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Puerperal sepsis (Aetiology (Wounds (Pathophysiology Episiotomy…
Puerperal sepsis
Aetiology
Wounds
Pathophysiology
Episiotomy wounds/lacerations
Caesarian section abdo wounds
Breakdown of wound can occur
Clinical presentation
Pain at site
discharge, erythema
Diagnosis
History: pain at site, discharge
Examination: swollen, discharging, erythematous, dehesicence
Investigations: bedside obs, swabs (MCS), bloods (FBC, CRP, U+Es, LFTs, cultures)
Mastitis
Clinical presentation
Painful breast
Hard breast
Diagnosis
History: pain, hard, swollen, erythema
Examination: tender, hard breast
Investigations: bedside obs, bloods (FBC, CRP, U+E, LFT, cultures)
Uterine
(endometritis)
Clinical presentation
Fever
Foul, bloody discharge
Diagnosis
History: fever, discharge, pain
Examination: discharge, tender bulky uterus
Investigations: bedside (obs), urine (dipstick, MCS), swabs (MCS), bloods (ABG, FBC, CRP, U+E, LFTs, cultures)
Risk factors
CS, especially w/o prophylactic abx
Breast abscess
Clinical presentation
Painful breast
Hard breast
Fever (may be swinging)
Diagnosis
History: pain, hard, swollen, erythema
Examination: tender, hard breast
Investigations: bedside obs, bloods (FBC, CRP, U+E, LFT, cultures)
UTI
Pathophysiology
Hypotonic bladder and urinary stasis
Catheterisation, trauma, pelvic exams
Clinical presentation
Frequency
Dysuria
Urgency
Fevers
Loin pain/tenderness
Diagnosis
History: LUTS, fever
Examination: tender bladder, tender flanks
Investigations: bedside obs, urine (dipstick, MCS),
bloods (FBC, CRP, U+E, LFT, cultures)
Respiratory
Pathophysiology
Often post-CS, as harder to cough and clear
airways with an abdominal wound
Clinical presentation
Cough
Sputum
Fever
Diagnosis
History: symptoms
Examination: fever, cough, crackles
Investigations: bedside obs, sputum MCS, bloods (FBC, CRP, U+E, LFT, cultures), imaging (CXR)
Complications
Adnexal infections
Pelvic abscess
Wound dehiscence
Septic thrombophlebitis
Sepsis
Subfertility
Epidemiology
Historically the commonest cause of maternal mortality (<1930s) before first antibiotics available (sulphonamides)
Resurgence of infections in recent years led
to confidential inquiries (2006-8, 2009-12)
'Saving Lives' (2014) emphasised importaance of
vaccinating pregnant women against influenza
Prevention
Perinatal
Infection control (hand washing, sterile equiptment)
Only catheterise if necessary, and use sterile precautions
Prophylactic abx for CS
Postnatal
Breast feeding advice
Hand washing after toilet use
Regular cleaning of perineal/CS wounds
Regular changing of pads
Early recognition and treatment with broad-spec abx
Antenatal
Treat anaemia
Treat UTIs
Diagnosis
Investigations
Bedside
Obs (sats, RR, HR, BP, temp)
Urine
Dipstick, MCS
Swabs
HVS, ECS, wound site (MCS)
Sputum
MCS
Bloods
ABG (lactate)
FBC, CRP, U+E, LFT
Blood cultures
Imaging
CXR (consolidation)
Examination
Respiratory
Cough, wheeze, sputum,
coarse crackles, reduced air entry
Abdominal
Tender bladder, tender uterus, tender flank,
CS wound healing
Genital
Perineal wounds
Breasts
Tenderness, masses, erythema
History
PC/HPC
Fever, signs of source (tender abdomen,
peritoneal pain, breast tenderness,
urinary symptoms, resp symptoms
Current pregnancy
Delivery (injuries, episiotomy, CS),
complications, breastfeeding or not
PMH
Medical conditions
Previous infections
Previous surgeries
DH
Current medications
Allergies (antibiotics)
FH
Nil
SH
Occupation, social support, alcohol, smoking
Definition
Puerperal sepsis
Sepsis occurring in the
puerperal period
Sepsis
Infection plus symptoms and signs of
a systemic inflammatory response
Risk factors
Antepartum
Anaemia
Longer duration of membrane rupture
Intrapartum
Longer duration of labour
Contamination during vaginal examination
Instrumental delivery
Trauma e.g. episiotomy, tears, CS
Haematoma
Management
Definitive
Medical
IV fluids
E.g. Hartmann's
Abx
Per source and local guidance
Avoid tetracycline in breastfeeding women
Analgesia
E.g. paracetamol, NSAIDs
Surgical
I+D
Indication: breast abscess, pelvic abscess/haematoma
MOA: cut and remove abscess contents to faciliate healing
SEs: pain, infection, bleeding, recurrence
Wound repair
Indication: dehiscence
Conservative
Monitor obs, lactate and fluid balance
Identify source of infection
Ice packs for painful swellings
Wound care
Initial ABCDE
SEPSIS 6