19.14 Puerperal sepsis

After childbirth a woman’s genital tract has a large bare surface, which can become infected. Infection may be limited to the cavity and wall of her uterus, or it may spread beyond to cause peritonitis (10.1), septicaemia, and death, especially when her resistance has been lowered by a long labour, severe bleeding, or HIV disease. If she is more fortunate, her infection may be walled off by her bowel and omentum. She may have a pelvic collection of pus in her pouch of Douglas, or she may have pus high in her pelvis or in her lower abdomen.

If sepsis is localized, only her lower abdomen is distended, she has guarding in both her iliac fossae, and an ill-defined tender mass arising from her pelvis. She may have hyperactive bowel sounds. Vaginally, she shows signs of recent childbirth or abortion, and may have infected lacerations. Her cervix is open and tender, painful on movement, and may be drawn up behind her symphysis. Her pouch of Douglas may be thickened or swollen, but you cannot feel a fluctuant mass vaginally. Her uterus and appendages form a mass which is difficult to define Fig because of their tenderness.

If sepsis is generalized, she is weak, with anorexia, fever (perhaps with rigors), a rapid thready pulse, a low blood pressure and generalized abdominal pain. Her abdomen is uniformly distended, tympanitic, silent, and acutely tender. She may have a visible mass extending up to her umbilicus; you may have to pass a catheter to make sure that it is not merely a distended bladder. She cannot walk. She may have diarrhoea until peritonitis causes ileus and this causes constipation and vomiting.

RESUSCITATION

See 10.12.

ANTIBIOTICS. Treat with chloramphenicol, ampicillin or gentamicin and metronidazole.

MONITOR HER daily for signs of the spread of infection.

MANAGEMENT: If she continues to bleed, she may have retained pieces of placenta. This is a common cause of puerperal sepsis, which will not resolve until her uterus is empty. Give her antibiotics and curette her 24 hours later with great care! Use the largest curette which will be less likely to perforate her uterus. Curetting a large, soft, infected uterus is dangerous.

If her uterus is enlarged and tender, with a closed cervix as the result of scarring or carcinoma, it may be full of pus (pyometra, 32-21). This can occur 2 weeks or more after delivery. Drain her cervix with Hegar’s dilators, 10 Ch is usually enough.

If she has a definite swelling at one side of her uterus, she has parametritis.

If she has generalized peritonitis without any localizing signs, make a muscle splitting incision as for appendicectomy in an iliac fossa. Open her peritoneum, sweep gently with your finger, and insert a sump sucker. Up to a litre of thin pus will probably escape. If you enter an abscess cavity, gently free any adhesions and open up all loculi. Lavage her abdominal cavity (10.1).

If her fever recurs after initial improvement, there is more pus somewhere which must be drained, best through a midline incision. If you fail to drain a subphrenic abscess (10.10), she will die.

If she recovers from the acute episode, but is left with a mass, she may eventually need a need a full laparotomy, with the separation of adhesions and the removal of a tubo-ovarian mass.