Puerperal Sepsis - ICUNOTES

Puerperal Sepsis

Definition

Infection of the genital tract occurring at any time between rupture of membranes, abortion, or miscarriage, or labor and the 42nd day postpartum in which ≥2 of the following are present:

Pelvic pain
Fever ≥38°C
Abnormal vaginal discharge
Foul-smelling discharge
Delay in uterine involution

Terminology

Term	Meaning
Puerperium	6 weeks after delivery
Puerperal pyrexia	Fever ≥38°C after delivery
Postpartum endometritis	Infection of decidua/endometrium
Septic abortion	Infection after abortion
Maternal sepsis	Organ dysfunction due to infection during pregnancy/postpartum

Epidemiology

One of the leading causes of maternal death
More common in low- and middle-income countries
Accounts for significant ICU admissions in obstetric patients

Common Timing

Time after Delivery	Common Cause
First 24 h	Group A Streptococcus, Clostridium
2–7 days	Endometritis
>1 week	Wound infection, retained products, pelvic abscess

Etiology

Puerperal sepsis is usually polymicrobial.

Common Organisms

Aerobic Bacteria

Organism	Importance
Streptococcus pyogenes (Group A strep)	Fulminant toxic shock
Staphylococcus aureus	Wound infections
Escherichia coli	Common gram-negative pathogen
Klebsiella	Severe nosocomial infection
Enterococcus	Post instrumentation
Group B streptococcus	Neonatal association

Anaerobes

Organism	Importance
Bacteroides fragilis	Pelvic abscess
Peptostreptococcus	Mixed infections
Clostridium spp.	Gas gangrene, shock

Others

Chlamydia
Gonorrhea
Mycoplasma
Ureaplasma

Risk Factors

Antepartum Risk Factors

Risk Factor	Mechanism
Anemia	Reduced immunity
Malnutrition	Poor host defense
Diabetes	Hyperglycemia promotes infection
Obesity	Wound complications
Immunosuppression	Severe infection risk
Preexisting genital infection	Ascending infection

Intrapartum Risk Factors

Risk Factor	Importance
Prolonged labor	Repeated contamination
Prolonged rupture of membranes (>18 h)	Ascending infection
Multiple vaginal examinations	Introduction of organisms
Instrumental delivery	Tissue trauma
Cesarean section	Major risk factor
Retained placenta/products	Bacterial growth medium
Postpartum hemorrhage	Immune dysfunction
Internal fetal monitoring	Ascending infection

Pathogenesis

Main Mechanism

Ascending infection from vaginal flora into:Endometrium/Decidua/Myometrium/Parametrium/Peritoneum/Bloodstream

Types of Puerperal Sepsis

Type	Features
Endometritis	Most common
Cesarean wound infection	Local erythema/pus
Episiotomy infection	Painful perineum
Septic pelvic thrombophlebitis	Persistent fever despite antibiotics
Pelvic abscess	Pelvic mass
Peritonitis	Diffuse abdominal pain
Necrotizing fasciitis	Rapid tissue destruction
Toxic shock syndrome	Shock with rash/MODS

Investigations

Blood Tests

Test	Purpose
CBC	Leukocytosis
CRP/ESR	Inflammation
Procalcitonin	Sepsis marker
Lactate	Tissue hypoperfusion
Renal function	Organ dysfunction
LFT	Hepatic involvement
Coagulation profile	DIC

Microbiology

Culture	Notes
Blood cultures	Before antibiotics
High vaginal/cervical swab	Identify pathogens
Wound swab	If surgical infection
Urine culture	Rule out UTI

Imaging

Ultrasound Pelvis

Most important imaging modality.

Findings:

Retained products
Intrauterine collection
Pelvic abscess

CT/MRI

Used when:

Deep pelvic abscess suspected
Necrotizing infection suspected
Persistent sepsis

Differential Diagnosis

Condition	Distinguishing Features
UTI	Dysuria, urine culture
Mastitis	Breast pain/redness
DVT/PE	Leg swelling, dyspnea
Drug fever	No infection source
Septic pelvic thrombophlebitis	Persistent fever despite antibiotics

Management

Sepsis Bundle

Within 1 Hour

Measure lactate
Obtain cultures
Start broad-spectrum antibiotics
Give IV fluids
Vasopressors if needed

Supportive Management

Hemodynamic Support

Fluids

Crystalloids preferred
Usually 30 mL/kg initially in shock

Vasopressors

First-line:Norepinephrine

Add if needed:Vasopressin,Epinephrine

SOURCE CONTROL

Source	Intervention
Retained products	Evacuation
Pelvic abscess	Drainage
Necrotizing fasciitis	Surgical debridement
Infected wound	Drainage/debridement
Peritonitis	Laparotomy

EMPIRICAL ANTIBIOTICS

Mild–Moderate Endometritis

Regimen	Dose
Clindamycin + Gentamicin	Standard regimen
Ampicillin-sulbactam	Alternative

Severe Sepsis / ICU

Antibiotic	Dose
Piperacillin-tazobactam	4.5 g IV q6h
Meropenem	1 g IV q8h
Vancomycin	If MRSA suspected

Classic Regimen

Drug	Dose
Clindamycin	900 mg IV q8h
Gentamicin	5–7 mg/kg IV daily
± Ampicillin	2 g IV q6h

Excellent anaerobic coverage.

Duration of Therapy

Severity	Duration
Mild infection	7–10 days
Bacteremia	10–14 days
Deep abscess	2–3 weeks

Continue IV antibiotics until:

Afebrile for 24–48 h
Clinically improved

Complications

Local Complications

Complication	Description
Pelvic abscess	Pus collection
Peritonitis	Intraperitoneal spread
Infertility	Tubal damage
Chronic pelvic pain	Adhesions

Systemic Complications

Complication	Mechanism
Septic shock	Vasodilation
ARDS	Cytokine storm
DIC	Coagulopathy
MODS	Severe sepsis
Death	Refractory shock

Prevention

Antenatal Prevention

Treat anemia
Treat vaginal infections
Good nutrition
Diabetes control

Intrapartum Prevention

Measure	Importance
Hand hygiene	Most important
Sterile delivery	Prevent contamination
Minimize vaginal exams	Reduce inoculation
Early treatment of PROM	Prevent ascending infection

Cesarean Section Prophylaxis

Recommended Antibiotic

Cefazolin before incision

WHO Prevention Strategies

Clean birth practices
Skilled birth attendants
Early recognition
Timely antibiotics
Access to emergency obstetric care

Recommended Guideline Sources

World Health Organization maternal sepsis recommendations
Surviving Sepsis Campaign sepsis guidelines
American College of Obstetricians and Gynecologists postpartum infection guidance
Royal College of Obstetricians and Gynaecologists puerperal sepsis guidance
Harrison’s Principles of Internal Medicine
Oh’s Intensive Care Manual