Infections in Pregnancy

Objectives of lecture

• To describe the main infectious complications during and after pregnancy

• To describe principles for prevention of infections

• To describe principles of treating infections

Magnitude of the problem

Infections in pregnancy is a main cause of maternal deaths.

• Early pregnancy complications (septic abortion)

• Infections during pregnancy

• Infection after delivery

Types of infection• Womb:• septic abortion/chorioamnionitis/endometritis• Wound: • perineum, vagina, cesarean section• Weaning: • breast engorgement, mastitis or absces• Water:• Urine Tract Infection• Wind: • pneumonia• (Walk:)• Venous Tromboembolism• Malaria• Meningitis

Preventing infection

Complications to abortion:

• Prevent adolescent pregnancies

• Prevent unwanted pregnancies

• Prevent unsafe abortions

Effects of the introduction in Romania in November 1966 of an anti abortion law, and legalization of abortion in December 1989

Preventing infections

At the antenatal clinic• Treat anaemia• Treat worms• Treat malaria and distribute bednets• Screen for HIV• Discuss good nutrition and maybe

micronutrients• Discuss hygiene

Preventing bacterial infections

Clean procedures:• Don’t wear watches or rings at work• Cut you nails short• Clean your hands before and after

touching a patient - always• Do not share soap and towel!• Alcohol is the best desinfecter• Keep the labour room clean and tidy

Preventing bacterial infections

Good obstetric and surgical procedures

• Use sterile techniques

• Prevent and stop bleeding: Anaemia is a major risk factor for infection and a hematoma is likely to become infected

• Avoid unnecessary episiotomies

• Do not perform cesarean section at a stilbirth unless on a vital indication

Preventing bacterial infection

PPROM

• Treat with Ampicillin IV 2 g. STAT followed by 1 g/6 hrs until delivery

At PROM >18-24 hrs:

• Treat with antibiotics as above

• Induce labour

Induction of labour

If cervix is ripe: soft, short, open 2-3 cm:

10 IU oxytocin in one liter N/S or R/L• Start dose: 12 drops/minuteEach 15-20 minutes• Increase by: 2-12 drops/minuteUntil desired effect• Maximum dose: 80-84 drops/minute

Induction of labour

If cervix is unripe: firm, long, closed:

Induce with misoprostol:

• 25 mikrogram vaginally

If no effect after 4 hours:

• 50 mikrogram vaginally

Contraindication: previous c. section

Treating infections

AT SEPSIS

IV antibiotics – as per WHO guidance: AMPICILLIN 2g/6 hrs (streptococcal infections)GENTAMYCIN 5mg/kg/24hrs (gram negatives)FLAGYL 500mg/8 hrs (clostridium and anaerobes)

If in a malaria risk area treat withQUININE 10 mg/kg in 5% dextrose IV over 4 hours/8 hrs

At septic shock:DEXAMETAZONE 4 mg/kg IV/6 hrs

Treating infections

A number of infections need surgical interventions because...

Dead products of pregnancy, haematomas and abscesses are not reached by antibiotics

In certain conditions Surgery should be performed immediately and not await ”antibiotic cover” becase...

Some antibiotics like ampicillin are only in therapeutic levels for 15-30 minutes so a cover is not possible.

Treating bacterial infections

Septic abortion:• Surgical abortion must be performed immediately!Endometritis (puerperal sepsis):• If no effect of antibiotics after 24-48 hrs D&C - or MVA. • If no effect after further 24 hrs - LaparotomyAbsces or infected hematoma: • Drainage and revision when diagnosed

All surgical procedures should be performed under ”antibiotic cover” that means giving antibiotics as surgery starts

Questions?