OVERVIEW

Puerperalsepsisthemostcommoncauseofmaternaldeaths.
Etiology:Endogenousmicroflora,Exogenousorganisms(tenanus&P.aeroginosa),Sexually
transmittedpathogens(N.gonorrhea,C.trachomatis,HIV),others(malaria,TB,amebiasis).
Pelvicinfectionsinobstetricsaregenerallyascendinginfections.
Endotoxin=gramnegative;ExotoxinA=P.aeruginosa;Toxicshocksyndrometoxin=S.aureus.
Warmphaseofsepticshockcirculationvolumeinitiallyrestoredleadstohighcardiacoutput+
lowsystemicvascularresistance.
Coldphaseofsepticshockuncorrectedwithvigorousfluidinfusionleadstoperipheral
vasoconstriction+oliguria.
Bacterimiapresenceofviablebacteriaintheblood.
Septicimiapresence&persistenceofpathogenicorganismsortheirtoxinsinthebloodassociated
withasystemicdisease.
Indicatessystemicresponsetobacteremiaorsepsis(2ormore):
>38Cor<36C
HR>90/min
RR>20/minorPaCO2<32mmHg
Leukocytecount>15,000or<4,000or>10%bands
Severesepsissepsisassociatedwithorgandysfunction,hypoperfusion,orhypotension.
Septicshocksepsis+hypotensiondespiteadequatefluidresuscitation;mostominousprognosis
ofallcomplications.
Effectofantibiotictreatmentreevaluatedwithin48hours.
SurgicalManagementmostvitalpartindefinitivemanagementofpelvicinfectionsinpregnancy.
Eliminatefocusofinfection;Pelviccleanup
Culdotomyformidlineculdesacabscess.
MATERNALINFECTIONS:UPPERGENITALTRACT
Chorioamniotisinfectionoftheamnioticfluidandmembranes.
Commonlyassociatedwithprematureruptureofmembranes(PROM).
Diagnosis:Maternalfever(38Corhigher)+2ofthefollowing:
Maternaltachycardia
Purulentandfoulsmellingamnioticfluid
Maternalleukocytosis
Abdominaldeliverysinglemostsignificantriskfactorforpostpartumuterineinfection.
Intrapartum:GroupBStrep.
Goldstandardantibiotics:Clindamycin+Gentamycin
Afebrilefor2448hourssuccessfultreatment.
NecrosisoflowersegmentofuterusfollowingCSdelivery>dohysterectomy.
Prophylaxisincesareandelivery>basedonhospitalsantibioticresistancepattern;Ampicilin&
firstgenerationcephalosphorinshavesimilarefficacy.
MATERNALINFECTIONS:LOWERGENITALTRACT
1.FungalVaginitis90%causedbyC.albicans;Curdyvaginaldischargewithbeefyreditchyvulva.
2.BacterialVaginosiscausedbyGardenerellavaginalis,Mycoplasmahominis,andotheranaerobes.
Diagnosisneeds3ofthefollowing:
VaginalpH>4.7
Cluecells
Thinhomogenousdischarge
Fishyodor(addingpotassiumhydroxide)
Treatment:MetronidazoleorClindamycin.
3.TrichomonasVaginalisInfectiongreenyellowfrothyvaginaldischarge,dyspareunia,irritationof
thevulvaandurethracausingvulvovaginalsoreness,itching,anddysuria.
Diagnosis:NormalSalinewetmountdemonstratesflagellates.
Treatment:Metronidazole,includepartner.

4.GonorrheaN.gonorrheacancausePROM,puerperalsepsisanddisseminatedgonococcalinfection.It
canalsocausegonococcalophthalmianeonaturuminthefirstfewdaysoflife.
Diagnosis:GoldstandardmodifiedThayerMartinBroth
Treatment:CeftriaxoneorSpectinomycinorCefixime.
Neonatalprophylaxis:1%silvernitrateor1%tetracyclineor0.5%erythromycin
5.ChlamydialInfectionsC.trachomatis.UseGiemsaorWrightsstain.
Treatment:ErythromycinorAzithromycin.Tetracyclineiscontraindicatedinpregnancy.
6.SyphiliscausedbyTreponemapallidum.
CongenitalsyphilisRash,rhinitis(snuffles),jaundice,hepatosplenomegaly,thrombocytopenia,
osteochondiritis,nonimmunehydrops,&pseudoparalysis.
Diagnosis:Darkfieldmicroscopy
Screeningtest:VDRLorRPR
Treatment:Penicillin
7.HumanPapillomaVirusInfectionpresentsasgenitalwartsorcondylomaacuminate.
Treatment:Trichloraceticacid,Podophyllin,Electrocautery,Cryotherapy,Lasertherapy,surgical
excision.
8.HerpesVirusInfectioncausedbyHerpessimplexvirustypes1and2.Type2primarilyfoundinthe
genitalarea.
Neonatalherpesinfectionisthemostsignificantcomplication.
Treatment:Vaginaldeliveryifnolesionspresent.Cesareansectionperformedonlyinwomenwho
havegenitallesionsatdelivery.DrugofchoiceisAcyclovir.
9.HumanImmunodeficiencyVirus
Heterosexualintercoursepredominantmodeoftransmission.
Approximately10yearsaveragetimefromviraltransmissiontofullblownAIDSwithoutspecific
antiretroviraltherapy.
BreastfeedingbyHIVinfectedwomenisnotrecommended.
Treatmentofchoice:Aziidothymidine(AZT)orZidovudine.
10.HepatitisVirus
ViralHepatitismostcommoncauseofseriousliverdiseaseorjaundiceinpregnancy.
HepatitisA(HAV)infectioushepatitis,shortincubationperiodof26weeks.Routeoftransmissionis
fecaloral.
Mainstayoftreatmentisfluidreplacement,antiemetics,andnutritionalreplacementor
supplementation.Preventionisthroughcarefulhygienicmeasuresandimmuneserumglobulin.
HepaptisB(HBV)InfantsborntoHbsAgpositivemothersbecomeHbsAgpositivewithinthefirst12
monthsoflife.
DiagnosisreliesondetectionofhepatitisBsurfaceantigen(HbsAg).
Treatmenthospitalizationandobservationwithisolationprecautions.Neonatesofmotherswith
HBVinfectiongiveHepBimmunoglobulinandHepBvaccinesoonafterbirth(within212
hours).
11.TuberculosiscausedbyM.tuberculosis.
Diagnosis:
(1)5unitsofPurifiedProteinDerivative(PPD)IntradermalSkinTest(Mantoux).Morethan
10mmindurationdevelopingafter48hoursispositive.
(2)Acidfastsmear&culturegoldstandard.

Treatment:minimumof6monthsdurationisoniazid(INH),ethambutol(EMB),and
rifampicin(RIF).
Streptomycincausescongenitaldeafness.

MATERNALINFECTIONS:URINARYTRACTINFECTIONS
Factorsthatincreasethehostssusceptibilityinclude(1)Physiologichydroureterofpregnancy,
(2)vesicoureteralreflux,and(3)hormonal(progesterone)influences.
Highestincidenceseenbetween9thand17thgestationalweeks.
Screeningforasymptomaticbacteriuriaon16thweek.
E.colimostcommonorganism.
20to40percentofuntreatedasymptomaticbacteriuriaprogresstoacutesymptomaticinfection
later.
Atleast100,000bacterial/mLofsameorganismisgenerallyconsideredtobesignificantinfection.
Treatment:AmoxicillinandNitrofurantoinifsensitivetopenicillin.
AvoidNitrofurantoinandSulfisoxazoleneartermincreaseriskofhyperbilirubinemiainthe
newborn.
1.CystitisandUrethritispresentswithhistoryofurinaryfrequency,dysuria,andurgency.
Treatment:Ampicillin.Sulfonamide,nitrofurantoin,orcephalosporinfor10days.
IfurinalysisrevealsSterilepyuria>suspectC.trachomatis>giveErythromycin.
2.AcutePyelonephritismostcommonnonobstetricindicationforhospitalizationofthepregnantpatient.
50%unilateralontherightbecauseofthedextrorotationoftheuterus.
Fever,shakingchills,costovertebralangletenderness,anorexia,nauseaandvomiting.
Ifcultureisstillpositiveorrecurrentinfection>suppressivetherapywithNitrofurantoin.
Notrespondingtoantibiotics>investigateforstructuralanomaliesorobstructivepathologies.
3.ChronicPyelonephritisresultsinchronicinterstitialnephritis.
Usuallyasymptomatic.Advancedstagespresentwithrenalinsufficiency.
HistoryofrecurrentUTI,acutepyelonephritis,orobstructivedisease.
PROTOZOANDISEASESINPREGNANCY
1.MalariacausedbyPlasmodiumspecies(vivax,ovale,malariae,falciparum).
Transmittedthroughthebiteoffemaleanophelinemosquito,mainlyA.flavivostris.
Severehypochromicmicrocyticanemialeadstocongestiveheartfailure.
Severehemolysisleadstorenalfailure.
Treatment:Chloroquinefornonchloroquineresistantmalaria.QuininewithPyrimethamine
sulfadoxineorantibiotics(Clindamycinorerythromycin)forcholoroquineresistantfalciparum
malaria.
Contraindicatedinpregnantwomen:MefloquineandDoxycycline.
2.AmebiasiscausedbyEntamoebahistolytica.
Diagnosis:Directmountinsalineofdischargeorfecesdemonstratesameboidtrophozoiteswith
phagocytosedRBCs.
Treatment:Metronidazoletargetstrophozoitestage.AlternativeParomomycin&Chloroquine.
3.ToxoplasmosiscausedbyToxoplasnagondii,anobligateintracellularparasite.
Eatingofraworundercookedmeat,infectedcatfeces,orcongenitaltransplacentaltransfer.
AffectedInfantsLBW,hepatosplenomegaly,icterusanemia,chorioretinitis,andneurologicaldisease
(convulsion,intracranialcalcifications,hydrocephalus,andmicrocephaly).
Diagnosis:Indirectfluorescenceantibody,ELISA,orPCR.
Treatment:Spiramycin,Sulfadiazinewithpyrimethamine.
1.ClostridialInfections

INFECTIONSOFTHEFETUSANDNEONATE

TetanusneonaturumcausedbyC.tetani.
C.perfringensassoc.withsepticabortionandpostpartumsepsis.
C.tetaniassoc.withtrismusorlockjaw.Respiratoryfailureandconvulsiveseizuresinsevere

forms.
Treatment:PenicillinIV.Alternative:Cefoxitin,clindamycin,chloramphenicol,anderythromycin.
Prevention:atleast2dosesofTetanustoxoidinsecondandthirdtrimester,onemonthapart.
2.GroupBStreptococcus(GBS)mostcommoncauseofneonataldeathsinothercountries.
Treatment:Ampicillin.(Cantraversebloodbrainbarrierifgivenwithin4hours)
3.ListeriosiscausedbyListeriamonocytogenes.Bacteriaischronicallyharboredinthefemalegenital
tract.Itisknowntocauseabortions,stillbirths,perinatalsepsis.
Diagnosis:Historyofdeliveryofaninfectedorstillborninfantbyanasymptomaticmother.
Treatment:Ampicillin+Aminoglycoside
4.ViralInfections
Virusesthelargestnumberofinfectiousagentsproducingsignificantpathology.

CongenitalRubellaSyndromeinfantsshedthevirusformanymonths.
HEARINGdefects
Dystrophiccalcifications
CATARACTS
BLUEBERRYMUFFINSYNDROME(dermalerythropoiesis)
Microcephaly,progressivepanencephalitis,retinopathy,interventricularandinterauriculardefects
Hepatosplenomegaly
CongenitalVaricellaSyndrome(LeForetandLynch)
LBW
Skinscarring
HYPERTROPHIClimbs
Eyeabnormalities
Neonatalgrowthretardation
Seizures
CytomegalicInclusionSyndromeCMV
LBW
Microcephaly
Intracerebralcalcifications
Chorioretinitis
Hepatosplenomegaly,Jaundice
Hemolyticanemiaandthrombocytopenicpurpura