1000-2000 5 ьшò

Tachycardia

Uterine tenderness on exam

Other localized abdominopelvic tenderness on exam

Purulent or malodorous lochia

Heavy vaginal bleeding

Ileus

Group Aor B streptococcal bacteremia may have no localizing signs.

DIFFERENTIALDIAGNOSIS

“5 Ws”: Wind (pneumonia); Water (UTI); Wound infection; Wow (mastitis); Wonder drug (medication-related fever)

Viral syndrome; dehydration

Thrombophlebitis

Thyroid storm

Appendicitis

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

CBC: Interpret with care. (Physiologic leukocytosis may be as high as 20,000 WBCs.)

Two sets of blood cultures (especially with suspected sepsis) Diagnosis often made on clinical grounds. Potential testing includes:

–Genital tract cultures and rapid test for group B streptococci (may be done during labor)

–Amniotic fluid Gram stain: usually polymicrobial

–Uterine tissue cultures: Prep the cervix with Betadine and use a shielded

specimen collector or Pipelle; difficult to obtain without contamination If patient not responding to antibiotics in 24 to 48 hours:

–Ultrasound for retained products of conception, pelvic abscess, or mass

–CT or MRI looking for pelvic vein thrombophlebitis, abscess, or deepseated wound infection

Diagnostic Procedures/Other

Paracentesis/culdocentesis with culture rarely necessary

Test Interpretation

Superficial layer of infected necrotic tissue in microscopic sections of uterine lining

mebooksfree.com

>5 neutrophils per high-power field in superficial endometrium; ≥1 plasma cell in endometrial stroma

TREATMENT

MEDICATION

First Line

Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h (5)[A]

Potential side effects include nephrotoxicity, ototoxicity, pseudomembranous colitis, or diarrhea (in up to 6%).

Second Line

Ampicillin/sulbactam 3 g IV q6h

Metronidazole 500 mg IV or PO q8–12h + penicillin 5,000,000 U IV q6h, or

Ampicillin 2 g IV q6h + gentamicin 5 mg/kg IV q24h (5)[A]

Cefoxitin 2 g IV q6h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours (5)[A].

Cefotetan 2 g IV q12h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours (5)[A].

Note: Base therapy on cultures, sensitivities, and clinical response. Contraindications

–Drug allergy

–Renal failure (aminoglycosides)

–Avoid sulfa, tetracyclines, and fluoroquinolones before delivery and if breastfeeding. Metronidazole is relatively contraindicated if breastfeeding.

Precautions:

–Clindamycin and other antibiotics occasionally cause pseudomembranous colitis.

–Antibiotic-associated diarrhea (Clostridium difficile)

Note: Consider adding a macrolide antibiotic (for chlamydia coverage) for infections occurring after 48 hours.

Note: Heparin typically indicated for septic pelvic vein thrombophlebitis; requires 10 days of full anticoagulation

SURGERY/OTHER PROCEDURES

Curettage for retained products of conception

mebooksfree.com

Surgery or image-guided drainage to drain abscess

Surgery to decompress the bowel

Surgical drainage of a phlegmon is not advised unless it is suppurative. Surgical removal of other inflamed tissue is usually not required.

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

Inpatient care is recommended for postpartum infections.

Many infections occur after hospital discharge.

IV antibiotics and close observation for severe infections

Open and drain infected wounds. Optimize fluid status.

ONGOING CARE

FOLLOW-UPRECOMMENDATIONS

Patient Monitoring

Individualize according to severity.

IV antibiotics can be stopped when the patient is afebrile for 24 to 48 hours.

Oral antibiotics on discharge are not necessary, unless patient was bacteremic; then continue oral antibiotics to complete a 7-day course.

DIET

As tolerated, although may be limited by ileus

PATIENT EDUCATION

Advise patient to contact physician with fever >38°C (100.4°F) postpartum, heavy vaginal bleeding, foul-smelling lochia, or other symptoms of infection.

Information available at http://www.healthline.com/health/pregnancy/complications-postpartum- endometritis

PROGNOSIS

With supportive therapy and appropriate antibiotics, most patients improve quickly and recover without complication.

mebooksfree.com

COMPLICATIONS

Resistant organisms; peritonitis; pelvic abscess

Septic pelvic thrombophlebitis

Ovarian vein thrombosis

Sepsis; death

REFERENCES

1.Smaill FM, Grivell RM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Sys Rev. 2014;(10):CD007482.

2.American College of Obstetricians and Gynecologist. ACOG Practice Bulletin No. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472–1483.

3.Tita AT, Szychowski JM, Boggess K, et al; for C/SOAPTrial Consortium. Adjunctive azithromycin prophylaxis for cesarean delivery. N Engl J Med. 2016;375(13):1231–1241.

4.Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections.

Cochrane Database Syst Rev. 2014;(12):CD007892.

5.French LM, Smaill FM. Antibiotic regimens for endometritis after delivery.

Cochrane Database Syst Rev. 2004;(4):CD001067.

ADDITIONALREADING

Chibueze EC, Parsons AJ, Ota E, et al. Prophylactic antibiotics for manual removal of retained placenta during vaginal birth: a systematic review of observational studies and meta-analysis. BMC Pregnancy Childbirth.

2015;15:313.

Hadiati DR, Hakimi M, Nurdiati DS, et al. Skin preparation for preventing infection following caesarean section. Cochrane Database Sys Rev. 2014; (9):CD007462.

Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2014; (10):CD004455.

Mackeen AD, Packard RE, Ota E, et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015;(2):CD001067. Mackeen AD, Packard RE, Ota E, et al. Timing of intravenous prophylactic

mebooksfree.com

antibiotics for preventing postpartum infectious morbidity in women undergoing cesarean delivery. Cochrane Database Syst Rev. 2014; (12):CD009516.

McKibben RA, Pitts SI, Suarez-Cuervo C, et al. Practices to reduce surgical site infections among women undergoing cesarean section: a review. Infect Control Hosp Epidemiol. 2015;36(8):915–921.

Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol. 2011;117(4):877–882.

SEE ALSO

Algorithm: Pelvic Pain

CODES

ICD10

O86.12 Endometritis following delivery

O86.4 Pyrexia of unknown origin following delivery

O86.13 Vaginitis following delivery

CLINICALPEARLS

Postpartum endometritis follows 1–3% of all births.

Infections are typically polymicrobial and involve organisms ascending from the lower genital tract.

Evidence supports antibiotic prophylaxis prior to skin incision for all cesarean deliveries but not for operative vaginal deliveries.

Clindamycin 900 mg IV q8h and gentamicin 5 mg/kg q24h are recommended as first-line therapy for endometritis. Treat until the patient is afebrile for 24 to 48 hours and stop antibiotics completely (unless there is documented bacteremia, which requires a 7-day course of therapy).

If no improvement occurs on antibiotics, consider retained placental products, abscess, wound infection, hematoma, cellulitis, phlegmon, or septic pelvic vein thrombosis.

mebooksfree.com

ENURESIS

Swati Avashia, MD, FAAP, FACP, ABIHM

BASICS

DESCRIPTION

Classification

–Primary nocturnal enuresis (NE): 80% of all cases; person who has never established urinary continence on consecutive nights for a period of ≥6 months

–Secondary NE: 20% of cases; resumption of enuresis after at least 6 months

of urinary continence

NE: intermittent nocturnal incontinence after the anticipated age of bladder control (age 5 years)

–Primary monosymptomatic NE (PMNE): bed wetting with no history of bladder dysfunction or other lower urinary tract (LUT) symptoms

–Nonmonosymptomatic NE (NMNE): bed wetting with LUT symptoms such as frequency, urgency, daytime wetting, hesitancy, straining, weak or intermittent stream, posturination dribbling, lower abdominal or genital discomfort, or sensation of incomplete emptying

ALERT

Adult-onset NE with absent daytime incontinence is a serious symptom; complete urologic evaluation and therapy are warranted.

System(s) affected: nervous, renal/urologic

Synonym(s): bed wetting; sleep enuresis; nocturnal incontinence; primary NE

EPIDEMIOLOGY

Incidence

Depends on family history

Spontaneous resolution: 15% per year

Prevalence

Very common; 5 to 7 million children in the United States (1)

10% of 7-year-olds; 3% of 11 to 12-year-olds; 0.5–1.7% at 16 to 17-year-olds

mebooksfree.com

(2)

1.5 to 2 times more common in males than females

Nocturnal > day (3:1)

Geriatric Considerations

Often associated with daytime incontinence (formerly referred to as diurnal enuresis)

ETIOLOGYAND PATHOPHYSIOLOGY

Adisorder of sleep arousal, a low nocturnal bladder capacity, and nocturnal polyuria are the three factors that interrelate to cause NE.

Both functional and organic causes (below); many theories, none absolutely confirmed

Detrusor instability

Deficiency of arginine vasopressin (AVP); decreased nocturnal AVPor decreased AVPstimulation secondary to an empty bladder (bladder distension stimulates AVP)

Maturational delay of CNS

Severe NE with some evidence of interaction between bladder overactivity and brain arousability: association with children with severe NE and frequent cortical arousals in sleep

Organic urologic causes in 1–4% of enuresis in children: UTI, occult spina bifida, ectopic ureter, lazy bladder syndrome, irritable bladder with wide bladder neck, posterior urethral valves, neurologic bladder dysfunction

Organic nonurologic causes: epilepsy, diabetes mellitus, food allergies, obstructive sleep apnea, chronic renal failure, hyperthyroidism, pinworm infection, sickle cell disease

NE occurs in all stages of sleep.

Genetics

Most commonly, NE is an autosomal-dominant inheritance pattern with high penetrance (90%).

1/3 of all cases are sporadic.

75% of children with enuresis have a first-degree relative with the condition.

Higher rates in monozygotic versus dizygotic twins (68% vs. 36%)

If both parents had NE, risk in child is 77%; 44% if one parent is affected. Parental age of resolution often predicts when child’s enuresis should resolve.

mebooksfree.com

RISK FACTORS

Family history

Stressors (emotional, environmental) common in secondary enuresis (e.g., divorce, death)

Constipation and/or encopresis

Organic disease: 1% of monosymptomatic NE (e.g., urologic and nonurologic causes)

Psychological disorders

–Comorbid disorders are highest with secondary NE: depression, anxiety, social phobias, conduct disorder, hyperkinetic syndrome, internalizing disorders.

–Association with ADHD; more pronounced in ages 9 to 12 years

Altered mental status or impaired mobility

GENERALPREVENTION

No known measures

COMMONLYASSOCIATED CONDITIONS

Obstructive sleep apnea syndrome (10–54%) (1): Atrial natriuretic factor inhibits renin-angiotensin-aldosterone pathway leading to diuresis.

Constipation (33–75%) (1)

Behavioral problems (specifically ADHD in 12–17%) (1)

Overactive bladder or dysfunctional voiding (up to 41%) (1) Urinary tract infection (18–60%) (1)

DIAGNOSIS

HISTORY

Age of onset, duration, severity

LUT tract symptoms

Daily intake patterns

Voiding diary and stooling patterns (especially constipation)

Psychosocial history

Family history of enuresis

Investigation and previous treatment history

PHYSICALEXAM

mebooksfree.com

ENT: evaluation for adenotonsillar hypertrophy

Abdomen: enlarged bladder, kidneys, fecal masses, or impaction

Back: Look for dimpling or tufts of hair on sacrum. Genital urinary exam

–Males: meatal stenosis, hypospadias, epispadias, phimosis

–Females: vulvitis, vaginitis, labial adhesions, ureterocele at introitus;

evidence of abuse

Consider rectal exam: tone, fecal soiling, fecal impaction

Neurologic exam, especially lower extremities

DIFFERENTIALDIAGNOSIS

Primary NE

–Delayed physiologic urinary control

–UTI (both)

–Spina bifida occulta

–Obstructive sleep apnea (both)

–Idiopathic detrusor instability

–Previously unrecognized myelopathy or neuropathy (e.g., multiple sclerosis, tethered cord, epilepsy)

–Anatomic urinary tract abnormality (e.g., ectopic ureter)

Secondary NE

–Bladder outlet obstruction

–Neurologic disease, neurogenic bladder (e.g., spinal cord injury)

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

Only obligatory test in children is urinalysis.

Urinalysis and urine culture: UTI, pyuria, hematuria, proteinuria, glycosuria, and poor concentrating ability (low specific gravity) may suggest organic etiology, especially in adults.

Urinary tract imaging is usually not necessary.

If abnormal clinical findings or adult onset: renal and bladder US

IV pyelogram, voiding cystourethrogram (VCUG), or retrograde pyelogram are rarely indicated (1).

MRI if spinal dysraphism is suspected

Follow-Up Tests & Special Considerations

Secondary enuresis: serum glucose, BUN, creatinine, thyroid-stimulating

mebooksfree.com

hormone (TSH), urine culture

In children, imaging and urodynamic studies are helpful for significant daytime symptoms, history of UTIs, suspected structural abnormalities, and in refractory cases.

Diagnostic Procedures/Other

Urodynamic studies may be beneficial in adults and nonmonosymptomatic NE.

Test Interpretation

Dysfunctional voiding

Detrusor instability and/or reduced bladder capacity most common findings

TREATMENT

GENERALMEASURES

Use nonpharmacologic approaches as first line before prescribing medications (1)[A].

Simple behavioral interventions (e.g., scheduled wakening, positive reinforcement, bladder training, diet changes) are effective, although less so than alarms or medications (1)[B]; found to achieve dryness in 15–20% of cases (3)

–Explain the three pathophysiologic factors.

–Encourage normal drinking patterns during daytime hours and reduction of intake 2 hours prior to sleep.

–Emphasize regular bedtime with full night’s sleep.

–Scheduled voiding before bed

–Scheduled waking for nighttime voiding

–Nightlights to light the way to the bathroom

–Reward system for dry nights

–Use pull up over regular underwear or cloth underwear with built in waterproof barrier.

–“Cleanliness training”: Child helps with changing wet bedding.

Do not shame or punish bedwetting but have the child participate in removing and laundering soiled bedding and garments.

Aggressive treatment of constipation, if present, with polyethylene glycol 3350 (MiraLAX); (peds: 0.8 g/kg; adults 17 g/day)

If behavioral interventions alone have no success, combined therapy (e.g.,

mebooksfree.com