Kembara Xtra - Medicine - Endometritis Endometritis, often known as an infection of the endometrium, is the type of postpartum infection that occurs the most frequently. It is possible for a bacterial infection of the vaginal tract to appear as late as six weeks after delivery. The infection often begins after delivery and reaches its peak occurrence on postpartum day 7 (by which time the majority of patients would have been discharged). Infections of the myometrium and the tissues around the parametrium are far less common after delivery. Other types of postpartum infections of the pelvic region include vaginal and cervical infections, perianal cellulitis, pelvic cellulitis, pelvic abscess, septic pelvic vein thrombophlebitis, and parametrial phlegmon. These infections are generally quite uncommon. Affected Operating System(s): reproductive Postpartum infection; endometritis; endoparametritis; endomyometritis; myometritis; endomyoparametritis; metritis; metritis with pelvic cellulitis; endomyometritis; myometritis; endomyoparametritis; endomyoparametritis; endomyoparametritis; endomyoparametritis; Epidemiology Incidence Occurs in women who are of age to produce children 1–3 percent of all births are affected by the condition. Prevalence a risk of infection that is ten times higher after a cesarean section - 2– 15% of infections start before the labor even begins. - After childbirth, 30–35% of cases occur when appropriate antibiotic prophylaxis was not administered; after labor, 2–15% of cases occur when appropriate prophylaxis was administered. — The fifth most common reason for a mother to pass away, accounting for eleven percent of all maternal deaths Causes and effects: etiology and pathophysiology Endometritis is more prevalent in pregnancies that develop complications due to chorioamnionitis. The perineum, vagina, cervix, and uterus are all susceptible to secondary infections if they are injured. Postpartum infections are often multimicrobial and involve organisms that rise from the lower genital canal, including but not limited to the following: - Streptococcus faecalis, Streptococcus agalactiae, Streptococcus viridans, Staphylococcus aureus, and Escherichia coli were found in aerobic isolates, which made up 70% of the total. - Anaerobic isolates (80%): Peptococcus sp., Peptostreptococcus sp., Clostridium sp., Bacteroides bivius, Bacteroides fragilis, Fusobacterium sp. ● Other genital Mycoplasma Herpes simplex virus and cytomegalovirus should be considered, in particular in immunocompromised patients who do not show improvement despite taking the necessary medications. • A thrombosis in any pelvic vein, including the vena cava The presence of phlegmon on the leaflets of the wide ligament factors of danger The most significant risk factor is having a cesarean section. Inflammation of the Chorioamnion Membrane Bacterial Vaginosis Group B streptococcal colonization of the vaginal tract HIV infection Prolonged labor and delivery Prolonged labor and delivery Membrane rupture for an extended period of time; highly meconium-stained amniotic fluid ● Multiple vaginal examinations Care in a teaching hospital; low socioeconomic status; obesity; anemia; internal monitoring of the fetus during labor; operative vaginal birth; manual extraction of the placenta; vaginal delivery with manual extraction of the placenta; Prevention Prophylaxis during labor and delivery against colonization of the genital tract by group B bacteria Delivery through the vaginal route Attempt to avoid having vaginal examinations that aren't essential. – Chorioamnionitis should be treated during the labor process. – Avoid having a physical extraction of the placenta done as well as any retained placental products. – When treating a laceration of the third or fourth degree, antibiotic prophylaxis should be considered. Prophylaxis with amoxicillin and clavulanic acid for operational vaginal delivery appears to be beneficial, according to the findings of a recent large multicenter research. Aseptic procedure for operative vaginal delivery is also discussed. – On the other hand, antibiotic prophylaxis prior to the physical removal of the placenta has not been shown to be efficacious in any studies. ● Cesarean delivery Puerperal infection can be reduced by as much as 38% by the use of preoperative paint and scrub with 10% povidone-iodine scrub or an alcohol-based solution. It is recommended to take prophylactic antibiotics prior to both planned and unplanned cesarean deliveries before the skin incision in order to lower the risk of postpartum infection. Antibiotics should be given no later than one hour after the beginning of the operation. Is recommended for re-administration in cases of prolonged procedures or significant blood loss. When antibiotics are administered correctly, there is a 40% decrease in the number of infections that occur in postpartum mothers, and there is no increase in the number of infections that occur in newborns. Extended coverage with cephalosporin and azithromycin both reduces the risk of infection even further and is cost-effective. Vaginal pretreatment with a solution of povidone and iodine or chlorhexidine and alcohol just prior to cesarean birth lowers the risk of postoperative endometritis. Antibiotic dosing that is determined by weight helps to ensure that enough tissue concentrations are present before the skin is incised. - Extraction of the placenta by using a light amount of traction The use of various interventions in conjunction with one another as part of a package is more effective than the use of individual components. Conditions That Often Occur Together a case of chorioamnionitis An infection of the wound Providing an Account of History a previous history of chorioamnionitis or cesarean delivery; fever and chills; malaise; headache; anorexia; abdominal pain; heavy vaginal bleeding; or foul-smelling lochia The Patient's Clinical Examination ● Oral temperature >38°C (100.4°F) tachycardia, uterine tenderness on exam (key finding), other localized abdominopelvic tenderness on exam, purulent or malodorous lochia, and other abdominal and pelvic soreness on exam. ● Heavy vaginal bleeding ● Ileus bacteremia caused by group A or B streptococci may not present with any localizing symptoms. Differential Diagnosis "5 Ws": wind (pneumonia), water (UTI), wound infection (mastitis), "wow" (wound infection), and "wonder drug" (fever associated to medication). ● Viral syndrome; dehydration abscess in the pelvic region, thrombophlebitis, and a thyroid storm ● Appendicitis Results From the Laboratory Initial Tests (lab, imaging) CBC: Please exercise caution when interpreting. (The number of white blood cells in physiologic leukocytosis can reach as high as 20,000.) Clinical manifestations and signs are frequently used as diagnostic criteria. Possible tests include the following: - Cultures of the genital tract and a quick test for group B streptococci (which can be performed while the patient is in labor) - Gram stain of amniotic fluid: typically a mixed microbial population - To obtain uterine tissue cultures, clean the cervix with betadine and collect the specimen in a shielded pipette or specimen collector. It is difficult to obtain these cultures without introducing contamination. If the patient fulfills the criteria for SIRS and or suspected sepsis, follow the institution's protocols for appropriate workup and identification (i.e., serum lactate, fluid resuscitation, two sets of blood cultures, and timely administration of broad spectrum antibiotics). If the patient does not meet the criteria for SIRS and or suspected sepsis, follow the institution's standards for suitable workup and identification. If the patient does not respond to antibiotic treatment within twenty-four to forty-eight hours: - Ultrasound examination to check for pelvic abscess, tumor, or retained products of conception – Computed tomography (CT) or magnetic resonance imaging (MRI) scan to look for pelvic vein thrombophlebitis, abscess, or deep-seated wound infection Paracentesis and culdocentesis with culture are diagnostic procedures that are only seldom required. The Interpretation of Tests a shallow layer of infected and necrotic tissue in microscopic sections of the uterine lining; a high number of neutrophils in the superficial endometrium; a low number of plasma cells in the endometrial stroma. First-Line Treatment: Medication Management Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h Nephrotoxicity, ototoxicity, pseudomembranous colitis, or diarrhea are some of the possible adverse reactions that could occur (in up to 6% of patients). Second Line: Ampicillin/sulbactam 3 grams intravenously every six hours; metronidazole 500 milligrams intravenously or orally every eight to twelve hours; penicillin 5 million units intravenously every six hours, or gentamicin 5 mg/kg IV q24h in addition to ampicillin 2 g IV every 6 hours Two grams of cefoxitin intravenously every six hours. If clinical failure has occurred after 48 hours, add ampicillin at a dose of 2 g IV every six hours. ● Cefotetan 2 g IV q12h. If clinical failure has occurred after 48 hours, add ampicillin at a dose of 2 g IV every six hours. Note: The therapy should be based on the patient's culture, sensitivity, and clinical response. Indications to the Contrary – An allergy to the medication – Renal failure (aminoglycosides) – Steer clear of sulfa, tetracycline, and fluoroquinolone antibiotics before giving birth and while breastfeeding. If you are breastfeeding, you should avoid taking metronidazole as much as possible. Take Precautions: Pseudomembranous colitis can be brought on by Clindamycin and other antibiotics on occasion. – Antibiotic-associated diarrhea (Clostridium difficile) – Gentamicin can cause kidney damage. Note: If the infection has been present for more than 48 hours, you may want to consider adding a macrolide antibiotic (for chlamydia coverage). Note: Heparin is commonly used for cases of septic pelvic vein thrombophlebitis; complete anticoagulation is necessary for a period of ten days. Surgical Methods and Operations Curettage for retained products of conception Surgery or image-guided drainage to drain abscess Surgery to decompress the bowel Surgical drainage of a phlegmon is not advised unless it is suppurative. Ultrasound to look for retained products of conception if not responsive to initial therapy. In most cases, it is not necessary to remove further inflammatory tissue through surgical means. Admission It is advised that patients receive inpatient care for postpartum infections, and many infections arise after patients are discharged from the hospital. Because of this, teaching regarding the significance of signs of infection such as fever, discomfort, copious vaginal bleeding, foul-smelling lochia, and other symptoms should take place prior to the patient being discharged. Antibiotics used intravenously and careful monitoring for patients with serious illnesses - Cut open and drain any wounds that are infected. ● Optimize fluid status. Keep in Touch Patient Monitoring Individualize in accordance with the degree of the problem. When the patient has been temperature-free for 24 to 48 hours, the IV antibiotics can be discontinued. Oral antibiotics should not be continued after the patient is discharged unless the patient had a bacteremia; in that case, oral antibiotics should be continued for a full week. As tolerated, although there may be some restrictions due to ileus. Patient Education - Advise the patient to consult a physician if she experiences postpartum fever of more than 38 degrees Celsius (100.4 degrees Fahrenheit), copious vaginal bleeding, offensive-smelling lochia, or any other indications of infection. Information can be found at the following website: http://www.healthline.com/ health/ pregnancy/ complications-postpartum-endometritis. Prognosis The majority of patients show rapid improvement and make a full recovery when they are provided with supportive care and the proper antibiotics. The following are examples of complications: resistant organisms; peritonitis; pelvic abscess; septic pelvic thrombophlebitis; ovarian vein thrombosis; sepsis; and death
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