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Department of Reproductive Health and Research (RHR), World Health Organization

Sexually transmitted and other reproductive tract infections

A guide to essential practice

 

 
    

Management of STIs/RTIs
Chapter 9. STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period


 

Infection following childbirth

Postpartum endometritis and puerperal sepsis

Postpartum endometritis (uterine infection) and puerperal sepsis are common causes of maternal morbidity and mortality respectively and are largely preventable with good antenatal care, delivery practices and postpartum care. When care is delayed or inadequate, however, infection can progress quickly to generalized sepsis, which can result in infertility, chronic disability and even death.

Postpartum endometritis is commonly caused by gonococci, chlamydia, anaerobic bacteria, Gram-negative facultative bacteria, and streptococci. In developed countries, most postpartum infections are related to caesarean section. Elsewhere, postpartum endometritis more often follows vaginal delivery. Early postpartum endometritis occurs within the first 48 hours, and late infection between 3 days and 6 weeks following delivery. Aggressive treatment should be given for all postpartum infections (for complete management, see Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003).

Women with signs of infection immediately postpartum should be stabilized, given a first dose of antibiotics intravenously (or intramuscularly) and referred urgently to hospital.

Flowchart 8 outlines the management of women presenting with fever between 24 hours and 6 weeks postpartum.

 

FLOWCHART 8. postpartum Infection

 

Activities to prevent postpartum infection include prevention and detection of STI/RTI during pregnancy (Chapter 2 and Chapter 3) and good delivery practice. See the WHO publications: Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003 or Managing complications in pregnancy and childbirth: a guide for midwives and doctors, Geneva, World Health Organization, 2000 for guidelines on prevention and comprehensive management of postpartum complications.

 

Treatment table 11. Antibiotic regimens for treatment of infection following miscarriage, induced abortion or delivery (septic abortion, postpartum endometritis)

Option 1

Option 2

Option 3

Option 4

Commonly available, least expensive. Give all 3 drugs

Choose one drug from each box
(= 3 drugs)

Give both drugs

Choose one drug from each box
(= 3 drugs)

ampicillin
2 g intravenously
or intramuscularly, then 1 g every 6 hours

ceftriaxone
250 mg by intramuscular injection, once a day

clindamycin 900 mg by intravenous injection, every 8 hours

ciprofloxacinb 500 mg orally, twice a day, or

spectinomycin
1 g by intramuscular injection, 4 times a day

gentamicin 80 mg intramuscularly every 8 hours

doxycycline 100 mg orally or by intravenous injection, twice a day, or

tetracycline 500 mg orally 4 times a day

gentamicin 1.5 mg/kg of body weight by intravenous injection every 8 hours

doxycycline 100 mg orally or by intravenous injection, twice a day, or tetracycline, 500 mg orally, 4 times a day

metronidazolea 500 mg orally or by intravenous infusion every 8 hours

metronidazolea 400500 mg orally or by intravenous injection, twice a day, or
chloramphenicol 500 mg orally or by intravenous injection, 4 times a day

metronidazolea 400500 mg orally or by intravenous injection, twice a day, or
chloramphenicol 500 mg orally or by intravenous injection, 4 times a day

For all regimens, therapy should be continued for 2 days after the patient is fever free.

a. Patients taking metronidazole should be counselled to avoid alcohol.

b. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

 

Treatment table 12. Antibiotic regimens for treatment of infectious complications with viable pregnancy (chorioamnionitis, rupture of membranes)

Option 1 safest for fetus when there are no signs of maternal infection

Option 2 best coverage when maternal signs of infection (fever, foul-smelling discharge) are present

Oral/intramuscular combination that is safe in pregnancy

Choose one from each box (= 3 drugs)

Commonly available, least expensive. Give all 3 drugs until delivery. If woman delivers vaginally, discontinue all antibiotics after delivery. If delivery is by Caesarean section, continue antibiotics until she is fever free for 48 hours

cefixime 400 mg orally as a single dose, or

ceftriaxone 125250 mg by intramuscular injection

ampicillin 2 g intravenously or intramuscularly, then 1 g every 6 hours

erythromycina 500 mg orally 4 times a day for 7 days, or

azithromycin 1 g orally as a single dose

gentamicin 80 mg intramuscularly every 8 hours

metronidazoleb 2 g orally as a single dose

metronidazoleb 500 mg orally or by intravenous infusion every 8 hours

a. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used. Note that oral erythromycin alone has been shown to decrease preterm birth in women with preterm, prelabour rupture of membranes in Europe (where gonorrhoea is uncommon). Since gonorrhoea is resistant to erythromycin in many areas, addition of cefixime or ceftriaxone is recommended where gonorrhoea is common.

b. Patients taking metronidazole should be counselled to avoid alcohol.

 

Contents
html files

 

Infections of the male and female reproductive tract and their consequences:

What are RTIs?

Why STI/RTIs are important?

What can be done about RTIs?

The role of clinical services in reducing the burden of STI/RTI

Preventing STIs/RTIs and their complications

How to prevent STI

How to prevent iatrogenic infections

How to prevent endogenous infections

Detecting STI/RTI

Detecting STI/RTI

Syphilis

Vaginal infections

Cervical infections

Pelvic inflammatory disease

HIV counselling and testing

STI/RTI education and counselling

Key points

Privacy and confidentiality

General skills for STI/RTI education and counselling

Health education

Counselling

Promoting prevention of STI/RTI and use of services

Key points

Reducing barriers to use of services

Raising awareness and promoting services

Reaching groups that do not typically use reproductive health services

STI/RTI Assessment during Routine Family Planning Visits

Key points

Integrating STI/RTI assessment into routine FP services

Family planning methods and STIs/RTIs

STI/RTI Assessment in pregnancy, childbirth and the postpartum period

Key points

Management of symptomatic STIs/RTIs

Syndromic management of STI/RTI

Management of common syndromes

STI case management and prevention of new infections

STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

Key points

Infection in early pregnancy

Infection in lated pregnancy

Infection following childbirth

Vaginal discharge in pregnancy and the postpartum period

Sexual violence

Key points

Medical and other care for survivors of sexual assault

Annex 1. Clinical skills needed for STI/RTI

History-taking

Common STI/RTI symptoms

Examining patients

Annex 2. Disinfection and universal precautions

Preventing infection in clinical settings

High-level disinfection: three steps

Universal precautions

Annex 3. Laboratory tests for RTI

Interpreting syphilis test results

Clinical criteria for bacterial vaginosis (BV)

Wet mount microscopy

Gram stain microscopy of vaginal smears

Use of Gram stain for diagnosis of cervical infection

Annex 4. Medications

Medications in pregnancy

Antibiotic treatments for gonorrhoa

Annex 5.

STI/RTI reference table

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Additionnal resources

 

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