Postpartum Fever

Postpartum fever is a common and often preventable complication that occurs within the 1st 10 postpartum days. The most common etiology is an infection of the uterine lining known as endometritis. Other common etiologies include surgical or perineal wound infections and mastitis. In addition to the fever, other presenting symptoms depend on the etiology. The diagnosis is made based on the clinical history and presentation, with additional laboratory tests (such as cultures) to help confirm the diagnosis and guide management. Management of postpartum fever typically involves antibiotics to treat infectious etiologies, and early intervention is important to prevent complications such as sepsis.

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Overview

Postpartum fever is defined as:

  • An oral temperature of ≥ 38℃ (≥ 100.4℉) on any 2 of the 1st 10 postpartum days, excluding the 1st 24 hours
  • An oral temperature of ≥ 38.7℃ (101.6℉) within the 1st 24 postpartum hours

The first 24 postpartum hours are different because low-grade fever during this period is common and typically resolves spontaneously, especially after uncomplicated vaginal deliveries.

Clinically, it would be inappropriate to wait until a fever is present for > 24 hours before acting; in almost all cases, patients should be evaluated in person with an appropriate diagnostic workup and treatment initiated immediately.

Epidemiology

  • Postpartum fever is a complication that occurs in 5%–7% of postpartum women.
  • Endometritis (uterine infection) is the most common cause.
  • The majority of cases occur > 2 days after birth.
  • Higher incidence in cesarean deliveries than in vaginal births

Risk factors

Most etiologies share common risk factors, which include:

  • History of C-section or operative vaginal delivery (e.g., vacuum extraction)
  • Emergency C-section
  • Prelabor rupture of membranes (PROM) or premature PROM (PPROM)
  • Prolonged rupture of membranes
  • Prolonged labor
  • Multiple or repeated vaginal examinations
  • Retained products of conception
  • Manual removal of the placenta
  • Recent or untreated infections at the time of delivery, for example:
    • Chorioamnionitis
    • Bacteriuria
    • Bacterial vaginosis
    • STIs (e.g., Chlamydia trachomatis
  • Factors associated with poor wound healing:
    • Poorly controlled diabetes mellitus
    • Anemia 
    • Smoking
    • Obesity
    • Immunodeficiency disorders (e.g., HIV) 
  • Unhygienic birth conditions

Etiology and Pathophysiology

Etiology

The most common etiologies of postpartum fever are:

  • Endometritis
  • Infection of the surgical site or perineal lacerations
  • Mastitis/breast abscess
  • Urinary tract infection (UTI), especially pyelonephritis
  • Respiratory causes:
    • Atelectasis
    • Aspiration pneumonia
    • Pulmonary embolism
  • Thrombotic causes:
    • Septic pelvic thrombophlebitis 
    • Deep vein thrombosis
  • Complications of neuraxial anesthesia (rare):
    • Bacterial or chemical meningitis 
    • Epidural abscess 
  • Clostridium difficile infection 
  • Drug fever (a diagnosis of exclusion)

To remember the primary causes of postpartum fever, think of the 7 Ws:

  • Wound*: surgical or perineal laceration wound infection
  • Womb: endometritis
  • Woobies: mastitis
  • Water*: UTI
  • Wind*: atelectasis, aspiration pneumonia, pulmonary embolism
  • Walking*: septic pelvic thrombophlebitis and/or deep vein thrombosis (DVT)
  • Wonder drugs*: drug fever

* Also part of the 5 Ws mnemonic to remember the causes of postoperative fever in all surgical patients.

Pathophysiology

The pathophysiology of postpartum fever is dependent on the etiology. 

  • Infections, including endometritis and wound/perineal infections, are typically caused by skin and vaginal flora; therefore, infections:
    • Are polymicrobial
    • Contain both aerobes and anaerobes
  • Mastitis is caused by oral flora in the infant, often introduced via nipple trauma that occurred during breastfeeding.
  • UTIs typically result when vaginal flora are introduced into the bladder during frequent or prolonged catheterization during labor (more common with epidural use).
  • Postpartum infections can develop into sepsis if not treated early.
  • Bacteremia → endothelial injury → inflammation, which can lead to:
    • Organ failure, including AKIs and ARDS
    • Hypotension and septic shock
    • Death

Clinical Presentation

Clinical presentation of postpartum fever depends on the underlying etiology, which will determine when the fever develops and other associated symptoms.

Table: Clinical presentation of postpartum fever
EtiologyDays postpartumAssociated symptoms
Endometritis1–10
  • Fever with chills
  • Uterine tenderness on exam (typically significant)
  • Tachycardia
  • Lower midline abdominal pain
  • Vaginal bleeding
Wound and perineal infections4–7
  • Erythematous, edematous tissue
  • Purulent exudate
  • Severe local pain at the site of infection (abdominal or vaginal)
  • Foul-smelling vaginal discharge
Septic pelvic thrombophlebitis3–5
  • Low-grade, intermittent fever that does not resolve with medication
  • Pelvic pain
  • Painful, swollen calf is possible.
Mastitis7–21
  • Fevers are often high.
  • Firm, red, inflamed, and tender breast (unilateral)
  • Red streaks on the breast
  • A tender fluctuant mass in case of an abscess
  • Myalgia
  • Chills
  • Malaise
Meningitis0–1
  • Recent history of neuraxial anesthesia (e.g., epidural)
  • Back and/or neck pain
  • Neurologic changes, which may include weakness, sensory loss, gait disturbances, bladder dysfunction
UTI: pyelonephritis1–2
  • Dysuria
  • Urinary urgency and frequency
  • Lower back and/or flank pain
  • Suprapubic pain
  • Nausea and/or vomiting
  • Note: Fever is typically absent if infection is confined to the bladder; fever develops as pyelonephritis develops.
Clostridium difficile infectionVaries
  • Diarrhea (10–15 episodes/day)
  • Low-grade fever
  • Abdominal pain/cramping
  • Recent antibiotic exposure
Drug feverVaries
  • Fever that coincides with administration of a drug and disappears with discontinuation
  • Typically develops about 1 week after initiating the drug (though could be hours to months)
  • Rashes are possible.

Diagnosis

Postpartum fever is frequently a clinical diagnosis based on the presentation and risk factors discussed above, with labs and imaging used to support/confirm the diagnosis.

History and exam

  • Ask questions to elicit information about risk factors and symptoms that may help rule in or out the etiologies discussed above.
  • Assess and monitor patient’s vital signs (BP, temperature, respiratory rate, and heart rate) to immediately identify sepsis if it is present or develops.
  • Assess the uterus for:
    • Significant tenderness: suggests endometritis
    • Abnormally bulky: suggests retained products of conception, which may be becoming infected
  • Assess perineal and/or surgical wounds. 
  • Check for abnormal vaginal discharge. 
  • Examine the breasts for signs of mastitis or abscess.
  • Examine the chest/lungs and legs for signs of infection and/or thrombosis.

Laboratory and imaging

Based on findings from the history and exam, lab and imaging studies may be appropriate to help support the diagnosis and guide treatment. These studies include:

  • CBC: 
    • Rising WBC counts and a left shift suggest infection.
    • Note: General leukocytosis is common and normal in postpartum women with average WBC counts (10,000–16,000/µL).
  • Urinalysis
  • Cultures (with antibiotic sensitivity testing):
    • Urine cultures
    • Wound cultures
    • Blood cultures
  • If sepsis is suspected: inflammatory markers (e.g., lactate)
  • If retained products of conception are suspected: 
    • Pelvic ultrasonography
  • Note: Pelvic ultrasonography is generally not indicated in cases of routine endometritis, as findings overlap with normal postpartum changes.
  • If thrombosis is suspected: 
    • Coagulation studies
    • Doppler imaging with ultrasound
  • If aspiration pneumonia is suspected: chest X-ray

Management and Prevention

Management of postpartum fever depends on the cause. 

General supportive measures

  • Adequate rest, nutrition, and fluid intake 
  • Pain control with analgesics
  • Regular monitoring of symptoms 
  • Pay attention to treatment effects on breastfeeding: 
    • Choose antibiotics that are safe in lactation.
    • Breastfeeding can and should be safely continued in almost all cases.

Endometritis

  • Treated with IV antibiotics until afebrile for 24–48 hours 
  • Preferred IV regimen: aminoglycoside (typically gentamicin) + clindamycin 
  • Alternative IV regimen: aminoglycoside + metronidazole 
  • Ampicillin should be added in patients colonized by group B Streptococcus (GBS).

Wound infections

  • Drainage, debridement, and irrigation
  • Administration of broad-spectrum antibiotics (often requires coverage for MRSA)
  • Keep wounds clean.
  • Vaginal cleansing with povidone–iodine in cases of infected perineal wounds
  • Fiber-rich diet to decrease straining with bowel movements (straining puts pressure on surgical sutures, causing pain and ↑ risk of dehiscence)

Mastitis

  • Penicillinase-resistant antibiotics such as cephalexin, dicloxacillin or cloxacillin, or clindamycin
  • Frequent and effective milk removal: 
    • Milk stasis ↑ infection, so milk needs to keep flowing.
    • Organisms came from infant’s oral flora, so infant is not at risk for infection → patients should continue breastfeeding
  • Ice packs to relieve inflammation
  • Nipple shields can be used during breastfeeding to prevent nipple cracking.

Urinary tract infection

  • Simple cystitis (rarely presents with fever) should be treated with oral antibiotics, typically with penicillins.
  • The following should generally be avoided in breastfeeding mothers with infants < 1 month old:
    • Nitrofurantoin ( ↑ risk of hemolytic anemia in the infant)
    • Trimethoprim–sulfamethoxazole ( ↑ risk of kernicterus)
  • In cases of pyelonephritis, IV antibiotics are typically required.

Septic pelvic phlebitis

  • Administration of broad-spectrum antibiotics 
  • Ampicillin + gentamicin + clindamycin is a common regimen.
  • Administration of anticoagulants, often low-molecular-weight heparin (e.g., Lovenox)

Prevention

Postpartum fever is often a preventable complication. The preventive measures to be taken are:

  • Aseptic technique should be used in all procedures, if possible, especially:
    • Bladder catheterization
    • Neuraxial anesthesia
    • Surgery (cesarean delivery)
  • Appropriate use of prophylactic antibiotics, for example:
    • Prior to cesarean delivery (typically cefazolin +/– azithromycin)
    • After manual extraction of the placenta
  • Vaginal cleansing with a povidone–iodine solution in the operating room before C-section in patients with ruptured membranes
  • Keep incisions clean.
  • Clean the vaginal area with water after using the restroom.
  • Regular breastfeeding and/or pumping to prevent milk stasis
  • Use of a nipple shield to prevent cracks in the nipples

Complications and Prognosis

Complications

  • Sepsis
  • Abscess formation 
  • Adhesions/scar tissue formation (which may lead to future pain and/or fertility issues) 
  • Pulmonary embolism 
  • DIC

Prognosis

  • Early intervention results in complete recovery with no complications for the vast majority of patients. 
  • Patients should be monitored carefully, and aggressive treatment should be administered in cases of progression to sepsis. 
  • Untreated postpartum fever or late intervention increases the chances of severe complications.

References

  1. Pamela Berens. (2021). Overview of postpartum period: disorders and complications. UpToDate. Retrieved June 23, 2021, from https://www.uptodate.com/contents/overview-of-the-postpartum-period-disorders-and-complications
  2. K. T. Chen. (2020). Postpartum endometritis. In Varss, V.A. (Ed.) UpToDate. Retrieved June 23, 2021, from https://www.uptodate.com/contents/postpartum-endometritis 
  3. Noreen Iftikhar, Carolyn Kay. (2021). What to do if you have a fever after pregnancy. Healthline. https://www.healthline.com/health/pregnancy/postpartum-fever#prevention
  4. Michael Moore. (2013). Postpartum fever. Medscape. Retrieved June 23, 2021, from https://www.medscape.com/viewarticle/804263
  5. Julie S. Moldenhauer. (2020). Postpartum care. MSD Manual Professional version. https://www.msdmanuals.com/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/postpartum-care
  6. Andy W. Wong, Adam J. Rosh. (2019). Postpartum infections. Medscape. Retrieved June 23, 2021, from https://emedicine.medscape.com/article/796892-overview

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