Postpartum Infection – Causes, Symptoms, Treatment

Postpartum Infection/Parametritis (also known as pelvic cellulitis) is an inflammation of the parametrium (connective tissue adjacent to the uterus). Inflammation of the parametrium, the connective tissue of the pelvic floor, extending from the subserous coat of the uterus laterally between the layers of the BROAD LIGAMENT.

It is considered a form of pelvic inflammatory disease.^[rx] It is a type of a Puerperal infection or postpartum infection, which is an infection that occurs when bacteria infect the uterus and surrounding areas after a woman gives birth. It’s also known as a postpartum infection.

While there are several types of postpartum infection, Parametritis is inflammation of the ligaments around the uterus. As opposed to endometritis or myometritis, which are infections of the uterine lining and uterine muscle, respectively.^[rx]

Parametritis is different from perimetritis which is inflammation of the serosa surrounding the uterus.

There are several types of postpartum infections, including:

• endometritis: an infection of the uterine lining
• myometritis: an infection of the uterine muscle
• parametritis: an infection of the areas around the uterus

Causes of Postpartum Infection

Ascending infection from the cervix causes Parametritis. In 85% of cases, the infection is caused by sexually transmitted bacteria. Of the offending agents, the bacteria Neisseria gonorrhoeae or Chlamydia trachomatis are the most common pathogens. Approximately 10% to 15% of women with endocervical N. gonorrhoeae or C. trachomatis will go on to develop Parametritis. Typically, gonorrheal Parametritis is more severe than Parametritis due to other causes. PID due to chlamydia is less likely to cause symptoms, and therefore, more likely to result in subclinical Parametritis. Subclinical Parametritis can produce little to no symptoms, but can still have adverse long-term consequences.

Other cervical microbes, including Mycoplasma genitalium, have been thought to contribute to the disease. Additionally, pathogens responsible for bacterial vaginosis (Peptostreptococcus species, Bacteroides species), respiratory pathogens (Haemophilus influenza, Streptococcus pneumonia, Staphylococcus aureus), and enteric pathogens (Escherichia coli, Bacteroides fragilis, group B Streptococci) have been implicated in acute Parametritis, and account for approximately 15% of cases overall.[rx][rx][rx]

There are additional factors that may make a woman more at risk for developing an infection. These can include:

• anemia
• obesity
• bacterial vaginosis, a sexually transmitted infection
• multiple vaginal exams during labor
• monitoring the fetus internally
• prolonged labor
• delay between amniotic sac rupture and delivery
• colonization of the vaginal tract with Group B streptococcus bacteria
• having remains of the placenta in the uterus after delivery
• excessive bleeding after delivery
• young age
• low socioeconomic group

Symptoms of Postpartum Infection

Parametritis has various different signs and symptoms. These symptoms can occur several days after the discharge from the hospital after birth, hence it’s critical to check for signs of infection even after the discharge. Some of these could include:^[rx]

• Fever
• Headaches
• Chills
• An increased heart rate
• Lack of appetite
• Experience pain in the lower abdomen
• Vaginal discharge that is smelly
• Feeling discomfort of illness

Diagnosis of Postpartum Infection

• Persistent increase in ESR.
• With the development of abscesses infiltrate:- neutrophilic leukocytosis occurs shift to the left,
• Dysproteinemia,
• In the bimanual study:- determining shortening and smoothing of the posterior or lateral vaginal vault, a more pronounced by the defeat (or uniformly – in total infiltration).
• The uterus is not fully contoured, as included in the inflammatory infiltrate in part or in whole. Then the side of the uterus is defined infiltrate – a dense consistency.
• Signs of peritoneal irritation are absent.
• Palpation of the abdomen at the beginning of the disease is painless when a festering belly it becomes sensitive to palpation.
• Complications can arise when late diagnosis of infiltration and the development of abscesses – a breakthrough of abscess in the free abdominal cavity, rectum, and bladder.
• Blood cultures should be obtained from patients with cellulitis to assess for sepsis before beginning therapy with antibiotics. The affected body part should be elevated above the level of the heart. Outlining the affected area with a skin marker allows the caregiver to readily determine if inflamed tissues are responding to therapy. Size, shape, color, and temperature of the affected area and surrounding tissues should be documented and any drainage described. Applying warm soaks to the area increases vasodilation, thus decreasing edema and relieving pain. Pain should be treated with prescribed oral analgesics and anti-inflammatory drugs.
• Blood sugars, if elevated, should be lowered to normal levels (preferably about 126 mg/dl or less). Patients on prolonged bedrest should be given heparin to prevent deep venous thrombosis as well as stool softeners to prevent constipation. Patients who develop cellulitis are often at risk for recurrence; they should learn general skin hygiene, how to clean cuts, scratches, cracked skin, and abrasions, and the importance of prompt treatment for infections.

Treatment of Postpartum Infection

Postpartum infections are treated depending on the stage of the infection. Parametritis is usually treated with Parametrite therapy, including oral antibiotics to prevent further spread of the infection. In acute stage, the patient might need to be hospitalized. To reduce inflammation on the site, a cold is placed on the anterior abdominal wall. Anesthetics and antipyretic drugs are used.

Indications for hospitalization include pregnancy, failed outpatient treatment, severe clinical illness, PID with pelvic abscess, or possible need for surgical intervention.

Empiric treatment for Parametritis in the inpatient setting includes:

• Cefotetan (2 g intravenously [IV] every 12 hours) plus doxycycline (100 mg by mouth every 12 hours) or
• Cefoxitin (2 g IV every 6 hours) plus doxycycline (100 mg by mouth every 12 hours) or
• Clindamycin (900 mg IV every 8 hours) plus gentamicin (3 to 5 mg/kg IV once daily)

The CDC recommends the following for first-line treatment for outpatient therapy:

• Doxycycline (100 mg orally twice a day for 2 weeks) plus ceftriaxone 250 mg intramuscularly (IM) for one dose or cefoxitin 2 g IM with probenecid (1g orally) for one dose or another parenteral third-generation cephalosporin

Metronidazole (500 mg orally twice per day for 14 days) should be added if there is a concern for trichomonas or recent vaginal instrumentation.

or

• Begin with a broad-spectrum antibiotic drug or a fluoroquinolone (ciprofloxacin) in combination with metronidazole for 5-7 days.
• The woman is on strict bed rest, cold press done on the lower abdomen,
• Intravenous infusion of calcium chloride and 150 ml of 3% solution. If a festering abscess is opened through the posterior vaginal vault or from the anterior abdominal wall (extraperitoneal).
• In the case of chronic process, daily prednisolone dose of 20 mg for 10 days followed by NSAIDs(Indomethacin), with normalization of blood parameters.
• The disease is reversible but requires a long time hence; for,4-6 months, a spa treatment with the use of mud vaginal tampons, irrigation, or hydrogen sulfide baths, pelvic massage must be followed.

References