Puerperal (postpartum) infections: why do they occur and what are their symptoms?

Puerperal infections occur in women after childbirth. They are caused by bacteria infecting the uterus and surrounding organs during the first 6 weeks.

Infection can also occur after spontaneous or induced abortion.

Postpartum infections affect the woman's genitals and their surrounding area. They are manifested by an increase in temperature above 38 °C.

Nowadays they are rare rather than common, thanks to disinfection and better hygiene during and after childbirth.

The likelihood of postpartum infection depends on the type of delivery:

Vaginal birth poses approximately a 1-3% risk.

After the birth of a baby or after a miscarriage, the cervix is dilated. This makes it easier for bacteria to rise and enter the uterus from the vagina. Bacteria can also get in through minor injuries caused by childbirth in the birth canal.

A planned caesarean section performed before the onset of labour puts 5-15% of women at risk.

Infection of the wound after a caesarean section occurs in 3 to 5% of women. Bacteria enter the wound and cause infection.

A caesarean section performed after the start of labour, when acute labour surgery was necessary, poses the highest risk of all the others, at 15-20%.

The risk factors are as follows:

• vaginal infection
• prolonged labour
• premature amniotic fluid discharge
• inflammation of the amniotic sac
• intrauterine fetal monitoring
• birth injuries
• caesarean delivery
• excessive postpartum haemorrhage
• repeated vaginal examinations during labour
• leaving part of the placenta in the uterus after delivery

Other risk factors independent of childbirth are:

• anemia
• obesity
• malnutrition
• low age of women and girls at puberty, independent of the length of labour
• urinary tract infections
• HIV

Puerperal sepsis, popularly called postpartum blood poisoning, is one of the most well-known diseases of the puerperium caused by infections.

It is a very unpleasant and dangerous infection for the mother. It is one of the leading causes of death in women after childbirth worldwide.

Classification of postpartum inflammation according to localization

Vulva and vagina

• Puerperal ulcer occurs when there is difficulty in healing injuries of the vagina and perineum, sometimes in the form of an ulcer. It is a defect of the mucous membrane resulting from tissue breakdown. It affects the deeper layers and is associated with inflammation.

Uterus

• Endometritis is an infection of the uterine mucosa. It most often occurs at the site of placental abruption, after premature rupture of the amniotic membranes, but also after caesarean section.
• Myometritis is an inflammation that has spread to the uterine musculature.
• Parametritis is an infection around the uterus. It most often occurs after injury to the cervix with spread of the infection to the surrounding area, for example between the rectum and vagina.

Ovaries and fallopian tubes

• Adnexitis is an inflammation affecting the fallopian tubes and ovaries.

Peritoneum

• Pelveoperitonitis is inflammation of the pelvic peritoneum. It often follows inflammation of the ovaries and fallopian tubes.
• Diffuse peritonitis means that the infection has spread and the inflammation has affected the entire peritoneum. As a result of the inflammation, there may be pus in the abdominal cavity.

Puerperal septic pelvic thrombophlebitis

This is a relatively rare condition consisting of persistent fever and inflammation in the pelvic area that does not respond to antibiotic treatment. As a result of the inflammation, the veins become inflamed and are accompanied by the formation of blood clots.

Puerperal thrombophlebitis of the ovarian veins

It is very rare. It involves inflammation of the superficial veins with the formation of blood clots in the ovarian veins.

Puerperal sepsis and obstetric septic shock

It is one of the very serious diseases with a threat to a woman's life.

Sepsis means poisoning of the blood. It results from sudden massive colonization by microbes and their toxic effect on the bloodstream.

The toxic effect affects the tissues, which are then inadequately blooded. This leads to cell damage or tissue death.

Postpartum sepsis is a common consequence of illegal abortions.

The cause of postpartum infections is inadequate hygiene or disinfection during childbirth, after childbirth or after miscarriage.

Infections spread in two ways, either through the birth canal towards the ovaries to the peritoneum, or through the lymphatic or blood route to the whole body.

Infections after caesarean section are more common than after spontaneous births.

The most common infection is nosocomial infection, which is also known as hospital-acquired infection. It is an infection that occurs in connection with admission to hospital.

The infectious agent can also come from the vaginal or intestinal flora.

The most common infectious agents are:

• Gram-positive streptococci
• Enterococci
• Staphylococci
• Peptococci
• Clostridia
• E. coli
• Klepsiella
• Herpes simplex virus

The site of placental abruption, trauma, perineal incision, or cervical injury during delivery may be the entry site of infection.

Puerperal sepsis and obstetric septic shock often occur in illegal abortions.

Urinary tract infections, wound infections, and mastitis can also be causes of sepsis.

Prevention of postpartum infection

Maintaining hygiene and sterility during labour is important in the prevention of postpartum infection.

After delivery, it is necessary to:

• maintaining hygiene
• frequent changing of pads
• hand washing before and after changing the pad
• frequent and timely breastfeeding of the newborn
• plenty of exercise
• regular emptying

Antibiotics are given prophylactically in at-risk patients. The risk occurs when amniotic fluid is drained 12 hours before delivery or 6 hours before delivery and the temperature rises afterwards, in prolonged labour, in large blood loss, in diabetes melitus.

Antibiotics are given prophylactically to avoid the subsequent risk of infection when:

• positive vaginal and rectal swabs
• at delivery before 37 weeks of pregnancy
• amniotic fluid outflow lasting more than 18 hours

It may take several days before the first symptoms appear. They are not always immediately apparent during hospitalisation and only develop after discharge.

Symptoms depend on when the infection started, where it went and what kind of inflammation it is. Whether it is a local infection or sepsis that has moved throughout the body.

Symptoms of postpartum infection include

• Poorly healing postpartum wounds
• Inflamed skin with swelling and pus
• Wound tenderness at the site of the caesarean section
• Itching in the wound area
• Fevers, lower abdominal pain
• Smelly lochia (postpartum discharge from the uterus) or smelly vaginal discharge that may contain blood
• Pallor
• Headache
• Abdominal and pelvic pain
• Loss of appetite
• Increased heart rate
• Feeling of nausea and discomfort
• In case of urinary tract infection, frequent urination, pain and pinching during urination is typical

Symptoms in specific postpartum inflammation

Endometritis - inflammation of the uterine lining

• Increase in temperature above 38 °C or more
• Increased leukocyte count in the blood count
• CRP - inflammatory parameters
• Pain in the lower abdomen
• Uterine tenderness
• Smelly purges and bleeding
• Purgatory smear comes out positive
• Uterine pain, which can be localized according to the part where the inflammation is located

Myometritis, myometritis - inflammation of the muscles of the uterus

• Worsening of endometritis symptoms
• Chills, shivering
• Purges containing pus
• Pain throughout the uterus
• General deterioration of health

Parametritis, parametritis - inflammation of the uterine ligaments

• Chills, shivering
• High temperatures
• Increased number of leukocytes in the blood
• Rise in CRP - inflammatory parameters
• Pain in the lower abdomen that shoots into the thighs, cramps
• Frequent urge to urinate
• General deterioration of the condition

Adnexitis - inflammation of the fallopian tube and ovary

• Increase in temperature
• Shivering
• Chills
• Increased pulse
• Subileosis - pain and cramps in the abdomen occurring with partial disruption of the intestinal passage
• Blood draw shows elevated leukocyte and CRP values, indicating ongoing inflammation

Pelveoperitonitis - inflammation of the pelvic peritoneum

• High rise in body temperature
• Chills, shivering
• Increased pulse
• Vomiting
• Bowel movement disorder
• Symptoms of peritonitis
• Pain on vaginal examination
• Dislocation of the Douglas space - the space between the uterus and rectum
• Increased inflammatory parameters from blood sampling

Diffuse peritonitis - the entire peritoneum is affected by inflammation

• Abdominal pain
• Symptoms of peritonitis
• Fever
• Increased pulse
• Paralytic ileus - intestinal obstruction caused by paralysis of the muscles of the intestinal wall:
  • Abdominal pain
  • Constipation
  • Vomiting
  • nausea
  • bloated abdomen
• Deterioration of the whole condition
• Hippocratic face - the face is sunken with protruding cheekbones, pointed nose and cold sweat on the forehead

Puerperal septic pelvic thrombophlebitis - persistent inflammation leads to infection of the venous wall with subsequent formation of blood clots.

Suspicion arises when pelvic infection persists after 5 days of intensive antibiotic treatment. Often a triple combination of antibiotics is given. Diagnosis is only clarified after CT or MRI.

Symptoms similar to endomyometritis or circumscribed peritonitis.

• Fever
• pain and tension in the abdomen, pelvis or rectum
• vaginal bleeding
• vaginal discharge
• fatigue
• bloating
• constipation

Puerperal thrombophlebitis of the ovarian veins is very rare. When the ovarian veins become inflamed, blood clots begin to form and clog the blood vessels.

The thrombus can directly occlude the ovarian vein and cause it to become damaged or die. Alternatively, it can travel further down the bloodstream into the body.

Symptoms occur 3 to 5 days after the caesarean section.

• Fever
• Nausea and vomiting
• Subileus - disorder of intestinal passage
• Pain in the lower abdomen on the right side

Prevention is a vaginal swab. It is performed at 34-36 weeks of pregnancy to catch the infection early. If the infection is confirmed, antibiotics are given to prevent subsequent postpartum infections.

Investigations to establish the diagnosis

• A medical history is obtained from the woman, which provides many clues
• Important information such as:
  • the time of delivery or miscarriage
  • whether the birth was by caesarean section or spontaneous delivery
  • what was the gestational age of the foetus
  • how the birth took place
  • any complications during pregnancy and delivery
• followed by a gynaecological examination with observation of lochia or excessive vaginal bleeding
• Blood tests and laboratory investigations are performed. Blood collection for sedimentation, blood count to monitor white blood cell count, inflammatory parameters, liver function tests, creatinine, urea, blood ion values, haemocoagulation and urinalysis
• Wound swab and lochia culture
• Follow-up of the postoperative wound after caesarean section
• Sonographic examination of the abdomen and pelvis
• X-ray examination of the lungs
• Possibly CT, MRI
• ECG

The course depends on the type of infection, the site of inflammation and the immunity of the organism.

After a cesarean delivery, the risk of infection is 10-30 times higher than in a normal delivery.

The form of the course

• The acute form develops within 3-7 days. It is often manifested by septic fever, chills, increased pulse, low blood pressure, bluish discoloration of the fingers and, if the liver is affected, a slight yellowing of the skin and the whites of the eyes.
• The chronic form appears slowly, sometimes lasting 3 to 6 weeks.

If pus appears in the wound, the wound must be opened and the pus drained.

If the inflammation is more severe and the layer that protects the muscle is affected, surgery is necessary, followed by lavage two to three times a day. If left untreated, purulent deposits can form in the lungs, liver, mucous membranes, kidneys and brain.

Septic shock is the most serious complication after childbirth.

It is manifested by high temperatures above 38°C, low blood pressure and values from high inflammatory markers on blood sampling.

Worsening inflammation can cause pulmonary oedema (swelling of the lungs) with a high risk of pulmonary embolism (blockage of the lung chambers by a blood clot) and cardiac arrest.

Toxic shock syndrome caused by golden staph (Staphylococcus aureus).

The course of the disease is rapid. It begins with the onset of high fever, drop in blood pressure, high pulse rate above 160 per minute, watery diarrhea, muscle pain, to kidney failure.

What else do you need to watch out for?

If the mother has had a puerperal infection, the newborn also requires medical attention and monitoring for suspected sepsis (blood poisoning).

Premature rupture of the amniotic membranes, fever occurring in the mother during labor, chorioamnionitis (infection of the membranes surrounding the fetus and infection of the amniotic fluid) are high risks for neonatal sepsis.