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Bacterial contamination

Indigenous vaginal flora


Inoculation and colonization of lower uterine segment, incisions, and lacerations

  1. Vaginal examinations
  2. Internal electronic monitoring
  3. Prolonged labor
  4. Uterine incision


Favorable anaerobic bacterial conditions

  1. Surgical trauma
  2. Foreign body
  3. Devitalized tissue
  4. Blood and serum collection


Polymicrobial proliferation with tissue invasion



Parametrial Phlegmon

  1. In some women in whom metritis develops following cesarean delivery, parametrial cellulitis is intensive and forms an area of induration, termed a phlegmon, within the leaves of the broad ligament. These infections should be considered when fever persists longer than 72 h despite intravenous antimicrobial therapy.
  2. Areas of parametrial cellulitis are more often unilateral, and they frequently may remain limited to the base of the broad ligament.
  3. Severe cellulitis of the uterine incision may cause necrosis and separation. Extrusion of purulent material commonly leads to peritonitis. Because puerperal metritis with cellulitis is typically a retroperitoneal infection, evidence of peritonitis suggests the possibility of uterine incisional necrosis, or, less commonly, a bowel injury or other lesion.
  4. In most women with a phlegmon, clinical improvement follows continued treatment with a broad-spectrum antimicrobial regimen.

Septic Pelvic Thrombophlebitis

  1. Puerperal infection may extend along venous routes and cause thrombosis. Lymphangitis often coexists.
  2. The ovarian veins may then become involved because they drain the upper uterus, which most often includes veins draining the placental site. Puerperal septic thrombophlebitis is likely to involve one or both ovarian venous plexuses.
  3. In a fourth of women, the clot extends into the inferior vena cava, and occasionally extends to the renal vein.
  4. Women with septic pelvic thrombophlebitis usually display some clinical improvement of their pelvic infection following antimicrobial treatment.
  5. When imaging modalities were not available to confirm venous involvement, "heparin challenge test" was used, If the temperature decreases on giving IV heparin, then it is diagnostic of septic pelvic thrombophlebitis.
  6. However, recent studies show that there is no role of heparin in the management of this condition.


  1. This term describes an arrest or retardation of involution. It is accompanied by prolongation of lochial discharge and irregular or excessive uterine bleeding, which sometimes may be profuse.
  2. On bimanual examination, the uterus is larger and softer than would be expected. Some causes of subinvolution are retention of placental fragments and pelvic infection.
  3. Because most cases of subinvolution result from local causes, they are usually amenable to early diagnosis and treatment.
  4. Methylergometrine (methergin), 0.2 mg every 3-4 h for 24-48 h, is recommended. On the other hand, metritis responds to oral antimicrobial therapy. Almost a third of cases of late postpartum uterine infection are caused by Chlamydia trachomatis; thus, azithromycin or doxycycline therapy may be appropriate.


  1. Parenchymatous infection of the mammary glands is a rare complication occasionally observed during the puerperium and lactation.
  2. It is estimated to occur in anywhere from 2% to 33% of breast-feeding women. The first sign of inflammation is chills or actual rigor, soon followed by fever and tachycardia. The breast becomes hard and reddened, and the woman complains of severe pain. About 10% of women with mastitis develop an abscess.
  3. Constitutional symptoms attending a mammary abscess are generally severe, but in some cases the first indication of the true diagnosis often is afforded by the detection of fluctuation. Ultrasonography may be helpful to detect an abscess.
  4. The most commonly isolated organism is Staphylococcus aureus. Other commonly isolated organisms are coagulase-negative staphylococci and viridans streptococci. The immediate source of organisms that cause mastitis is almost always the infant's nose and throat.
  5. Mastitis requires antibiotics (penicillin/ cephalosporins/ erythromycin).
  6. Abscess requires incision and drainage under general anesthesia.

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