PUERPERAL INFECTION

Start from the beginning

 The abscess is usually unilateral and typically present 1 to 2 weeks after delivery

PARAMETRIAL PHLEGMON

 Parametrial cellulitis is intensive and forms an area of induration within th leaves of the broad ligament

 These infections should be considered when fever persists longer than 72 hours despite intravenous antimicrobial therapy

 Areas of parametrial cellulitis are more often unilateral , and they may remain limited to the base of the broad ligament

 The most common form of extension is laterally, along the base of the broad ligament, with tendency to extend to the lateral pelvic wall

 In most women with a phlegmon, clinical improvement follows continued treatment with a broad spectrum antimicrobial regimen

 Women usually febrile for 5 to 7 days and in some cases even longer

 Surgery is reserved for women in whom uterine incisional necrosis is suspected

 Hysterectomy and surgical debridment are usually difficult - often appreciable blood loss

 Uterine debridment and resuturing of the incision are feasible

PELVIC ABCESS

 a parametrial phlegmon supurates, forming a fluctuant broad ligament mass that may point above the poupart ligament

 This abscess may dissect anteriorly and be amenable to needle drainage directed by CT imaging

SEPTIC PELVIC THROMBOPHLEBITIS

 Purperal infection may extend along the venous routes and cause thrombosis

 The ovarian veins may then become involved because they drain the upper uterus

CLINICAL FINDINGS -

display some clinical improvement of their pelvic infection following antimicrobial treatment, however continue to have fever

- asymptomatic except for chills

- pain typically manifested on the second or third postpartum day

- in some cases a tender mass is palpated lateral to the uterine cornu on either side

DIAGNOSIS - Pelvic CT or MRI

Infections Of the Perineum,

Vagina, and Cervix

PATHOGENESIS AND CLINICAL COURSE

 Episiotomy dehiscence is most commonly associated with infection

 Other factors include coagulation disorders, smoking and human papillomavirus infection

 Signs and Symptoms - pain 65%, purulent discharge 65%, fever 44%

in extereme cases , the vulva may become edematous , ulcerated, covered with exudate

 Cervical lacerations are common

when infected deep lacerations often extend directly into the tissue at the base of the broad ligament, and infections may cause lymphangitis, parametritis, and bacteremia

TREATMENT

- should be treated with establishing drainage

- In most case, sutures are removed and the infected wound opened

- In some women with obvious cellulitis but no purulence - broad-spectrum antimicrobial therapy with close observation

- Early repair after evidence of infection subsided

- The average duration from dehiscence to repair was 6 days

- All but two women had a succesful repair and both of them developed a pinpoint rectovaginal fistula treated succesfully with a small rectal flap.

PREOPERATIVE PROTOCOL OF EARLY REPAIR OF EPISIOTOMY DEHISCENCE

Intravenous antimicrobial therapy until afebrile

Remove sutures and open wound entirely

WOUND CARE

Sedation is indicated

2% lidocaine jelly applied to wound

Debridement of all necrotic tissue

Scrub wound twice daily with povidone- iodine

Sitz bath several times daily or hydrotherapy

Mechanical bowel preparation day before surgery- for 4th degree repairs, NPO the evening before surgery

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