The risk of a woman dying in the puerperal period varies from 7/100 000 in Scandinavia to 1 000/100 000 in some parts of Africa and Middle-East, a horrifying contrast between the industrialized and developing worlds. Most of maternal deaths are due to:
1. Sepsis
2. Hypertensive disorders of pregnancy
3. Haemorrhage
4. Complications of obstructed labour
Causes of sepsis: sepsis is caused by the entry of bacteria into the genitel tract through the use of unwashed hands and unsterilized instruments during delivery.
Abortion is also a major cause of sepsis unsafe abortions kill at least 70 000 women each year. Septic abortions are the most common reason for admission to gynaecological wards and may account for 30% ~42% of maternal deaths in some communities. Such deaths are rare where abortions are both legal and accessible.
Reducing the number of unwanted pregnancies will reduce the number of women dying from illegal abortions. A prerequisite for this will be sexual equality, so that women can avoid coercive sexual relationships and use safe contraceptive methods.
Puerperal sepsis
Puerperal sepsis presents with:
1. Lower abdominal pain
2. Fever
3. Vomiting
4. Vaginal discharge <4weeks after childbirth (often within first few days)
Caesarean section and a long delay between membrane rupture and delivery greatly increase the risk. The infections are usually polymicrobial and include streptococci, enterococci, and Gram negative gut bacteria.
▶The presence of group A β-haemolytic streptococci (S. pyogenes ) suggests that health workers are infecting patients-stress rigid adherence to aseptic technique and handwashing, and attempt to identify the infected caregiver.
Septic abortion
The infection is normally polymicrobial. It may include resident bacteria of the vagina and endocervix, sexually-transmitted pathogens, Clostridium perfringens and C. tetani. Patients present in early to mid-pregnancy with fever and foul-smelling discharge. Those with temperature >38C, pelvic peritonitis, and tachycardia should be admitted to hospital for IV untibiotics and immediate uterine evacuation. Such patients are at high risk of sepsis and ARDS.
Patients presenting with mild illness (Iow-grade fever; mild lower abdominal pain; moderate vaginal bleeding) require immediate evacuation plus antibiotics such as ciprofloxacin and metronidazole. The patient should be admitted if there is no improvement at 48hrs.
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