotics.
Puerperal sepsis remains common in LMICs due to issues such as lack of or restricted access to appropriate care during childbirth, inadequate hygiene in the birthing process and limited reception of an effective antibacterial weapon- antibiotics.
Anatomy
Pathophysiology
The primary reason for postpartum infections occurring after vaginal delivery is the extension of infection from bacteria that have settled in that region. The infection which is most common in the postpartum period is endometritis.” The subtypes of postpartum infections are the following:
(1) wound infections that develop after surgery;
(2) perineal cellulitis;
(3) mastitis;
(4) respiratory infections from anesthesia;
(5) retained fragments of placenta;
(6) urinary tract infections; and
(7) septic pelvic phlebitis.
Infections are more fatal in the case of a cesarean section as compared to a normal delivery. According to the recommendation provided by Haas et al. there is an opinion that the vaginal preparation with povidone-iodine or chlorhexidine solution before cesarean delivery may decrease the chances of postoperative endometritis.
Etiology
Majority of the postnatal infections are due to normal and pathological invasions of the abdominal wall and the reproductive, genital and urinary systems during labor or during an abortion. This trauma enables bacteria to be introduced in areas which are usually devoid of bacterial presence.
Genetics
Prognostic Factors
The morbidity rate from postpartum infections is reported to be between 5 and 10% among pregnant patients. That is much depending on the severity of the infection, as for the overall prognosis of puerperal infections. Sepsis patients die from the condition with an estimated mortality of 20%, while the mortality of patients with septic shock is approximately 40%.
Clinical History
Clinical Presentation
Fever
Abdominal pain
Foul-smelling lochia
Tachycardia
Uterine tenderness
General malaise
Subinvolution of the uterus
Signs of systemic infection
Age Group
Physical Examination
The physical assessment of puerperal sepsis may reveal an acutely ill woman with signs of infection such as fever, tachycardia, and hypotension. Specifically, the abdominal examination shows that the uterus is tender and may be distended, and there could be signs of subinvolution. If there is foul-smelling lochia during the pelvic exam, the uterus can be palpated as tender or even enlarged. Infection in the episiotomy or a surgical site must be checked, and there might be manifestations of septicemia on the skin. Assessment of the respiratory and cardiac systems involves listening to lung sounds for abnormal breath sounds and reviewing the patient’s pulse rate for tachycardia in case of positive findings.
Age group
Associated comorbidity
Pre-existing medical conditions such as anemia, immunosuppressive conditions, Diabetes mellitus
Obstetric factors
Poor hygiene practices
Socioeconomic factors
Associated activity
Acuity of presentation
Acute onset: The signs of Puerperal sepsis may appear early, within the first postnatal day but can start at any time up to one week to ten days after childbirth.
Rapid progression: Lack of early detection and management of puerperal sepsis can easily lead to severe sepsis, and septic shock consequently warranting immediate attention.
Differential Diagnoses
Endometritis
Postpartum Hemorrhage
Urinary Tract Infection (UTI)
Pelvic Inflammatory Disease (PID)
Postoperative Wound Infection
Thrombophlebitis
Mastitis
DVT (Deep Vein Thrombosis)
Pneumonia
Lactational Mastitis
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
Antibiotic Therapy
Administer broad-spectrum antibiotics as soon as possible which ideally should be the first one hour of patient being considered to have sepsis. Common regimens include:
Combination Therapy: An antibiotic with activity against Gram-positive organisms (e.g., clindamycin or ceftriaxone) with an aminoglycoside/fluoroquinolone active against Gram-negative organisms and anaerobes (e. g., gentamicin/ciprofloxacin). As soon as culture and sensitivity results become available, modify the antibiotic therapy according to the isolated pathogens.
Supportive Care
Fluid Resuscitation: Provide the patients with IV fluids to treat and maintain the level of hypovolemia and to stabilize blood pressure. Isotonic fluids such as normal saline or lactated Ringer ’s solution can be used.
Vasopressors: When mean BP remains low after intravenous fluid administration, vasopressors like norepinephrine may be useful in targeting tissue perfusion pressure.
Oxygen Therapy: Give supplemental oxygen since adequate oxygenation is important and helps with respiration.
Nutritional Support: Evaluate and feed if appropriate and necessary depending on the patient’s condition, if they cannot eat or have increased energy requirements.
Surgical and Obstetric Management: Regarding key symptoms, if there are abscesses or retained products of conception surgery may be required for abscess drainage or removal of retained products of conception respectively. Apportion and manage complications at the delivery or surgical site including infections and incision dehiscence.
Monitoring and Support: Supervise temperature, pulse, blood pressure, and respiratory rates to evaluate the efficacy of applied measures and reveal signs of worsening patient’s status. It is recommended to evaluate the white blood cell count, renal function and liver function laboratory parameters with the frequency used for the evaluation of laboratory parameters in the diagnosis of chronic diseases.
Infection Control and Hygiene: Adhere to the appropriate measures of aseptic and sanitation practices during and after delivery time to reduce the consequences of sepsis. This includes aseptic techniques practiced during labor, delivery, and after birth. Ensure that patients and attendants stick to good hand hygiene by washing their hands with soap and water regularly and for the correct duration of time.
Wound Care: Make it a routine to check and clean up any area that has been sutured or had an episiotomy done. Wounds should be cleaned to avoid infections and then allowed to dry. Employ the appropriate aseptic procedure on the wound dressing and general dressing techniques.
Supportive Care Measures: Ensure that comfort measures including analgesia, positioning, and physical care are offered with the view that it will make the patient as comfortable as possible. Ensure the patient is offered well-balanced meals and adequate fluids for recovery from the operation as well as general health.
Role of Antibiotics
Cefoxitin: A second generation cephalosporine active against gram positive cocci and some gram-negative rods. It can be useful in the management of infections due to cephalosporin resistant or penicillin resistant gram-negative organism. Combined with clindamycin or doxycycline and an aminoglycoside it is preferred in endometritis and should be used in the first 48 postpartum hours in case of postpartum infection.
Doxycycline: Bacteriostatic by binding to the 30S and possibly the 50S ribosomal subunit, thereby preventing bacterial protein synthesis. It should be administered along with other pharmaceutical products for the management of endometritis. Usually for early ambulatory management of septicemia in the puerperium period (48 hours to 6 weeks post-delivery).
Gentamicin (Garamycin): A broad-spectrum antibiotic belonging to the aminoglycoside group that provides for gram-negative organisms. It is often used in conjunction with antibiotics active against gram positive organisms in treatment of endometritis. Use gentamicin if other penicillins or other less toxic antibiotic agents cannot be employed, particularly in infections with staphylococci and other gram-negative bacteria.
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal): It acts by binding to the 50S ribosomal protein and disrupting bacterial protein synthesis at the polymerase step thereby inhibiting bacterial growth. This drug is taken together with drugs for management of endometritis. It is the second-line antibiotic recommended for maternal infection following dicloxacillin for postpartum mastitis treatment.
Dicloxacillin: It is the first-line antibiotic for the management of infections due to penicillinase-producing staphylococci especially used for postpartum mastitis by Staphylococcus aureus.
Metronidazole: Combined with heparin and a third-generation parenteral cephalosporin in septic pelvic vein thrombophlebitis, it covers streptococci, Bacteroides, and the Enterobacteriaceae species.
Cephalexin: An antibiotic belonging to first-generation cephalosporin that is effective for mastitis providing cover for Staphylococcus aureus. Extended breastfeeding can be recommended to reduce the days that are likely to be experienced with the symptoms defined above.
Drainage of Abscesses: If there is an abscess like pelvic abscess or postpartum endometrial abscess, then treatment may involve abscess drainage. This is usually done using the technique of incision and drainage or, in some instances, using ultrasound percutaneous drainage.
Removal of Retained Products of Conception: These should be removed if the retained placental fragments or products are to be the cause of infection. This can be done in the form of dilation and curettage (D&C), where the patient is anaesthetized.
Hysterectomy: If the case of endometritis is severe or the other treatments fail, a hysterectomy or removal of the uterus might be considered.
Debridement
Wound Debridement: For any infected surgical or episiotomy site we may need to carry out debridement which involves the removal of the necrotic tissues to facilitate healing. This may be done by a surgical operation or by a bedside procedure depending on the seriousness of the infection.
Draining Septic Pelvic Thrombophlebitis
Surgical or Radiological Drainage: In instances where the septic pelvic thrombophlebitis fails to respond to antibiotics or the infection continues to cause fever, angiography-guided or surgical drainage of the pelvic veins or abscesses may be necessary.
Initial Assessment and Stabilization: Include signs and signals (e.g., elevated body temperature, painful or sensitive uterus, fast heart rate). Provide necessary fluids and oxygen and other medications required to put the patient in a stable condition.
Antibiotic Therapy: Begin with empirical broad-spectrum intravenous antibiotics if there is suspicion of infection and obtain cultures later. Treat antibiotics according to culture and sensitivity tests obtained.
Source Control: If necessary, the physician may need to carry out operations to remove necrotized tissue or to evacuate pus in abscess cavities. Treat any other underlying causes that may be present such as retained products of conception.
Supportive Care: Temperature, blood pressure, pulse, and respiratory may be essential to take at least once per hour. Give intravenous fluids, electrolytes, and any medications needed to aid the organs to carry out their functions.
Postpartum sepsis, also referred to as puerperal sepsis, is a type of bacterial infection that is often experienced by women in the postnatal period, or after they have had a miscarriage or an abortion. It is a major source of maternal mortality and morbidity, especially in developing countries where health facilities may be limited.
19th Century: Puerperal sepsis was also common among women and was a major cause of maternal mortality. The use of antiseptic measures by Ignaz Semmelweis and Joseph Lister saw a drastic drop in the infection rate.
20th Century: Continued advances in public health measures and the discovery and utilization of antibiotics also contributed to reducing death rates from puerperal sepsis.
It is challenging to estimate the global puerperal sepsis rate mainly because of the under-reporting and variation of criterion measurement. Nonetheless, it is believed that between 4 to 10 percent of adolescent motherly mortality is a result of puerperal sepsis globally.
The mortality rate for pregnant women is higher in developing countries than in developed nations. Patients in high-income countries have a lesser mortality rate than those from low and medium economies because of better infrastructures such as medical and healthcare, sanitation, among others and antibiotics.
Puerperal sepsis remains common in LMICs due to issues such as lack of or restricted access to appropriate care during childbirth, inadequate hygiene in the birthing process and limited reception of an effective antibacterial weapon- antibiotics.
The primary reason for postpartum infections occurring after vaginal delivery is the extension of infection from bacteria that have settled in that region. The infection which is most common in the postpartum period is endometritis.” The subtypes of postpartum infections are the following:
(1) wound infections that develop after surgery;
(2) perineal cellulitis;
(3) mastitis;
(4) respiratory infections from anesthesia;
(5) retained fragments of placenta;
(6) urinary tract infections; and
(7) septic pelvic phlebitis.
Infections are more fatal in the case of a cesarean section as compared to a normal delivery. According to the recommendation provided by Haas et al. there is an opinion that the vaginal preparation with povidone-iodine or chlorhexidine solution before cesarean delivery may decrease the chances of postoperative endometritis.
Majority of the postnatal infections are due to normal and pathological invasions of the abdominal wall and the reproductive, genital and urinary systems during labor or during an abortion. This trauma enables bacteria to be introduced in areas which are usually devoid of bacterial presence.
The morbidity rate from postpartum infections is reported to be between 5 and 10% among pregnant patients. That is much depending on the severity of the infection, as for the overall prognosis of puerperal infections. Sepsis patients die from the condition with an estimated mortality of 20%, while the mortality of patients with septic shock is approximately 40%.
Clinical Presentation
Fever
Abdominal pain
Foul-smelling lochia
Tachycardia
Uterine tenderness
General malaise
Subinvolution of the uterus
Signs of systemic infection
Age Group
The physical assessment of puerperal sepsis may reveal an acutely ill woman with signs of infection such as fever, tachycardia, and hypotension. Specifically, the abdominal examination shows that the uterus is tender and may be distended, and there could be signs of subinvolution. If there is foul-smelling lochia during the pelvic exam, the uterus can be palpated as tender or even enlarged. Infection in the episiotomy or a surgical site must be checked, and there might be manifestations of septicemia on the skin. Assessment of the respiratory and cardiac systems involves listening to lung sounds for abnormal breath sounds and reviewing the patient’s pulse rate for tachycardia in case of positive findings.
Pre-existing medical conditions such as anemia, immunosuppressive conditions, Diabetes mellitus
Obstetric factors
Poor hygiene practices
Socioeconomic factors
Acute onset: The signs of Puerperal sepsis may appear early, within the first postnatal day but can start at any time up to one week to ten days after childbirth.
Rapid progression: Lack of early detection and management of puerperal sepsis can easily lead to severe sepsis, and septic shock consequently warranting immediate attention.
Endometritis
Postpartum Hemorrhage
Urinary Tract Infection (UTI)
Pelvic Inflammatory Disease (PID)
Postoperative Wound Infection
Thrombophlebitis
Mastitis
DVT (Deep Vein Thrombosis)
Pneumonia
Lactational Mastitis
Antibiotic Therapy
Administer broad-spectrum antibiotics as soon as possible which ideally should be the first one hour of patient being considered to have sepsis. Common regimens include:
Combination Therapy: An antibiotic with activity against Gram-positive organisms (e.g., clindamycin or ceftriaxone) with an aminoglycoside/fluoroquinolone active against Gram-negative organisms and anaerobes (e. g., gentamicin/ciprofloxacin). As soon as culture and sensitivity results become available, modify the antibiotic therapy according to the isolated pathogens.
Supportive Care
Fluid Resuscitation: Provide the patients with IV fluids to treat and maintain the level of hypovolemia and to stabilize blood pressure. Isotonic fluids such as normal saline or lactated Ringer ’s solution can be used.
Vasopressors: When mean BP remains low after intravenous fluid administration, vasopressors like norepinephrine may be useful in targeting tissue perfusion pressure.
Oxygen Therapy: Give supplemental oxygen since adequate oxygenation is important and helps with respiration.
Nutritional Support: Evaluate and feed if appropriate and necessary depending on the patient’s condition, if they cannot eat or have increased energy requirements.
Surgical and Obstetric Management: Regarding key symptoms, if there are abscesses or retained products of conception surgery may be required for abscess drainage or removal of retained products of conception respectively. Apportion and manage complications at the delivery or surgical site including infections and incision dehiscence.
Monitoring and Support: Supervise temperature, pulse, blood pressure, and respiratory rates to evaluate the efficacy of applied measures and reveal signs of worsening patient’s status. It is recommended to evaluate the white blood cell count, renal function and liver function laboratory parameters with the frequency used for the evaluation of laboratory parameters in the diagnosis of chronic diseases.
Emergency Medicine
Infection Control and Hygiene: Adhere to the appropriate measures of aseptic and sanitation practices during and after delivery time to reduce the consequences of sepsis. This includes aseptic techniques practiced during labor, delivery, and after birth. Ensure that patients and attendants stick to good hand hygiene by washing their hands with soap and water regularly and for the correct duration of time.
Wound Care: Make it a routine to check and clean up any area that has been sutured or had an episiotomy done. Wounds should be cleaned to avoid infections and then allowed to dry. Employ the appropriate aseptic procedure on the wound dressing and general dressing techniques.
Supportive Care Measures: Ensure that comfort measures including analgesia, positioning, and physical care are offered with the view that it will make the patient as comfortable as possible. Ensure the patient is offered well-balanced meals and adequate fluids for recovery from the operation as well as general health.
Emergency Medicine
Cefoxitin: A second generation cephalosporine active against gram positive cocci and some gram-negative rods. It can be useful in the management of infections due to cephalosporin resistant or penicillin resistant gram-negative organism. Combined with clindamycin or doxycycline and an aminoglycoside it is preferred in endometritis and should be used in the first 48 postpartum hours in case of postpartum infection.
Doxycycline: Bacteriostatic by binding to the 30S and possibly the 50S ribosomal subunit, thereby preventing bacterial protein synthesis. It should be administered along with other pharmaceutical products for the management of endometritis. Usually for early ambulatory management of septicemia in the puerperium period (48 hours to 6 weeks post-delivery).
Gentamicin (Garamycin): A broad-spectrum antibiotic belonging to the aminoglycoside group that provides for gram-negative organisms. It is often used in conjunction with antibiotics active against gram positive organisms in treatment of endometritis. Use gentamicin if other penicillins or other less toxic antibiotic agents cannot be employed, particularly in infections with staphylococci and other gram-negative bacteria.
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal): It acts by binding to the 50S ribosomal protein and disrupting bacterial protein synthesis at the polymerase step thereby inhibiting bacterial growth. This drug is taken together with drugs for management of endometritis. It is the second-line antibiotic recommended for maternal infection following dicloxacillin for postpartum mastitis treatment.
Dicloxacillin: It is the first-line antibiotic for the management of infections due to penicillinase-producing staphylococci especially used for postpartum mastitis by Staphylococcus aureus.
Metronidazole: Combined with heparin and a third-generation parenteral cephalosporin in septic pelvic vein thrombophlebitis, it covers streptococci, Bacteroides, and the Enterobacteriaceae species.
Cephalexin: An antibiotic belonging to first-generation cephalosporin that is effective for mastitis providing cover for Staphylococcus aureus. Extended breastfeeding can be recommended to reduce the days that are likely to be experienced with the symptoms defined above.
Emergency Medicine
Surgical Intervention
Drainage of Abscesses: If there is an abscess like pelvic abscess or postpartum endometrial abscess, then treatment may involve abscess drainage. This is usually done using the technique of incision and drainage or, in some instances, using ultrasound percutaneous drainage.
Removal of Retained Products of Conception: These should be removed if the retained placental fragments or products are to be the cause of infection. This can be done in the form of dilation and curettage (D&C), where the patient is anaesthetized.
Hysterectomy: If the case of endometritis is severe or the other treatments fail, a hysterectomy or removal of the uterus might be considered.
Debridement
Wound Debridement: For any infected surgical or episiotomy site we may need to carry out debridement which involves the removal of the necrotic tissues to facilitate healing. This may be done by a surgical operation or by a bedside procedure depending on the seriousness of the infection.
Draining Septic Pelvic Thrombophlebitis
Surgical or Radiological Drainage: In instances where the septic pelvic thrombophlebitis fails to respond to antibiotics or the infection continues to cause fever, angiography-guided or surgical drainage of the pelvic veins or abscesses may be necessary.
Emergency Medicine
Initial Assessment and Stabilization: Include signs and signals (e.g., elevated body temperature, painful or sensitive uterus, fast heart rate). Provide necessary fluids and oxygen and other medications required to put the patient in a stable condition.
Antibiotic Therapy: Begin with empirical broad-spectrum intravenous antibiotics if there is suspicion of infection and obtain cultures later. Treat antibiotics according to culture and sensitivity tests obtained.
Source Control: If necessary, the physician may need to carry out operations to remove necrotized tissue or to evacuate pus in abscess cavities. Treat any other underlying causes that may be present such as retained products of conception.
Supportive Care: Temperature, blood pressure, pulse, and respiratory may be essential to take at least once per hour. Give intravenous fluids, electrolytes, and any medications needed to aid the organs to carry out their functions.
Postpartum sepsis, also referred to as puerperal sepsis, is a type of bacterial infection that is often experienced by women in the postnatal period, or after they have had a miscarriage or an abortion. It is a major source of maternal mortality and morbidity, especially in developing countries where health facilities may be limited.
19th Century: Puerperal sepsis was also common among women and was a major cause of maternal mortality. The use of antiseptic measures by Ignaz Semmelweis and Joseph Lister saw a drastic drop in the infection rate.
20th Century: Continued advances in public health measures and the discovery and utilization of antibiotics also contributed to reducing death rates from puerperal sepsis.
It is challenging to estimate the global puerperal sepsis rate mainly because of the under-reporting and variation of criterion measurement. Nonetheless, it is believed that between 4 to 10 percent of adolescent motherly mortality is a result of puerperal sepsis globally.
The mortality rate for pregnant women is higher in developing countries than in developed nations. Patients in high-income countries have a lesser mortality rate than those from low and medium economies because of better infrastructures such as medical and healthcare, sanitation, among others and antibiotics.
Puerperal sepsis remains common in LMICs due to issues such as lack of or restricted access to appropriate care during childbirth, inadequate hygiene in the birthing process and limited reception of an effective antibacterial weapon- antibiotics.
The primary reason for postpartum infections occurring after vaginal delivery is the extension of infection from bacteria that have settled in that region. The infection which is most common in the postpartum period is endometritis.” The subtypes of postpartum infections are the following:
(1) wound infections that develop after surgery;
(2) perineal cellulitis;
(3) mastitis;
(4) respiratory infections from anesthesia;
(5) retained fragments of placenta;
(6) urinary tract infections; and
(7) septic pelvic phlebitis.
Infections are more fatal in the case of a cesarean section as compared to a normal delivery. According to the recommendation provided by Haas et al. there is an opinion that the vaginal preparation with povidone-iodine or chlorhexidine solution before cesarean delivery may decrease the chances of postoperative endometritis.
Majority of the postnatal infections are due to normal and pathological invasions of the abdominal wall and the reproductive, genital and urinary systems during labor or during an abortion. This trauma enables bacteria to be introduced in areas which are usually devoid of bacterial presence.
The morbidity rate from postpartum infections is reported to be between 5 and 10% among pregnant patients. That is much depending on the severity of the infection, as for the overall prognosis of puerperal infections. Sepsis patients die from the condition with an estimated mortality of 20%, while the mortality of patients with septic shock is approximately 40%.
Clinical Presentation
Fever
Abdominal pain
Foul-smelling lochia
Tachycardia
Uterine tenderness
General malaise
Subinvolution of the uterus
Signs of systemic infection
Age Group
The physical assessment of puerperal sepsis may reveal an acutely ill woman with signs of infection such as fever, tachycardia, and hypotension. Specifically, the abdominal examination shows that the uterus is tender and may be distended, and there could be signs of subinvolution. If there is foul-smelling lochia during the pelvic exam, the uterus can be palpated as tender or even enlarged. Infection in the episiotomy or a surgical site must be checked, and there might be manifestations of septicemia on the skin. Assessment of the respiratory and cardiac systems involves listening to lung sounds for abnormal breath sounds and reviewing the patient’s pulse rate for tachycardia in case of positive findings.
Pre-existing medical conditions such as anemia, immunosuppressive conditions, Diabetes mellitus
Obstetric factors
Poor hygiene practices
Socioeconomic factors
Acute onset: The signs of Puerperal sepsis may appear early, within the first postnatal day but can start at any time up to one week to ten days after childbirth.
Rapid progression: Lack of early detection and management of puerperal sepsis can easily lead to severe sepsis, and septic shock consequently warranting immediate attention.
Endometritis
Postpartum Hemorrhage
Urinary Tract Infection (UTI)
Pelvic Inflammatory Disease (PID)
Postoperative Wound Infection
Thrombophlebitis
Mastitis
DVT (Deep Vein Thrombosis)
Pneumonia
Lactational Mastitis
Antibiotic Therapy
Administer broad-spectrum antibiotics as soon as possible which ideally should be the first one hour of patient being considered to have sepsis. Common regimens include:
Combination Therapy: An antibiotic with activity against Gram-positive organisms (e.g., clindamycin or ceftriaxone) with an aminoglycoside/fluoroquinolone active against Gram-negative organisms and anaerobes (e. g., gentamicin/ciprofloxacin). As soon as culture and sensitivity results become available, modify the antibiotic therapy according to the isolated pathogens.
Supportive Care
Fluid Resuscitation: Provide the patients with IV fluids to treat and maintain the level of hypovolemia and to stabilize blood pressure. Isotonic fluids such as normal saline or lactated Ringer ’s solution can be used.
Vasopressors: When mean BP remains low after intravenous fluid administration, vasopressors like norepinephrine may be useful in targeting tissue perfusion pressure.
Oxygen Therapy: Give supplemental oxygen since adequate oxygenation is important and helps with respiration.
Nutritional Support: Evaluate and feed if appropriate and necessary depending on the patient’s condition, if they cannot eat or have increased energy requirements.
Surgical and Obstetric Management: Regarding key symptoms, if there are abscesses or retained products of conception surgery may be required for abscess drainage or removal of retained products of conception respectively. Apportion and manage complications at the delivery or surgical site including infections and incision dehiscence.
Monitoring and Support: Supervise temperature, pulse, blood pressure, and respiratory rates to evaluate the efficacy of applied measures and reveal signs of worsening patient’s status. It is recommended to evaluate the white blood cell count, renal function and liver function laboratory parameters with the frequency used for the evaluation of laboratory parameters in the diagnosis of chronic diseases.
Emergency Medicine
Infection Control and Hygiene: Adhere to the appropriate measures of aseptic and sanitation practices during and after delivery time to reduce the consequences of sepsis. This includes aseptic techniques practiced during labor, delivery, and after birth. Ensure that patients and attendants stick to good hand hygiene by washing their hands with soap and water regularly and for the correct duration of time.
Wound Care: Make it a routine to check and clean up any area that has been sutured or had an episiotomy done. Wounds should be cleaned to avoid infections and then allowed to dry. Employ the appropriate aseptic procedure on the wound dressing and general dressing techniques.
Supportive Care Measures: Ensure that comfort measures including analgesia, positioning, and physical care are offered with the view that it will make the patient as comfortable as possible. Ensure the patient is offered well-balanced meals and adequate fluids for recovery from the operation as well as general health.
Emergency Medicine
Cefoxitin: A second generation cephalosporine active against gram positive cocci and some gram-negative rods. It can be useful in the management of infections due to cephalosporin resistant or penicillin resistant gram-negative organism. Combined with clindamycin or doxycycline and an aminoglycoside it is preferred in endometritis and should be used in the first 48 postpartum hours in case of postpartum infection.
Doxycycline: Bacteriostatic by binding to the 30S and possibly the 50S ribosomal subunit, thereby preventing bacterial protein synthesis. It should be administered along with other pharmaceutical products for the management of endometritis. Usually for early ambulatory management of septicemia in the puerperium period (48 hours to 6 weeks post-delivery).
Gentamicin (Garamycin): A broad-spectrum antibiotic belonging to the aminoglycoside group that provides for gram-negative organisms. It is often used in conjunction with antibiotics active against gram positive organisms in treatment of endometritis. Use gentamicin if other penicillins or other less toxic antibiotic agents cannot be employed, particularly in infections with staphylococci and other gram-negative bacteria.
Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal): It acts by binding to the 50S ribosomal protein and disrupting bacterial protein synthesis at the polymerase step thereby inhibiting bacterial growth. This drug is taken together with drugs for management of endometritis. It is the second-line antibiotic recommended for maternal infection following dicloxacillin for postpartum mastitis treatment.
Dicloxacillin: It is the first-line antibiotic for the management of infections due to penicillinase-producing staphylococci especially used for postpartum mastitis by Staphylococcus aureus.
Metronidazole: Combined with heparin and a third-generation parenteral cephalosporin in septic pelvic vein thrombophlebitis, it covers streptococci, Bacteroides, and the Enterobacteriaceae species.
Cephalexin: An antibiotic belonging to first-generation cephalosporin that is effective for mastitis providing cover for Staphylococcus aureus. Extended breastfeeding can be recommended to reduce the days that are likely to be experienced with the symptoms defined above.
Emergency Medicine
Surgical Intervention
Drainage of Abscesses: If there is an abscess like pelvic abscess or postpartum endometrial abscess, then treatment may involve abscess drainage. This is usually done using the technique of incision and drainage or, in some instances, using ultrasound percutaneous drainage.
Removal of Retained Products of Conception: These should be removed if the retained placental fragments or products are to be the cause of infection. This can be done in the form of dilation and curettage (D&C), where the patient is anaesthetized.
Hysterectomy: If the case of endometritis is severe or the other treatments fail, a hysterectomy or removal of the uterus might be considered.
Debridement
Wound Debridement: For any infected surgical or episiotomy site we may need to carry out debridement which involves the removal of the necrotic tissues to facilitate healing. This may be done by a surgical operation or by a bedside procedure depending on the seriousness of the infection.
Draining Septic Pelvic Thrombophlebitis
Surgical or Radiological Drainage: In instances where the septic pelvic thrombophlebitis fails to respond to antibiotics or the infection continues to cause fever, angiography-guided or surgical drainage of the pelvic veins or abscesses may be necessary.
Emergency Medicine
Initial Assessment and Stabilization: Include signs and signals (e.g., elevated body temperature, painful or sensitive uterus, fast heart rate). Provide necessary fluids and oxygen and other medications required to put the patient in a stable condition.
Antibiotic Therapy: Begin with empirical broad-spectrum intravenous antibiotics if there is suspicion of infection and obtain cultures later. Treat antibiotics according to culture and sensitivity tests obtained.
Source Control: If necessary, the physician may need to carry out operations to remove necrotized tissue or to evacuate pus in abscess cavities. Treat any other underlying causes that may be present such as retained products of conception.
Supportive Care: Temperature, blood pressure, pulse, and respiratory may be essential to take at least once per hour. Give intravenous fluids, electrolytes, and any medications needed to aid the organs to carry out their functions.
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