Puerperal Sepsis
The guidelines recommend management of common obstetric conditions at primary and referral level, based on local experience and evidence-based practice. They are not intended as strict protocols nor as standard operating procedures, but rather as a guide to safe effective management of common obstetric problems. The guidelines should be most useful to interns, medical officers and registrars.
Risk factors for puerperal infection
Caesarean section wound sepsis
This is infection of the upper genital tract after delivery. It may involve the endometrium, myometrium, pelvic peritoneum or the entire peritoneal cavity.
Risk factors for puerperal infection
- Caesarean section
- Prolonged labour or rupture of membranes
- Frequent vaginal examinations in labour
- Traumatic delivery
- Anaemia
- Poor immunity, such as HIV infection, diabetes & chronic steroid use
- Extensive vulval warts
- Retained placenta
- Low socioeconomic status
Mild puerperal sepsis
Clinical features include mild uterine tenderness without signs of peritonitis, a heart rate <100/minute, temperature <37.5 degrees, & offensive lochia.
Management
- Give amoxycillin 500 mg 8 hourly orally & metronidazole 400 mg 8 hourly orally
- If allergic to penicillin, give clindamycin 450 mg 8 hourly orally & ciprofloxacin 500 mg 12 hourly
- Encourage adequate intake of oral fluids
- If there is evidence of retained products, admit for evacuation of the uterus
- Follow up for reassessment after 24-48 hours
SEVERE PUERPERAL SEPSIS
This is postpartum infection of the genital tract, with a temperature ≥38 degrees, tachycardia ≥100/min, the presence (not always) of offensive lochia & uterine or abdominal tenderness. Always admit to hospital. Consider other diagnoses or co-infections, e.g. malaria, TB, pneumonia, endocarditis, meningitis.
History
- Take a careful history of pain, discharge, bleeding & associated problems
- Consider risk factors as for mild puerperal sepsis
- Also ask about bowel, urinary tract & respiratory symptoms
- Include relevant medical history – HIV, diabetes, hypertension, travel, etc.
Examination
- Be thorough & systematic
- Note temperature, colour, heart rate, BP, & respiratory rate
- Note level of consciousness
- Examine heart & lungs, and breasts for mastitis or abscess
- Examine abdomen for distension, tenderness, rigidity, masses & bowel sounds. Carefully inspect & palpate caesarean section wound (below)
- On vaginal examination, note state of the cervix (open, excitation tenderness, palpable products of conception) & feel for abscesses or haematomas, & for fluid collections in front of the cervix or in the pouch of Douglas
- Note offensiveness of the lochia
- Do speculum examination & inspect the cervix for discolouration
Special investigations
- Do ultrasound scan of the whole abdomen, looking for free fluid collections, cysts, masses, hydronephrosis, size of uterus & retained products
- Aspirate any free fluid & note if pus, blood, serous or serosanguinous fluid
- Send aspirated fluid for MCS, & also order TB investigations (AFB, culture, GeneXpert) on serous/serosanginous fluid
- Take blood FBC, U&E, INR, LFT, blood culture, & ABG
Multisystem evaluation
Based on the above clinical assessment & special investigations, evaluate systems: big 5 (cerebral, cardiac, respiratory, renal & liver/gastrointestinal), forgotten 4 (haematological, immune, endocrine, musculoskeletal) & core 1 (genital tract, breasts), & consider care for each involved organ system.
Management
- With evidence of septic shock (tachycardia, systolic BP <90 mmHg), start a rapid intravenous infusion of Ringer-Lactate 1-2 L (20 mL/kg), & closely observe BP, heart rate & respiratory rate. Call for senior help if BP does not respond to these measures. Manage in a high care area
- Insert a urinary catheter
- Aim for systolic BP ≥100 mmHg, or mean arterial BP ≥65 mmHg, SaO2≥90%, respiratory rate <30/min & haematocrit ≥30%
- Ensure antibiotics are given within one hour of presentation, after taking blood for culture: ampicillin 1-2 g IV 6 hourly with gentamicin 240 mg IV daily, & metronidazole 400 mg orally 8 hourly, or broad-spectrum alternatives
- Observe hourly fluid intake & output, heart rate, SaO2, respiratory rate, & BP for the first 24-48 hours, reducing to 4 hourly with clinical improvement
- Fluid orders depend on hydration & ability to take orally – adjust to U&E & urine output, writing up fluids clearly including time when each infusion should be completed. Only write in mL/hour if in a high care area
- Perform uterine evacuation if there are retained products
- Consider laparotomy with hysterectomy, & transfer to intensive care if:
- There is generalised peritonitis
- Pus or frank blood is withdrawn on paracentesis colpopuncture
- There is evidence of septic shock not responding to fluid management
- There is dysfunction of two organ systems other than the core 1
- There is no improvement after 24-48 hours of treatment
CAESAREAN SECTION WOUND SEPSIS
This usually presents 4-10 days after the operation. The wound is tender & indurated, & pus may be expressed from the suture line.
Management
- Assess for severe sepsis & manage accordingly if present (above)
- Open the wound and remove sutures from the skin & subcutaneous tissue
- Aspirate tender or fluctuant areas with a needle & syringe & send blood or pus for MCS. Do not send pus swabs
- Subcutaneous abscesses may be drained using local &/or opiate analgesia
- Inspect the depth of the wound – if the rectus sheath is not intact:
- If the bowel is visible arrange laparotomy & possible hysterectomy
- If the peritoneal cavity appears to be sealed off, do an abdominal ultrasound scan. In the absence of fluid collections or clinical peritonitis, laparotomy is not necessary at this stage
- Add cloxacillin 500 mg oral/IV 6 hourly to the antibiotic regimen
- Order wound dressings as appropriate for the dressing method used
Severe wound sepsis and necrotizing fasciitis
- Signs of severe wound sepsis or underlying necrosis include:
- Persistent pyrexia despite opening of the wound & other causes excluded
- Skin blisters overlying the indurated tissue
- Severe wound hyperaesthesia (extremely tender on gentle touch of intact tissue)
- If a wound is frankly necrotic & ulcerating, urgent debridement in theatre is indicated, with prior ultrasound to assess the abdomen for laparotomy
- Debrided necrotic tissue must be sent for MCS
- After debridement, leave the wound open, & pack with swabs soaked with metronidazole & gentamicin, & covered with Op-site dressing