What is puerperal infection?

What is Puerperal Infection

Puerperal infection is any bacterial infection of the female genital tract that occurs after childbirth or abortion, typically presenting with fever ≥101°F (or >100.4°F/38.0°C on more than two occasions >6 hours apart) after the first 24 hours post-delivery and up to 10 days postpartum, accompanied by abdominal pain, uterine tenderness, and foul-smelling lochia. 1, 2

Clinical Definition and Timing

Puerperal infection encompasses a spectrum of postpartum infections affecting the reproductive tract 2, 3:

• Postpartum endometritis (endomyometritis or endomyoparametritis) is the most common manifestation, presenting with high fever after the first 24 hours post-delivery, abdominal pain, uterine tenderness, and foul lochia 1
• The infection window extends up to 10 days post-delivery 1
• Most postpartum infections actually occur after hospital discharge, which typically happens within 24 hours of delivery 2, 3

Microbiology

Puerperal infection is usually a multi-organism syndrome involving mixed bacterial flora 1:

• Endogenous organisms from the woman's own genital tract are a primary source, consisting of mixed flora colonizing the genital tract 2, 3
• Gram-negative bacteria include Escherichia coli (most common), Klebsiella pneumoniae, and Acinetobacter baumannii 4
• Gram-positive bacteria include Staphylococcus aureus (most common), Coagulase-Negative Staphylococci, and Group B Streptococci 4
• Anaerobic bacteria such as Bacteroides, Peptostreptococcus, and Peptococcus species are frequently involved 1
• Other organisms include Gardnerella vaginalis, Streptococcus species, and Haemophilus influenzae 1

Major Risk Factors

The primary risk factor is cesarean section, which increases infection risk 5- to 20-fold compared to vaginal delivery 5:

• Unplanned cesarean section carries the highest risk due to inability to introduce prophylactic antibiotics quickly 1
• Prolonged rupture of membranes and prolonged labor 2, 3, 6
• Multiple vaginal examinations during labor 2, 3, 6
• Multiparous parity (women with multiple previous deliveries are at significantly higher risk than primiparous women) 4
• Obstetrical maneuvers and interventions during childbirth 2, 3, 6
• Retained placental tissue within the uterus 2, 3
• Postpartum hemorrhage and anemia 2, 3, 6
• Poor prenatal hygiene and home birth in unhygienic conditions 2, 3, 6

Routes of Transmission

Infections are categorized into three transmission routes 2, 3:

• Nosocomial infections: Acquired in hospitals from the hospital environment or patient's own flora 2, 3
• Exogenous infections: From external contamination, especially during deliveries under unhygienic conditions 2, 3
• Endogenous infections: From mixed flora colonizing the woman's own genital tract 2, 3

Prevention Strategies

Testing and treating symptomatic bacterial vaginosis (BV) late in pregnancy reduces postpartum endometritis 1:

• Screening for Group B Streptococci colonization (both vaginal and anal swabs) at 35-37 weeks gestation with prophylaxis during labor and delivery reduces neonatal and maternal infection 1
• Aseptic precautions during delivery 2, 3
• Prophylactic antibiotics, particularly for cesarean section 5

Clinical Significance

Puerperal infection remains a leading cause of preventable maternal morbidity and mortality worldwide, particularly in developing countries 2, 5, 3:

• Maternal complications include septicemia, endotoxic shock, peritonitis, abscess formation requiring surgery, and compromised future fertility 2, 3
• Multidrug resistance is common, with 84% of bacterial isolates showing resistance to multiple antibiotics 4
• All Gram-positive and Gram-negative isolates in recent studies showed 100% resistance to tetracycline 4