PUERPERAL SEPSIS

Puerperal Fever/Sepsis

Infection of the female internal genital tract within 6 weeks of childbirth. Signs and symptoms usually occur after 24
hours, although the disease may manifest earlier in settings of prolonged rupture of membranes and prolonged labour without prophylactic antibiotics.

Causes

  • Ascending infection from contamination during delivery or abortion
  • Bacteria include: Staphylococcus aureus and Gram negative bacteria from the gut, e.g. Escherichia coli,
    Bacteroides, Streptococcus pyogenes, clostridium spp, chlamydia, gonococci
  • In peurperal sepsis, multiple organisms are likely

Clinical features

  • Persistent fever >38°C
  • Chills and general malaise
  • Pain in the lower abdomen
  • Persistent bloody/pus discharge (lochia) from genital tract, which may have an unpleasant smell
  • Tenderness on palpating the uterus
  • Uterine sub-involution

Risk factors

  • Anaemia, malnutrition in pregnancy
  • Prolonged labour, prolonged rupture of membranes
  • Frequent vaginal exams
  • Traumatic delivery (instrumental deliveries, tears)
  • Retained placenta

Differential diagnosis

  • Other causes of fever after childbirth, e.g. malaria, UTI, DVT, wound sepsis, mastitis/breast abscess, RTI

Investigations

  • Blood: CBC, C&S, BS for malaria parasites / RDT
  • Lochia: swab for C&S
  • Urine: For protein, sugar, microscopy, C&S

MANAGEMENT

Puerperal fever carries a high risk of sepsis with a high mortality, and needs immediate attention

Parenteral antibiotic therapy

  • Ampicillin 500 mg IV or IM every 6 hours
  • Plus gentamicin 5-7 mg/kg IV or IM daily in 2 divided doses (every 12 hours)
  • Plus metronidazole 500 mg IV every 8 hours for at least 3 doses
  • Alternative
    • Clindamycin 150 mg IV/IM every 6 hours + gentamicin as above

Supportive/additional therapy

  • Give IV fluids
  • Give analgesics
  • If anaemic, transfuse with blood
  • Look for retained products and evacuate uterus if necessary

Prevention

  • Use of clean delivery kits and ensuring clean deliveries, proper hygiene
  • Prophylactic antibiotic when indicated (prolonged labour and premature rupture of membranes, manual removal of placenta)