1 Chorioamnionitis

This is the inflammation of the membranes and chorion of the placenta which may extend up to the umbilical cord. It is strongly associated with spontaneous rupture of membrane (SROM).

• 
  

  Associated Pathogens:

The majority of the infections are polymicrobial due to ascending colonisation from the genital flora.

The most common species include genital mycoplasmas – Ureaplasma and Mycoplasma species.

Enteric gram-negative bacilli (E. coli, Klebsiella spp., Enterobacter spp.), group B Streptococci.

2 Endometritis

This is the infection of the decidua in the uterine cavity which occurs postpartum. This condition may occur within a normally sterile uterine cavity or with associated adnexal infection.⁵

• 
  

  • Associated Pathogens:

  
  
  
  
  • 
    

    ○ Aerobic gram-positive cocci (GPC): group B Streptococci, Staphylococcus aureus, Enterococci

    
    
  • 
    

    ○ Anaerobic GPC: Peptococci and Pepto-streptococci

    
    
  • 
    

    ○ Anaerobic gram-negative bacilli (GNB): Bactericides and Prevotella spp.

    
    
  • 
    

    ○ Aerobic GNB: E. coli, K. pneumoniae and Proteus spp.

  
  

3 Surgical Site Infection (Wound Infection Post-Caesarean Section)

This is the most common complication of caesarean section, leading to maternal sepsis.

In a UK study across 14 hospitals it was found that 9.6 per cent developed post-caesarean infection of which 0.6 per cent required readmission.

• 
  

  Associated Pathogens:

Staphylococcus aureus is the most common pathogen followed by coagulase-negative Staphylococcus aureus (CONS), Enterococcus spp. gram-negative bacilli like E. coli.

The common microbial source of pathogens comprises skin and vaginal flora that colonise the wound and cause surgical site infection (SSI).⁶

Preoperative practices and management of co-morbidities (like diabetes mellitus), hair removal, skin preparation and antibiotic prophylaxis reduce the chances of post-caesarean section wound infection.

4 Perineal Infection

During childbirth the stretching of the perineum makes the tissue thinner to the extent that it might lead to a tear.

Most perineal wounds heal well; however, it sometimes leads to complications like:

• 
  

  Haematoma: which interferes with the wound healing, having the following signs and symptoms – intense pain, inability to sit on the wound directly, difficulty in walking⁷

  
  
• 
  

  Wound infection: the wounds are at high risk due to their location, and the infection sets in from three to five days

Common signs and symptoms include feverish feeling, increasing pain, offensive odour from the wound, yellowish discharge/pus from the wound, difficulty in walking.

• 
  

  Associated Pathogens:

Common pathogens include group B Streptococci, G. vaginalis, M. hominis, E. coli.

5 Lactation Mastitis

Mastitis is clinically defined as localised, painful inflammation of the breast occurring with flu-like symptoms (fever, malaise etc.). If the condition occurs at the time of lactation then it is termed as lactation mastitis.

Common signs and symptoms include pain, redness, swelling, tenderness in the area of the breast.

Fever, malaise, enlarged axillary lymph nodes and well-defined fluctuant lump in the affected breast are the other features.

Nursing mothers are most vulnerable to breast abscess at two stages:

1. 
   

   1. During the first month of lactation due to inexperience, inadequate hygiene when the nipples are more likely to be traumatised.

   
   
2. 
   

   2. During the time of weaning when the breasts are likely to be engorged and the trauma caused by the baby’s teeth increases the likelihood of nipple trauma.

• 
  

  Associated Pathogens:

Staphylococcus aureus, Staphylococcus epidermidis, methicillin-resistant Staphylococcus aureus (MRSA), Streptococcus species.

Antibiotics that are alkaline and which concentrate well in the breastmilk are preferred, e.g. erythromycin.

β-lactamase–resistant penicillins like fucloxacilin, dicloxicillin and cloxacillin are also used.

In case of allergy to penicillin, cephalexin or clindamycin may be used.

1 Pneumonia

• 
  

  Community-acquired pneumonia (CAP) is the most frequent cause of non-obstetric infection. The widely reported causes for development of pneumonia include decreased lymphocyte proliferation in second and third trimesters, decrease in circulating helper T cell and reduced lymphocyte activity

  
  
• 
  

  The difficulty in diagnosis during pregnancy is mainly due to the complexity of distinguishing symptoms related to physiological changes of pregnancy and the symptoms of pneumonia

  
  
• 
  

  Common signs and symptoms include fever, cough, sputum, dyspnoea, pleuritic chest pain

  
  
• 
  

  Chest X-ray

  
  
• 
  

  Common X-ray changes include pulmonary infiltrate, atelectasis, pleural effusion, pneumonitis, pulmonary oedema, and about 42 per cent of chest X-rays will show no changes in pregnant women

  
  
• 
  

  Most X-ray diagnostic procedures expose the embryo to less than 50 mSv. This level of radiation exposure will not increase reproductive risks (either birth defects or miscarriage). A much higher dose above 200 mSv is associated with an increased incidence of birth defects or miscarriage

  
  
• 
  

  Laboratory investigations include: complete blood picture, total leucocyte count (TLC), haemoglobin concentration, fasting and postprandial blood sugar, liver function tests (alanine aminotransferase (ALT), angiotensin sensitivity test (AST), alkaline phosphatase, direct bilirubin – total proteins, and kidney function tests like urea and creatinine.

Other investigations include direct smear with Gram and Ziehl–Neelson (ZN) stain, aerobic culture for bacteria, polymerase chain reaction (PCR)/nucleic acid amplification to detect nucleic acid for chlamydia, pneumoniae and mycoplasma pneumonia.

• 
  

  Associated Pathogens:

Streptococcus pneumoniae, H. influenzae, Mycoplasma pneumoniae, Staphylococcus, Chlamydophila pneumoniae, Legionella pneumophila, Klebsiella pneumoniae, Pseudomonas aeruginosa.⁸

2 Listeria Infection⁹

Please refer to Chapter 20.

3 Urinary Tract Infection

Please refer to Chapter 21.

4 Genital Tract Infections

With signs and symptoms of:

1. 
   

   (a) Purulent vaginal discharge

   
   
2. 
   

   (b) Lower abdominal pain/tenderness

• 
  

  Associated Pathogens:

  
  
  
  
  • 
    

    Frequently isolated species

    
    
  • 
    

    Enterococcus faecalis

    
    
  • 
    

    Enterococcus faecium

    
    
  • 
    

    Enterococcus gallinarum

    
    
  • 
    

    Enterococcus casseliflavus

    
    
  • 
    

    E. faecalis is the most commonly isolated species followed by E. faecium. E. faecium is on the rise among hospitals, probably due to acquisition of resistance to vancomycin and other antibiotics.