Infecciones puerperales

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Infections

Endometritis

Endometritis is an ascending polymicrobial infection. The causative agents are usually normal vaginal flora or enteric bacteria.
Etiology
Endometritis is the primary cause of postpartum infection. The most common organisms are divided into 4 groups: aerobic gram-negative bacilli, anaerobic gram-negative bacilli, aerobic streptococci, and anaerobic gram-positivecocci.
Endometritis occurring on postpartum day 1 or 2 most frequently is caused by group A streptococci. If the infection develops on day 3 or 4, the causative organism is frequently enteric bacteria, most commonly E coli, or anaerobic bacteria. Endometritis that develops more than 7 days after delivery is most frequently caused by Chlamydia trachomatis. Endometritis following cesarean delivery ismost frequently caused by anaerobic gram-negative bacilli, specifically Bacteroides species.
Known risk factors for endometritis include cesarean delivery, young age, low socioeconomic status, prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, placement of an intrauterine catheter, preexisting infection or colonization of the lower genital tract, twin delivery, andmanual removal of the placenta. It has also been shown that manual removal of the placenta at cesarean delivery increases the incidence of endometritis.
Incidence
Endometritis complicates 1-3% of all vaginal deliveries and 5-15% of scheduled cesarean deliveries.
Morbidity and mortality
Following 48-72 hours of intravenous antibiotic therapy, 90% of women recover. Fewer than 2% of patientsdevelop life-threatening complications such as septic shock, pelvic abscess, or septic pelvic thrombophlebitis.
History
A patient may report any of the following symptoms: fever, chills, lower abdominal pain, malodorous lochia, increased vaginal bleeding, anorexia, and malaise.
Physical
A patient with endometritis typically has a fever of 38°C, tachycardia, and fundal tenderness. Some patients maydevelop mucopurulent vaginal discharge, whereas others have scant and odorless discharge.
Workup
• Laboratory tests: The appropriate tests for a febrile postpartum patient may include a CBC count with differential, urinalysis, urine culture, and blood cultures.
Treatment
Treatment of endometritis is with intravenous antibiotics. Parenteral antibiotics are usually stopped once the patient isafebrile for 24-48 hours, tolerating a regular diet, and ambulating without difficulty.17 In general, an extended course of oral antibiotics has not been found to be beneficial,18 although 2 exceptions have been noted. In patients who respond quickly to intravenous antibiotics and who desire early discharge, a short course of oral antibiotics may be substituted for continued intravenous therapy.The other exception includes patients with staphylococcal bacteremia requiring an extended period of treatment.
In emergency cesarean deliveries, use of prophylactic cefazolin has been shown to reduce the rate of postpartum endometritis and wound infection.

Urinary Tract Infections

A urinary tract infection (UTI) is defined as a bacterial inflammation of the bladder or urethra. Greater than100,000 colony-forming units on a catheterized specimen is considered diagnostic of a UTI.
Etiology
Risk factors for postpartum UTI include cesarean delivery, forceps delivery, vacuum delivery, tocolysis, induction of labor, maternal renal disease, preeclampsia, eclampsia, epidural anesthesia, bladder catheterization, length of hospital stay, and previous UTI during pregnancy.
The most commonpathogen is E coli.31 In pregnancy, group B streptococci are a major pathogen.
Incidence
Postpartum bacteruria occurs in 3-34% of patients, resulting in a symptomatic infection in approximately 2% of these patients.
History
A patient may report frequency, urgency, dysuria, hematuria, suprapubic or lower abdominal pain, or no symptoms at all.
Physical
On examination, vital signs are stable...
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