Open access peer-reviewed chapter
Description: Etiologic agents of puerperal infections.
Abstract
The risk of endometritis and puerperal fever can be decreased by reducing the upward infection of the vaginal bacterial load, even in patients with ruptured membranes. The use of prophylactic antibiotic treatment for puerperal sepsis remains under investigation. Sepsis during pregnancy and the postpartum period accounts for 11% of maternal deaths and ranks third globally. Its global incidence has been increasing, in countries with a maternal mortality rate of 8%, and is caused by multisystem dysregulation resulting from an infection, which can develop during pregnancy, abortion, childbirth, or in the postpartum period and is considered an obstetric emergency. Sepsis is a state of multisystem dysfunction, which is caused by a dysregulated host response to infection. Several factors influence the severity, clinical manifestations, and progression of sepsis, such as immunological heterogeneity, cell signaling pathways, and dynamic regulation of cell signaling pathways.
Keywords
- preventative care
- primordial prevention
- postpartum sepsis
- pregnancy complications
- hospital infections
1. Introduction
The rationale for this chapter is based on the importance of the prevention of puerperal infections and their complications in order to reduce maternal mortality.
Puerperal sepsis is a pathology that significantly affects maternal health, increases morbidity, and complicates childbirth [1].
Sepsis during pregnancy and the postpartum period accounts for 11% of maternal deaths [2] and ranks third globally [3]. Its overall incidence has been increasing [4]; in countries such as France, they have a maternal mortality rate of 8% [5]. The overall incidence grouped in studies was 3.9% [6]; the prevalence is higher in countries such as Ethiopia (14.81%) [7] and other regions of sub-Saharan Africa (19.21%) [8].
It occurs as a consequence of a multisystem dysregulation resulting from an infection, which can develop during pregnancy, abortion, childbirth, or in the puerperium [9] and is considered an obstetric emergency, being one of the main causes of morbidity with high mortality; therefore, it is necessary to treat it early, a paradigm represents it, viral infections such as COVID 19, during the pandemic, which caused sepsis in pregnant patients, with the main complications being: premature birth, preeclampsia, maternal and perinatal death [10].
1.1 Etiology of puerperal infections
The causes of infection during pregnancy or puerperium in puerperal sepsis are characterized by cardiovascular, respiratory, renal, and hepatic dysfunction and disseminated intravascular coagulation. The main causes of puerperal sepsis are: surgical wound infection, endometritis, and chorioamnionitis as a consequence in some cases of genital tract infections (Figure 1). Other causes include pneumonia, urinary tract infections—pyelonephritis, and digestive tract infections, in 50% of cases being caused by Gram-negative bacteria [11].
Figure 1.
Description: Genital tract infection in a pregnant patient with Müllerian malformation (double vagina), with presence of Candida vulvovaginitis. Source: Dr. María Fernanda Calderon León.
Table 1 lists the bacteria most frequently observed in puerperal infection. There are less common cases of infection such as acute endocarditis in pregnancy [14].
| Author | Etiology of puerperal infection |
|---|---|
| Liu et al. [11] | He isolated 91 microorganisms cultured in blood, vaginal discharge, and discharge from infected surgical wounds; 6 were fungi and 85 bacteria. |
| Harris et al. [12] | Group A streptococci |
| Calderón et al. [13] | Gram-positive |
Table 1.
Elaboration: Dra. María Fernanda Calderón León.
In cesarean section, episiotomy and morphological changes in pregnancy are associated with an increased risk of puerperal infection [15]. Endometritis and surgical site infection complicate the postpartum period and require longer hospital stay and the need for antibiotics. Other infections include infection of the mammary region such as abscesses or necrotizing fasciitis, which are less common (Figure 2) [16].
Figure 2.
Description: Panel A: necrotizing fasciitis in a pregnant patient with malignant tumor of the left breast. Panel B: left breast abscess in 30 days of puerperium of vaginal delivery. Source: Dra. María Fernanda Calderón León.
In puerperal sepsis, it is necessary to apply the following recommendations: firstly, the recognition of maternal sepsis, always maintaining a high index of suspicion and activating the hospital sepsis code, in addition to implementing a rapid tool for the detection of maternal deterioration. Second: The golden hour in which sepsis packages or groupers should be applied, which are: serum lactate, blood cultures, administration of fluids, antibiotics, and initiation of vasopressors in case of hypotension in the first hour of the registration of puerperal sepsis, in addition to laboratory and radiological studies, which are key to the search for the etiology and control of the source. Recognize the most common germs and their likely origin. Choice of antimicrobials must be adapted to diagnosis [17]. Broad-spectrum empiric antibiotic treatment is given as soon as possible, within 1 hour, to any pregnant woman in whom puerperal sepsis is suspected [18]. Fluid resuscitation should be initiated promptly in patients with a blood lactate greater than 2 mmol/L or a mean arterial pressure less than 65 mm Hg. After the golden hour: Stepping up attention is critical to survival. Once the patient is stabilized, the source of the problem should be sought to anticipate and prevent adverse pregnancy outcomes.
Sepsis is a state of multisystem dysfunction that is caused by a dysregulated host response to infection. There are a number of factors that influence the severity, clinical manifestations, and progression of sepsis, such as immunological heterogeneity, cell signaling pathways, and dynamic regulation of cell signaling pathways.
Pathophysiologically, sepsis begins with the recognition of microorganisms through receptors present, generating an amplification of the inflammatory response, due to the identification of endogenous molecules, associated with damage PAMP (Molecular Patterns Associated with Pathogens) and DAMP (Molecular Patterns Associated with Damage), causing an alteration of the respiratory chain, which is known as mitochondrial dysfunction secondary to sepsis.
Septic shock is defined as a state of acute circulatory failure, associated with an infection, characterized by hypotension or hypoperfusion.
The ability to predict mortality from sepsis is measured using the Acute Physiology and Chronic Health Evaluation (APACHE) II, III, IV classification system. Another scale that measures mortality and organ dysfunction is through the Sequential Assessment of Organ Failure (SOFA) score during the first 24 hours after admission to the intensive care unit (ICU) [19].
Norepinephrine is the first-line drug in the early onset of vasopressor support, even before the end of initial fluid resuscitation. In cases of mean arterial pressure < 65 mmHg, vasopressin should be added [19]. Infections are associated with adverse maternal outcomes, in the puerperium untreated infections such as genital infections, chorioamnionitis, breast abscesses are of great importance since they can have negative results and complicate the normal evolution of the puerperal period [20, 21].
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2. Methodology
A search was carried out in databases and medical journals such as Pubmed, Mendeley, Intech Open, Latindex, and LILACS; puerperal sepsis and puerperal infections were used as a search pattern; clear, precise, and concise articles that addressed the subject, published in the last 5 years, were included.
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3. Important aspects of puerperal sepsis
SeeTable 2, current management to prevent puerperal infections after caesarean section with the administration of antibiotics, a single dose of antibiotic outperforms placebo in vaginal delivery to prevent infections, prophylactic antibiotics do not reduce endometritis, single-dose high-dose azithromycin in premature rupture of membranes exceeds low doses by several days, The use of 4% chlorhexidine for vaginal cleansing before caesarean section in patients with premature rupture of membranes reduces endometritis.
| Author | Population | Pharmacological intervention | Conclusions |
|---|---|---|---|
| Igwemadu et al. [22] | Prevention of postpartum cesarean section infections | Ceftriaxone and metronidazole versus cefuroxime for 5 days | Single-dose ceftriaxone and metronidazole is as effective as multiple-dose antibiotic prophylaxis in preventing post-cesarean section infections |
| Knight et al. [18] | Infection after vaginal delivery | Amoxicillin and clavulanic acid versus placebo | The use of a single dose of prophylactic antibiotic after vaginal delivery is beneficial |
| Voon et al. [23] | Prevention of endometritis in ruptured placental membranes | Amoxicillin-clavulanic acid 625 mg three times daily VERSUS watchful waiting | Preventive use of antibiotics after vaginal delivery in women with irregular placental membranes did not result in a reduction in endometritis. |
| Abdelfattah et al. [24] | Azithromycin for the treatment of premature rupture of membranes before delivery | Single dose of 1 g of azithromycin compared to 500 mg accompanied by doses of 250 for four days | Single-dose high azithromycin was associated with improved maternal and neonatal outcomes. |
| Ureña et al. [25] | Patients with ruptured membranes | The use of 4% chlorhexidine for vaginal cleansing before a cesarean delivery | Patients with ruptured membranes reduced the risk of endometritis and puerperal fever. |
| Mohammed et al. [26] | Prophylactic antibiotics after a cesarean section | 2 x 1.2 g doses of amoxicillin-clavulanic acid compared to 7 days of amoxicillin-clavulanic acid and metronidazole | No statistically significant differences were found in infectious morbidity |
Table 2.
Description: Antibiotic management in puerperal sepsis.
Elaboration: Dr. Javier Aquiles Hidalgo Acosta.
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4. Conclusions
Puerperal sepsis is a pathological entity of high mortality, which can be prevented through the prophylactic management of promising measures that prevent bacterial progression and ascent in the period of pregnancy, childbirth, and puerperium. In the present research, it is concluded that vaginal antiseptic solutions before cesarean delivery decrease the risk of endometritis by reducing ascending infection through a reduction of vaginal bacterial load, including patients with ruptured membranes, even if bacteria have already ascended and colonized the uterus prior to cleaning.
The use of prophylactic antibiotic treatment for puerperal sepsis, in a single dose of higher amounts, has better results than the use of doses of lower amounts in milligrams, divided and applied over several days.
The level of lactate in the blood is a useful marker of the severity of sepsis or multi-organ failure, as higher levels predict higher mortality and allow us to better identify high-risk patients; an elevated lactate level was associated with a higher level of hypoperfusion. It is currently recommended as part of the package within the first hour in patients with sepsis.
According to guidelines for surviving sepsis, appropriate dosing and administration of antimicrobials should be applied. In the first hour, blood cultures should be performed, in addition to taking into account alterations in pharmacokinetics and pharmacodynamics and characteristics such as multiple comorbidities, mainly in those who receive organ life support or are in a state of shock, applying the precise dose. In a multicenter study, prolonged antibiotic administration was found to be associated with higher mortality; in contrast, rapid antibiotic administration was associated with lower in-hospital mortality.
Current standards for resuscitation in septic shock indicate following the goals of clinical resuscitation and appropriate use of antibiotics, fluids, and vasoactive drugs. Blood lactate level is a useful marker of the severity of sepsis or multiple organ failure, as higher levels predict higher mortality, allowing us to better identify high-risk patients. Puerperal sepsis is associated with an increased risk of death, secondary to various causes, such as insulin use or acute adrenal insufficiency.
Intravenous fluid doses should be tailored to the patient’s condition, and guidelines for surviving sepsis suggest resuscitating sepsis-induced hypoperfusion patients with at least 30 mL/kg of intravenous crystalloids within the first 3 h. In patients with puerperal infection who progress to acute renal failure, multiorgan failure, or septic shock, intermittent or continuous renal replacement therapy is part of intensive care unit management of severe cases.
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Appendices and nomenclature
intensive care unit acute physiology and chronic health assessment classification system sequential organ failure assessment
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