Puerperal Sepsis

Puerperal sepsis is infection of the genital tract that begins after birth or abortion, within 42 days of delivery, and spreads to cause fever, a fast heart rate and organ dysfunction. Group A streptococcus, Escherichia coli, Staphylococcus aureus, Clostridium species and anaerobes are the usual organisms. It is a leading cause of maternal death in Kenya, and antibiotics given within the first hour of recognition lower mortality.

• Risk factors: caesarean section, prolonged or obstructed labour, rupture of membranes for 18 hours or more, many vaginal examinations, retained placenta, perineal tears, birth with unclean hands or instruments, anaemia, HIV, diabetes, obesity.
• Group A streptococcus can kill within 24 hours and spreads between patients.
• Early antibiotics, fluids and removal of the source are the three pillars of care.

Women have fever above 38 degrees Celsius (or a temperature below 36 degrees Celsius), rigors, lower abdominal pain, foul or purulent lochia, a tender uterus that is slow to shrink, and a fast pulse and breathing rate. Severe cases have confusion, low blood pressure and little urine.

• Pulse above 100 per minute, respiratory rate above 22 per minute, systolic blood pressure of 100 mmHg or less.
• Severe pain with a rigid abdomen, crepitus or dusky skin suggests necrotising infection or clostridial myometritis.
• Differential diagnosis: wound or breast infection, urinary tract infection, pneumonia, malaria, septic pelvic thrombophlebitis, pelvic abscess, appendicitis, pulmonary embolism.
• Complications: septic shock, disseminated intravascular coagulation, acute kidney injury, acute respiratory distress syndrome, pelvic abscess, peritonitis, necrotising fasciitis, septic pelvic thrombophlebitis, infertility, hysterectomy, maternal death.

The diagnosis is clinical, and treatment starts before test results return.

• Temperature, pulse, blood pressure, respiratory rate, oxygen saturation, mental state and hourly urine output.
• Blood cultures (2 sets) before antibiotics, high vaginal swab, urine culture, full blood count, C-reactive protein, lactate (above 2 mmol/L signals severe sepsis), urea, creatinine, liver enzymes, clotting screen, malaria test, HIV test.
• Pelvic ultrasound for retained products, collections and haematoma; CT of the abdomen and pelvis for abscess, septic thrombophlebitis or gas in the tissues.
• Where laboratory tests are limited, treat on clinical grounds and refer.

The principle is antibiotics within 1 hour, fluid resuscitation, and early removal or drainage of the source of infection.

• Supportive: oxygen to keep saturation at 94 percent or above; two large-bore cannulae; Ringer's lactate 30 mL/kg IV over the first 3 hours; hourly urine output with a catheter; high dependency care; contact precautions for group A streptococcus; breastfeeding may continue.
• Pharmacological: clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily, or ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly; for septic shock or poor response use piperacillin-tazobactam 4.5 g IV 8-hourly where available, or meropenem 1 g IV 8-hourly; for group A streptococcus add benzylpenicillin 2.4 g (4 million units) IV 4-hourly and keep clindamycin 900 mg IV 8-hourly; continue IV therapy until afebrile for 48 hours, then amoxicillin-clavulanate 625 mg oral 8-hourly to finish 7 days (10 to 14 days with bacteraemia or abscess); noradrenaline 0.05 micrograms/kg/minute IV titrated to a mean arterial pressure of 65 mmHg or more if shock persists after fluids; paracetamol 1 g oral or IV 6-hourly (maximum 4 g in 24 hours); enoxaparin 40 mg subcutaneous once daily until mobile.
• Procedures: evacuation of retained products after the first antibiotic dose; drainage of pelvic abscess by ultrasound guided or surgical drainage; laparotomy and hysterectomy for necrotising infection, clostridial myometritis or uncontrolled sepsis; debridement of infected wounds.
• Special groups: renal impairment replaces gentamicin with ceftriaxone 2 g IV once daily; severe penicillin allergy uses clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily, omits benzylpenicillin and piperacillin-tazobactam, and completes oral treatment with clindamycin 450 mg oral 8-hourly plus metronidazole 400 mg oral 8-hourly.
• Red flags: systolic blood pressure below 90 mmHg, lactate above 2 mmol/L, urine below 30 mL per hour, confusion, spreading skin discolouration, rigid abdomen, no improvement after 48 hours.
• Follow-up: temperature, pulse and blood pressure 4-hourly; review cultures at 48 hours and change antibiotics to match; review at 1 week and 6 weeks; ultrasound if fever persists; counselling on hygiene and clean birth practice.