Obstetric Topic 47. Pathologic puerperium. Puerperal sepsis

I. Pathologic Puerperium

Definition

• Pathologic puerperium: abnormal physical or psychological condition after delivery, classically within the first 6 postpartum weeks.
• Main groups: bleeding/subinvolution, infection/sepsis, thromboembolism, breast/urinary disorders and psychiatric disease.

Important Disorders

• Subinvolution: uterus fails to return toward normal size → prolonged lochia, abnormal uterine bleeding, pelvic pain.
• Endometritis: infection of endometrial lining → fever, uterine/pelvic pain, foul-smelling lochia.
• Mastitis / breast abscess: breast pain, erythema, fever; abscess needs drainage.
• UTI/pyelonephritis: dysuria, frequency, flank pain, fever.
• Wound infection: C-section/episiotomy/laceration pain, erythema, discharge and fever.
• DVT/PE: unilateral leg swelling/pain, chest pain, dyspnea, tachycardia, collapse.
• Psychiatric: postpartum depression and postpartum psychosis.

II. Puerperal Sepsis

Definition and Sources

• Maternal sepsis: life-threatening organ dysfunction caused by dysregulated maternal response to infection during pregnancy, birth, abortion or postpartum period.
• Main source: ascending infection from lower genital tract → endometritis/endomyometritis.
• Other sources: wound infection, UTI/pyelonephritis, mastitis/abscess, pneumonia, retained POC, pelvic abscess.
• Pathogens: Group A Streptococcus (S. pyogenes), E. coli, S. aureus; postpartum infection is often polymicrobial with anaerobes/enterococci/GBS.

Risk Factors

• Prolonged labor, prolonged ROM, chorioamnionitis.
• Operative delivery/C-section, vaginal trauma, repeated cervical examinations.
• Retained POC, postpartum hemorrhage, uterine instrumentation.
• Diabetes, obesity, anemia, immunosuppression, poor hygiene/limited care access.

Clinical Features

• Systemic: fever, chills, tachycardia, tachypnea, hypotension, confusion/oliguria in severe disease.
• Local genital: lower abdominal/pelvic pain, uterine tenderness, foul-smelling or purulent lochia, abnormal bleeding.
• Other source clues: dysuria/flank pain, breast redness, wound discharge, cough or rash.

Complications

• Pelvic abscess, peritonitis.
• Septic pelvic thrombophlebitis.
• Septic shock, DIC, multiorgan failure, maternal death.

III. Diagnosis and Treatment

Diagnosis

• Clinical: postpartum fever + pelvic pain/uterine tenderness + abnormal/foul lochia suggests endometritis.
• Labs: ↑ WBC, ↑ ESR/CRP; add renal/liver/coagulation/lactate if severe.
• Cultures: blood cultures with systemic signs; urine, lochia/wound/breast culture when useful.
• Pelvic US: retained POC, pelvic abscess or unclear source.

Treatment of Puerperal Sepsis

• Hospitalization; treat shock with IV fluids, oxygen and monitoring of urine output/vitals.
• Broad-spectrum IV antibiotics promptly; classic regimen: ampicillin + gentamicin + clindamycin.
• Other accepted exam/clinical regimens:
• Endometritis: clindamycin + gentamicin ± ampicillin.
• MRSA risk: add vancomycin.
• Source control: evacuate retained POC, drain pelvic/breast/wound abscess, open infected wound.
• Supportive: antipyretics, pain relief, electrolyte/glucose correction, thromboprophylaxis when safe.

Prevention

• Aseptic delivery technique and minimize unnecessary vaginal examinations.
• Antibiotic prophylaxis before C-section according to protocol.
• Treat chorioamnionitis, UTI and mastitis early.
• Remove retained placental tissue; ensure postpartum hygiene and wound care.