Infection

International

PP Infection

Infection
International

Objectives

definition
predisposing factors
pathophysiology
clinical features
sites of postpartum infection
treatment
prevention

Infection
International

Definition:
Any patient with fever of 38.5C 48-72
hours following a vaginal or forceps
delivery with uterine tenderness

Infection
International

Incidence and scope:

Major cause of maternal death in emerging
countries
Less frequent with vaginal births
Complications
include:
shock,
pelvic
abscesses and pelvic thrombosis

Infection
International

Pathophysiology
Normal flora of genital tract contains
potential pathogens
Amniotic fluid and increase in white
blood cells during labour

Infection
International

Predisposing factors
Trauma and tissue necrosis following deliver
creates a culture medium for ascending
Cesarean
section
is
most
important
predisposing
Prolonged labour and ruptured membranes
Poverty and poor hygiene/nutrition

Infection
International

Bacteria
- polymicrobial
- most common:
Escherichia coli, Kelbsiella, Proteus and
Bacteroides fragilis
- less common:
Clostridium, Staphylococcus aurea and
Pseudomona
- exogenous source:
Group A beta-hemolytic streptococci

Infection
International

Clinical Features
- usually 2-3 days post partum
- low grade temperature, lower abdominal
pain and uterine tenderness
- also: malaise, anorexia, foul lochia
- if severe:
high temperature and
generalized peritonitis

Infection
International

Clinical Features
- Group A beta-hemolytic stretpococci
may be fulminant with peritonitis and
septicemia
- if cultured, hospital personnel must be
screened to try and identify the source

Infection
International

Diagnosis
- sites of infection to consider in post partum
patient (culture if able):
endomyometritis
urinary tract
episiotomy site
abdominal incision
breast
thrombophlebitis: legs, pelvis
appendicitis
other: upper respiratory infection

Infection
International

Management - Prevention
- correct aseptic technique
- antibiotic use in women with cesarean
section or prolonged rupture of membranes
(1g ampicillin IV given prophylactically in
cesarean section reduces infection)

Infection
International

Management -- Treatment
mild case: single broad spectrum antibiotic
(eg. ampicillin 1 g IV q6h Or orally)
if cesarean section:
flagyl 500 mg q8h + cefoxitin 2g q6h
OR
aminoglysocide (gentamycin or tobramycin)
60-100 mg q8h +clindamycin 900 mg q8h

Infection
International

Management - Treatment
if intravenous antibiotics used, continue for
48 hours after fever has stopped.
if fever continues and aminoglycosideclindamycin combination was used, add
penicillin (5M units q6h) to cover
enterococci
oral antibiotics should be used for 5 days

Infection
International

Other issues
- the more antibiotics used, > the higher the
chance of necrotizing colitis
- antibiotics do appear in breast milk but in
most cases are not clinically significant
(avoid tetracyclines)

Infection
International

Specific issues:
episiotomy
infection:
treat
with
antibiotics, baths (clean water!), heat
- remove sutures if fluctuation or pus
- rarely needs debridement
necrotizing
fascitis:
rare,
rapid
progression of local inflammation followed
by gangrene -patient is toxic: high dose
antibiotics but MUST surgically DEBRIDE

Infection
International

Other issues
- Septic pelvic thrombophlebitis--usually
anaerobic sepsis
- usually patient is already on antibiotics
but continues to have high spiking fevers
- diagnosis of exclusion
- treatment is intravenous heparin
- condition should respond to heparin

Infection
International

Other issues
- Mastitis--penicillin G or penicillinaseresistant (methicillin or cloxacillin)
for 7-10 days
continue breast feeding!
if breast abcess--drain

Infection
International

Special case:
Postpartum or postabortal septic shock
Definition: any toxic patient who has
hemodynamic or acid base changes with
fever 38.5C (after abortion, vaginal or
operative delivery)

Infection
International

Etiology of postpartum/postabortal shock

Usually gram-negative bacteria
(eg.E.Coli)and occasionally gram positive
(staphylococci,
anaerobic
streptococci,
clostridium)

Infection
International

Pathophysiology of postpartum
postabortal shock
- not fully understood
- endotoxins from cell wall of bacteria initiate
vascular damage and vasodilatation
- hypotension / hypoperfusion

Infection
International

Conclusions
-

major problem
proper diagnosis
early and aggressive treatment
prevention

Infection
International

MALARIA IN PREGNANCY

Infection
International

Objectives

Describe epidemiology of malaria

Describe maternal and fetal complication
Principle of management and preventive
strategies

Infection
International

Global Effect

Affects 300-500 million people yearly

Causes 1 to 2.7 million deaths
90% of deaths occur in Sub -Saharan
Africa
(approximately 3000 deaths each day)

Infection

International

Size of problem in Africa

(WHO 1999)

Population: 564
Annual births: 24.7
Exposed to malaria: 93%
ANC coverage: 63%
Low birth weight: 16%
Malaria attributable fraction to LBW:12-50%

Infection
International

Scope of Focused ANC

Majority of pregnant
women need these
services only

Some pregnant women

require these services also

Fewer pregnant women require

these services

Infection
International

Anopheles Mosquito

Anopheles mosquitoes differ from other mosquitoes in the way

their body is positioned. The body of the Anopheles points up in the
air in one line, but in other mosquitoes, the rear end is bent and
points down.

Infection
International

Infected
Mosquit
o

Infect
ed
Huma
n

Malaria Ecology and Burden

Clinical Manifestations

Acut
e
febril
e
illnes
s

Chroni
c
effect
s

Pregnan
cy

Severe
illness

Anem
ia
Neurolog
ic/
cognitive
Developme
ntal

Fet
us
Matern
al

Hypoglyce
mia
Anem
ia
Respirato
ry
distress
Cerebral
malaria

Impaired
growth
and
developm
ent

Low birth
weight
Acute
illness
Anemi
a

Deat
h

Malnutriti
on

Infant
mortality
Impaired
producti
vity

Infection
International

Factors Affecting
Transmission

Breeding sites
Parasites
Climate
Population

Infection
International

Insecticide-Treated Nets

Untreated Nets
Provide some protection
against malaria
Do not kill or repel
mosquitoes that touch net
Do not reduce number of
mosquitoes
Do not kill other insects
like lice and bedbugs
Are safe for pregnant
women, young children
and infants

Insecticide-Treated Nets

Provide a high level of

protection against malaria
Kill or repel mosquitoes
that touch the net
Reduce number of
mosquitoes in/outside net
Kill other insects such as
lice and bedbugs
Are safe for pregnant
women, young children
and infants

Infection
International

Insecticide-Treated Nets

ITN tucked under a bed

ITN tucked under a mat

Infection
International

Effect of malaria on pregnancy

Related to Level of transmission and

immunity of individual exposed
In areas of high transmission ,
endemic or stable malaria area.
In areas of low transmission or
non endemic or unstable areas

Infection
International

Maternal complication

In Endemic areas
malaria related
anaemia
Febrile illness
Placental
sequestration

In non-Endemic areas
Greater risk of
severe disease
Higher risk of death
Anaemia,
hypoglycemia,
pulmonary oedema,
renal failure

Infection
International

Anaemia

Multi factorial:affects 50-60% pregnant women in

Sub-Saharan region
Haemolysis
Increased immune clearance of infected and non
infected RBCs
Malarial hyperactive splenomegaly
Nutritional & hookworm infestation
Increased risk in pregnancy to Post -partum
Hemorrhage & Heart failure

Infection
International

Severe malaria

Cerebral malaria: Unrousable coma

with asexual peripheral parsitaemia or
placental infection.
Hypoglycemia
Pulmonary edema (ARDS)
Acute renal failure

Infection
International

Fetal complications

In endemic areas
Low birth weight
Intra-uterine growth
retardation

In non-endemic areas
Abortions
preterm delivery
Congenital malaria
Low birth weight

Infection
International

Malaria Diagnosis

Usually based on signs and symptoms of

the patient, clinical history and physical
examination and/or laboratory confirmation
of the malaria parasite, if available.
Prompt and accurate diagnosis leads to:
Improved differential diagnosis of febrile illness
Improved management of non-malarial illness
Effective case management of malaria

37

Infection
International

Methods of Diagnostic Testing

The two methods of diagnostic testing for
malaria are light microscopy and rapid
diagnostic testing (RDT).
Once the woman presents with malaria
symptoms and is tested, results should be
available within a short time (< 2 hours).
When this is not possible, she must be
treated on the basis of clinical diagnosis
(WHO 2006).

Infection
International

Indications for
Diagnostic Testing

For pregnant women, a parasitological diagnosis is

recommended prior to starting treatment:
Those who live in or have come from areas of unstable
transmission are the most likely candidates for severe
malaria, which can be life-threatening

As a test of cure in clients who have been treated for

malaria but still have symptoms:
If treatment was adequate, clients may have been reinfected
or have another problem causing similar symptoms
Counterfeit or poor quality drugs may also be a the cause of
treatment failure

Infection
International

Clinical Diagnosis

Based on the patient's symptoms and on

physical
findings at examination
The first symptoms of malaria and
physical findings are often not specific
and are common to other diseases

Infection
International

Types of Malaria

Uncomplicated:
Most common

Severe:
Life-threatening, can affect brain
Pregnant women more likely to get
severe malaria than non-pregnant
women

Infection
International

Recognizing Malaria in
Pregnant Women

Uncomplicated Malaria

Fever
Shivering/chills/rigors
Headaches
Muscle/joint pains
Nausea/vomiting
False labor pains

Severe Malaria
Signs of uncomplicated malaria PLUS one or more of
the following:

Confusion/drowsiness/coma
Fast breathing, breathlessness,
dyspnea
Vomiting every meal/unable to eat
Pale inner eyelids, inside of mouth,
tongue, and palms
Jaundice

Infection
International

Combination Therapy

Plasmodium falciparum has become resistant

to single-drug therapy, resulting in ineffective
treatment and increased morbidity and
mortality
WHO now recommends that countries use a
combination of drugs to fight malaria
Drug resistance is far less likely with
combination therapy than with single-drug
treatments

Infection
International

Types of Combination Therapy

Artemisinin-based Combination Therapy
(ACT):
The simultaneous use of drugs that
includes a derivative of artemisinin along
with another anti-malarial drug
This combination is currently the most
effective treatment for malaria
For second and third trimesters, ACTs
should be the first-line treatment if
available and in line with local protocol

Infection
International

Selecting Treatment

Follow local guidelines regarding which

combination therapies to use (if any) and
how to use them
For uncomplicated malaria in the 1st
trimester and for severe malaria in any
trimester, quinine is the drug of choice
If ACTs are the only effective treatment
available, they can be used in the first
trimester

Infection
International

Treating Uncomplicated Malaria

First trimester:
Quinine 10 mg salt/kg body weight three times daily +
clindamycin 10 mg/kg body weight twice daily for 7 days
If clindamycin is not available, use quinine only

ACT can be used if it is the only effective treatment

available
Second and third trimesters:
Use the ACT known to be effective in the country/region,
OR
Artesunate + clindamycin (10 mg/kg body weight twice
daily) for 7 days, OR
Quinine + clindamycin for 7 days

Infection
International

Treating Uncomplicated Malaria

Observe client taking anti-malarial
drugs
Advise client to:

47

Complete course of drugs

Return if no improvement in 48 hours
Consume iron-rich foods
Use ITNs and other preventive
measures

Infection
International

Conclusions

Improve implementation of existing

strategies and health delivery system with
emphasis on integration in existing services
Improve on Health education to community
on dangers of malaria and early ,regular
ANC attendance.