Postpartum Infections - Causes, Risk Factors, Types, Symptoms, Diagnosis, and Treatment

Introduction

Postpartum infections are the most common female reproductive tract bacterial infections. The infections occur after 24 hours or within ten days of giving birth or miscarriage. It is also known as puerperal fever or childbirth fever. Postpartum infections are one of the most common causes of maternal deaths worldwide. The proportion of overweight pregnant women is increasing worldwide, and it is a common complication for pregnant women and newborn children. The infection can be observed in various body parts, including the breasts and the uterus. It can increase maternal anxiety, social burden, and risk of postpartum depression. Postpartum infections can be due to trauma or during vaginal or cesarean delivery. According to the World Health Organization (WHO), 3,60,000 maternal deaths occur due to childbirth problems, and around 30% are associated with postpartum infections. The infections are more common in developed and developing countries. In low and middle-income countries, the burden of postpartum infections is more.

What Are the Causes of Postpartum Infections?

The severity of illness depends upon the affecting organisms and women's health. The intact uterus is considered sterile. After childbirth, the genital tract is more prone to infections. The infection may spread to the uterus and bloodstream, causing cellulitis (bacterial skin infection), peritonitis (inflammation of the abdominal lining), and septicemia (bloodstream infection). Bacterial organisms, including

• Streptococcus pyogenes.

• Anaerobic streptococcus.

• Staphylococcus.

• Clostridium perfringes.

• Clostridium tetani, cause postpartum infections.

The bacteria may enter through vaginal or cesarean delivery and can cause infections.

What Are the Risk Factors for Postpartum Infections?

Postpartum infections are more common in women who have undergone cesarean delivery. The risk factors include:

• High body mass index.

• Diabetes.

• Hypertension (high blood pressure).

• Sexually transmitted diseases.

• Bacterial vaginosis (vaginal inflammation).

• Extremes of maternal age.

• Preterm and post-term labor (live birth occurring at less than 37 weeks or more than 42 weeks).

• Multiple internal examinations.

• Prolonged rupture of membranes.

• Operative vaginal delivery.

• Retained products of the placenta.

• Manual removal of placenta.

• Postpartum hemorrhage (internal bleeding).

What Are the Most Common Postpartum Susceptible Infections?

Postpartum infections can occur at any site, including the placenta, cervix, perineum, and vagina, or incision site in case of cesarean section. The infection can also occur in the urinary bladder or kidneys in case of catheterization. The different types of postpartum infections which can affect the mother and the uterus include;

• Endometritis: It is an infection of the genital tract, including the myometrium (outer layer of the uterus), endometrium (inner layer of the uterus), and surrounding uterus tissues. The risk factors include prolonged operative time, multiple vaginal examinations, and colonization of the uterus with group A and B Streptococci. Endometritis is a severe postpartum infection and requires hospitalization.

• Puerperal Mastitis: It is an infection of the breast. A skin infection or oral microflora of infants due to breastfeeding causes the infection. The microorganisms enter through the cracked nipple, multiply, and cause infection. The doctor can tell the patient to breastfeed by infant or breast pump to prevent intraductal accumulation of infected material.

• Urinary Tract Infections (UTIs): The infections occur in women who underwent vaginal and cesarean delivery. UTIs can occur due to trauma during delivery or multiple catheterizations during labor. The infections are related to discomfort and long-term hospitalization and can be treated with antibiotics.

• Wound Infection or Surgical Site Infection: It can occur after a cesarean section. The symptoms include fever, lower abdominal pain, and redness at the incision site. The incision area during cesarean section can be infected with bacteria. The wound infection may spread through blood and cause problems in the skin, organs, and local tissue.

• Perineal Infection: It affects the perineum area. The infection may range from mild to severe health-related issues. The infection can be recognized with redness, pain in the lower abdominal area after giving birth, and fever. Perineal infection can be properly taken care of in the case of diabetes and hypertension.

• Toxic Shock Syndrome: It is seen in postpartum patients. The infection can occur from wound infection, endometrial infection, or breast infection. The bacteria causing the infection are Staphylococcus aureus and Staphylococcus epidermidis. It is a serious of infection and can lead to multiple organ failure. Treatment includes immediate removal of debrided tissue followed by antibiotics.

• Necrotizing Fasciitis: It is an infection of subcutaneous tissue. It usually begins as a wound infection and can spread to the abdominal wall, thighs, and buttocks and later can lead to tissue necrosis. The infection does not involve the deep skin layer and muscle tissue. Treatment includes the surgical debridement of the tissue.

• Pseudomembranous Colitis: It occurs in patients who receive or still receiving antibiotics. Symptoms include watery diarrhea, blood in stools, and high fever. Clostridium difficile cause the infection. The microorganism's overgrowth produces sufficient toxins that cause intestinal sloughing (removal of the intestinal layer).

What Are the Signs and Symptoms of Susceptible Postpartum Infections?

The symptoms depend upon the severity of the illness and the health status and condition of the women. Symptoms include

• Nausea and vomiting.

• Swelling of the uterus.

• High fever.

• Bleeding from the vagina.

• Foul smell from the vagina.

• Pain in the breasts.

• Tenderness in the legs.

• Breathing problems.

• Flu-like symptoms.

• Constipation.

• Dark urine.

• Headache and chills.

• Abscess in the breasts.

• Abdominal pain.

• Itching around the vagina.

• Inflammation of urethra lining.

How Can Postpartum Infections Be Diagnosed?

Postpartum infections can be diagnosed in the following ways.

• Physical Examination: The doctor can check for fever above 100.4 degrees Fahrenheit (38 degrees Celsius), bleeding, pain, and foul smelly vaginal discharge.

• Complete blood count (CBC) Test: A doctor can prescribe CBC (complete blood count) for white blood cells and hemoglobin estimation. There may be increased levels of white blood cells.

• Laboratory Examination: It includes vaginal swabs for culture to diagnose the bacteria causing the postpartum infections.

How Can Postpartum Infections Be Managed?

• Antibiotics are the first-line drugs to treat postpartum infections. The doctor can prescribe the antibiotics like Cephalosporin, Clindamycin, Metronidazole, and Gentamycin.

• Some postpartum infections require surgical treatment. The doctor can surgically open and drain the infected abscess and place a saline-soaked packing followed by antibiotics. Depending on the severity of the infection, the doctor may prescribe the drugs orally or through an intravenous route.

• The nurse can manage abdominal wounds during cesarean section by scrubbing the wound twice a day and closing the wound with a secondary suture.

How Can Postpartum Infections Be Prevented?

It is impossible to avoid postpartum infections, but some preventive steps are taken to reduce them. The preventive steps include.

• Wash your hands before touching the perineal area, and keep the area clean and dry.

• Isolation of the infected patients.

• Improvement of the nutritional status to raise the hemoglobin level.

• Care about personal hygiene.

• Mothers should use sterile sanitary pads.

• Traumatic vaginal delivery should be avoided.

• The vulva and vagina are to be cleaned with an antiseptic solution.

Conclusion

Postpartum infections are common infections related to mortality and morbidity. Healthcare providers can follow some steps to decrease the patient's risk of infection. Increased domestic violence and postpartum psychiatric conditions may increase the risk of infections. Limited vaginal examinations and internal fetal monitoring can decrease postpartum infections. Healthcare providers, including doctors, nurses, and pharmacists, can educate people about postpartum infections and prevention.