What is the most significant complication to anticipate in a mother postpartum, aside from postpartum hemorrhage, and what are the risk factors that contribute to it?

Postpartum Infection (Puerperal Sepsis) is the Most Significant Maternal Complication After Delivery, Aside from Hemorrhage

Maternal infection, particularly puerperal sepsis, is the most significant and potentially life-threatening complication for mothers in the postpartum period after hemorrhage, with reported incidence rates of 1.7-4.3% of deliveries and mortality rates up to 14.2% when inadequately treated. 1, 2

Epidemiology and Significance

• Puerperal sepsis is among the leading causes of preventable maternal morbidity and mortality worldwide, ranking as the third major cause of maternal deaths in many countries 2
• Most postpartum infections occur after hospital discharge (typically 24 hours after delivery), making them easily missed without proper follow-up 1
• Maternal sepsis has been reported to occur in up to 6.8% of cases of preterm prelabor rupture of membranes (PPROM), with higher rates in expectant management compared to immediate intervention 3
• In severe cases, infection can progress rapidly - a French national study found that once infection was identified in PPROM cases, the median time to death was only 18 hours (IQR, 12-120 hours) 3

Clinical Manifestations

• Primary manifestations include fever, foul-smelling vaginal discharge, uterine tenderness, and general signs of infection 1
• Complications can rapidly progress to:
  • Endometritis (endomyometritis or endomyoparametritis) 1
  • Septicemia and endotoxic shock 2
  • Peritonitis or pelvic abscess formation (reported in 8.6% and 10.8% of cases respectively) 2
  • Disseminated intravascular coagulation (DIC) (2.1% of cases) 2
  • Septic thrombophlebitis 1

Risk Factors for Puerperal Sepsis

Sociodemographic Factors

• Low socioeconomic status (65.2% of cases) 2
• Young maternal age (15-25 years) (66.3% of cases) 2
• Poor education level (78.2% of cases) 2
• Poor nutrition and anemia (69.2% of cases) 4, 2

Obstetric Factors

• Cesarean section (significantly increases risk compared to vaginal delivery) 1, 3
• Prolonged labor (>12 hours) (58.6-65.7% of cases) 4, 2
• Prolonged rupture of membranes (48-72 hours) (73.8% of cases) 2
• Multiple vaginal examinations during labor (>5) (50.7% of cases) 4
• Retained products of conception (44.5% of cases) 2
• Home births or deliveries by untrained birth attendants (73.9% and 60.5% of cases respectively) 2
• Postpartum hemorrhage (increases risk of subsequent infection) 1
• Primiparity (63% of cases) 2

Medical Factors

• Preexisting infections or colonization 1
• Non-adherence to aseptic techniques during delivery 4
• Lack of antibiotic prophylaxis during cesarean section 5

Prevention and Management Considerations

• Proper antenatal care and supervised hospital delivery significantly reduce risk 4
• Prophylactic antibiotics during cesarean section substantially reduce infection risk 5
• Optimal antiseptic measures during labor and delivery are essential 2
• Early recognition and prompt treatment of infection are critical to prevent progression to sepsis 3
• Careful monitoring throughout labor and the postpartum period is necessary, especially for high-risk women 2
• Postpartum hemorrhage should be actively managed, as it increases infection risk 3

Special Considerations

• Women with preterm prelabor rupture of membranes (PPROM) are at particularly high risk, with maternal sepsis occurring in up to 6.8% of cases 3
• Postpartum sepsis can be categorized by source of infection:
  • Nosocomial (hospital-acquired)
  • Exogenous (external contamination)
  • Endogenous (from woman's own genital tract flora) 1

Recognizing risk factors and implementing preventive measures are crucial for reducing the incidence of this serious postpartum complication. Early diagnosis and prompt treatment are essential to prevent progression to life-threatening sepsis.