Puerperal Sepsis

Sepsis arising in the postpartum period, most commonly originating from the genital tract (endometritis, see that entry, being the most common specific source), though also from the urinary tract, surgical wounds (cesarean section, episiotomy or perineal repair), breast (mastitis, see that entry, though this rarely progresses to systemic sepsis unless complicated by abscess), or, more rarely, from an unrelated source. Remains a leading cause of maternal mortality globally, and the general principles of sepsis recognition and management (see that entry) apply, with physiological changes of pregnancy and the puerperium (relative tachycardia, physiological leukocytosis) sometimes masking or delaying recognition.

Sepsis Six bundle principles apply immediately: oxygen, blood cultures before antibiotics where feasible, IV fluids, lactate measurement, urine output monitoring, and broad-spectrum IV antibiotics within the hour, with empirical coverage broad enough for polymicrobial genital tract infection (commonly a combination such as IV co-amoxiclav 1.2 g tds plus metronidazole, or IV piperacillin-tazobactam 4.5 g tds, or, where group A streptococcus is a specific concern given its rapid, severe course, adding clindamycin for its additional toxin-suppressing effect) per local sepsis protocol and severity
Source control is essential and should not be delayed: evacuation of retained products (see that entry), wound debridement or drainage if a surgical site collection is present, catheter removal or urinary source management as relevant
Escalation to ICU/HDU for evolving septic shock, following the principles detailed in that entry
Group A streptococcal sepsis carries a particularly rapid and severe course in the puerperium and should be treated with a high index of suspicion and aggressive early management given its capacity for rapid deterioration

Referral: obstetric and, where relevant, gynecology/surgical input for source control; ICU for severe sepsis or septic shock.

Obstetric Fistula

An abnormal communication between the genital tract and the urinary tract (vesicovaginal fistula, the most common) or rectum (rectovaginal fistula), most commonly resulting from prolonged, obstructed labor without timely access to cesarean section (see Obstructed Labour entry), where sustained pressure of the fetal head against the maternal pelvis causes ischemic necrosis of the intervening soft tissue, with the fistula becoming clinically apparent several days after delivery as the necrotic tissue sloughs.

Remains a significant cause of morbidity in regions with limited access to emergency obstetric care, and carries profound social and psychological consequences given the resulting continuous incontinence.

Continuous, uncontrollable leakage of urine (vesicovaginal fistula) or feces/flatus (rectovaginal fistula) from the vagina, typically beginning several days to two weeks after a prolonged, obstructed, or otherwise traumatic delivery (often, though not exclusively, associated with a stillbirth given the severity of the obstruction involved).

Associated skin excoriation from constant moisture, and, given the profound social stigma often attached to this condition in many settings, significant psychological distress, social isolation, and marital or family breakdown.

Clinical history and examination, with the fistula often visible or palpable on speculum and digital examination.

Dye tests (instilling methylene blue into the bladder and observing for vaginal leakage) can help localize and confirm a vesicovaginal fistula where it is not immediately obvious.

Cystoscopy and, where available, MRI or CT with contrast further characterize the fistula tract, size, and location, which is essential for surgical planning.

Prevention through timely access to emergency obstetric care (partograph use, timely recognition of obstructed labor, and prompt cesarean section where indicated) is the single most important intervention at a population level, given that established fistula requires major reconstructive surgery
Early, small fistulas identified promptly (within days of delivery) may occasionally heal with prolonged bladder catheterization alone (typically 2 to 6 weeks), allowing spontaneous closure in a minority of cases
Established fistula requires specialist surgical repair, timing individualized (many centers wait 3 months from the injury to allow inflammation to settle before attempting repair, though earlier repair is increasingly practiced in some specialist units), performed vaginally or abdominally depending on fistula location, size, and complexity, with success rates for an experienced fistula surgeon generally high for a first repair attempt, though repeat surgery may be needed for complex or recurrent cases
Postoperative bladder rest with prolonged catheterization (commonly 2 weeks or more) following repair, to protect the repair while healing occurs
Psychosocial support and reintegration assistance are an essential, and often under-resourced, component of holistic fistula care, given the profound social consequences many women experience
Subsequent pregnancy after fistula repair is managed with planned cesarean delivery before the onset of labor, given the risk of recurrence with any subsequent vaginal delivery attempt

Referral: specialist fistula surgical center for all confirmed cases; psychosocial support services.

Puerperal Sepsis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management