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 Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis. Other common etiologies include surgical or perineal wound infections and mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). 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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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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 Prelabor Rupture of Membranes Prelabor rupture of membranes (PROM), previously known as premature rupture of membranes, refers to the rupture of the amniotic sac before the onset of labor. Prelabor rupture of membranes may occur in term or preterm pregnancies. Prelabor Rupture of Membranes (PROM) or premature PROM (PPROM)
  • Prolonged rupture of membranes
  • Prolonged labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor
  • Multiple or repeated vaginal examinations
  • Retained products of conception
  • Manual removal of the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity
  • Recent or untreated infections at the time of delivery, for example:
    • Chorioamnionitis Chorioamnionitis Chorioamnionitis, commonly referred to as intraamniotic infection (IAI), is a common obstetric complication involving infection and inflammation of the fetal membranes, amniotic fluid, placenta, or the fetus itself. Chorioamnionitis is typically caused by a polymicrobial infection that ascends from the lower genitourinary tract. Chorioamnionitis
    • Bacteriuria
    • Bacterial vaginosis
    • STIs (e.g., Chlamydia Chlamydia Chlamydiae are obligate intracellular gram-negative bacteria. They lack a peptidoglycan layer and are best visualized using Giemsa stain. The family of Chlamydiaceae comprises 3 pathogens that can infect humans: Chlamydia trachomatis, Chlamydia psittaci, and Chlamydia pneumoniae. Chlamydia trachomatis
  • Factors associated with poor wound healing Wound healing Wound healing is a physiological process involving tissue repair in response to injury. It involves a complex interaction of various cell types, cytokines, and inflammatory mediators. Wound healing stages include hemostasis, inflammation, granulation, and remodeling. Wound Healing:
    • Poorly controlled diabetes mellitus Diabetes mellitus Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus
    • Anemia Anemia Anemia is a condition in which individuals have low Hb levels, which can arise from various causes. Anemia is accompanied by a reduced number of RBCs and may manifest with fatigue, shortness of breath, pallor, and weakness. Subtypes are classified by the size of RBCs, chronicity, and etiology. Anemia: Overview 
    • 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 Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract infection ( UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections), especially pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess
  • Respiratory causes:
    • Atelectasis Atelectasis Atelectasis is the partial or complete collapse of a part of the lung. Atelectasis is almost always a secondary phenomenon from conditions causing bronchial obstruction, external compression, surfactant deficiency, or scarring. Atelectasis
    • Aspiration pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia
    • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism
  • Thrombotic causes:
    • Septic pelvic thrombophlebitis 
    • Deep vein thrombosis Deep vein thrombosis Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis
  • Complications of neuraxial anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts (rare):
    • Bacterial or chemical meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. 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 Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis
  • Woobies: mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis
  • Water*: UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections
  • Wind*: atelectasis, aspiration pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. Pneumonia, pulmonary embolism
  • Walking*: septic pelvic thrombophlebitis and/or deep vein thrombosis ( DVT DVT Deep vein thrombosis (DVT) usually occurs in the deep veins of the lower extremities. The affected veins include the femoral, popliteal, iliofemoral, and pelvic veins. Proximal DVT is more likely to cause a pulmonary embolism (PE) and is generally considered more serious. Deep Vein Thrombosis)
  • 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 Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis and wound/perineal infections, are typically caused by skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the 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 Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding.
  • UTIs typically result when vaginal flora are introduced into the bladder during frequent or prolonged catheterization during labor Labor Labor is the normal physiologic process defined as uterine contractions resulting in dilatation and effacement of the cervix, which culminates in expulsion of the fetus and the products of conception. Normal and Abnormal Labor (more common with epidural use).
  • Postpartum infections can develop into sepsis Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock if not treated early.
  • Bacteremia → endothelial injury → inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation, which can lead to:
    • Organ failure, including AKIs and ARDS ARDS Acute respiratory distress syndrome is characterized by the sudden onset of hypoxemia and bilateral pulmonary edema without cardiac failure. Sepsis is the most common cause of ARDS. The underlying mechanism and histologic correlate is diffuse alveolar damage (DAD). Acute Respiratory Distress Syndrome
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension and septic shock Septic shock Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Septic shock is diagnosed during treatment when vasopressors are necessary to control hypotension. Sepsis 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
Etiology Days postpartum Associated symptoms
Endometritis 1–10
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever with chills
  • Uterine tenderness on exam (typically significant)
  • Tachycardia
  • Lower midline abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Vaginal bleeding
Wound and perineal infections 4–7
  • Erythematous, edematous tissue
  • Purulent exudate
  • Severe local pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain at the site of infection (abdominal or vaginal)
  • Foul-smelling vaginal discharge
Septic pelvic thrombophlebitis 3–5
  • Low-grade, intermittent fever that does not resolve with medication
  • Pelvic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Painful, swollen calf is possible.
Mastitis 7–21
  • 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
Meningitis 0–1
  • Recent history of neuraxial anesthesia Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts (e.g., epidural)
  • Back and/or neck pain Neck Pain Neck pain is one of the most common complaints in the general population. Depending on symptom duration, it can be acute, subacute, or chronic. There are many causes of neck pain, including degenerative disease, trauma, rheumatologic disease, and infections. Neck Pain
  • Neurologic changes, which may include weakness, sensory loss, gait disturbances, bladder dysfunction
UTI UTI Urinary tract infections (UTIs) represent a wide spectrum of diseases, from self-limiting simple cystitis to severe pyelonephritis that can result in sepsis and death. Urinary tract infections are most commonly caused by Escherichia coli, but may also be caused by other bacteria and fungi. Urinary Tract Infections: pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess 1–2
  • Dysuria
  • Urinary urgency and frequency
  • Lower back and/or flank pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Suprapubic pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
  • Nausea and/or vomiting
  • Note: Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. Fever is typically absent if infection is confined to the bladder; fever develops as pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess develops.
Clostridium difficile infection Varies
  • Diarrhea Diarrhea Diarrhea is defined as ≥ 3 watery or loose stools in a 24-hour period. There are a multitude of etiologies, which can be classified based on the underlying mechanism of disease. The duration of symptoms (acute or chronic) and characteristics of the stools (e.g., watery, bloody, steatorrheic, mucoid) can help guide further diagnostic evaluation. Diarrhea (10–15 episodes/day)
  • Low-grade fever
  • Abdominal pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain/cramping
  • Recent antibiotic exposure
Drug fever Varies
  • Fever Fever Fever is defined as a measured body temperature of at least 38°C (100.4°F). Fever is caused by circulating endogenous and/or exogenous pyrogens that increase levels of prostaglandin E2 in the hypothalamus. Fever is commonly associated with chills, rigors, sweating, and flushing of the skin. 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 Rashes Rashes are a group of diseases that cause abnormal coloration and texture to the skin. The etiologies are numerous but can include irritation, allergens, infections, or inflammatory conditions. Rashes that present in only 1 area of the body are called localized rashes. Generalized rashes occur diffusely throughout the body. Generalized and Localized 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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock if it is present or develops.
  • Assess the uterus Uterus The uterus, cervix, and fallopian tubes are part of the internal female reproductive system. The uterus has a thick wall made of smooth muscle (the myometrium) and an inner mucosal layer (the endometrium). The most inferior portion of the uterus is the cervix, which connects the uterine cavity to the vagina. Posterior Abdominal Wall for:
    • Significant tenderness: suggests endometritis Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. 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 Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts for signs of mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis or abscess.
  • Examine the chest/ lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. 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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock 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 Endometritis Endometritis is an inflammation of the endometrium, the inner layer of the uterus. The most common subtype is postpartum endometritis, resulting from the ascension of normal vaginal flora to the previously aseptic uterus. Endometritis, as findings overlap with normal postpartum changes.
  • If thrombosis is suspected: 
    • Coagulation studies Coagulation studies Coagulation studies are a group of hematologic laboratory studies that reflect the function of blood vessels, platelets, and coagulation factors, which all interact with one another to achieve hemostasis. Coagulation studies are usually ordered to evaluate patients with bleeding or hypercoagulation disorders. Coagulation Studies
    • Doppler imaging with ultrasound
  • If aspiration pneumonia Pneumonia Pneumonia or pulmonary inflammation is an acute or chronic inflammation of lung tissue. Causes include infection with bacteria, viruses, or fungi. In more rare cases, pneumonia can also be caused through toxic triggers through inhalation of toxic substances, immunological processes, or in the course of radiotherapy. 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 Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. 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 Streptococcus Streptococcus is one of the two medically important genera of gram-positive cocci, the other being Staphylococcus. Streptococci are identified as different species on blood agar on the basis of their hemolytic pattern and sensitivity to optochin and bacitracin. There are many pathogenic species of streptococci, including S. pyogenes, S. agalactiae, S. pneumoniae, and the viridans streptococci. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of 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 Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding
  • Ice packs to relieve inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation
  • Nipple shields can be used during breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding to prevent nipple cracking.

Urinary tract Urinary tract The urinary tract is located in the abdomen and pelvis and consists of the kidneys, ureters, urinary bladder, and urethra. The structures permit the excretion of urine from the body. Urine flows from the kidneys through the ureters to the urinary bladder and out through the urethra. Urinary Tract infection

  • Simple cystitis (rarely presents with fever) should be treated with oral antibiotics, typically with penicillins Penicillins Beta-lactam antibiotics contain a beta-lactam ring as a part of their chemical structure. Drugs in this class include penicillin G and V, penicillinase-sensitive and penicillinase-resistant penicillins, cephalosporins, carbapenems, and aztreonam. Penicillins.
  • The following should generally be avoided in breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding mothers with infants < 1 month old:
    • Nitrofurantoin ( ↑ risk of hemolytic anemia Hemolytic Anemia Hemolytic anemia (HA) is the term given to a large group of anemias that are caused by the premature destruction/hemolysis of circulating red blood cells (RBCs). Hemolysis can occur within (intravascular hemolysis) or outside the blood vessels (extravascular hemolysis). Hemolytic Anemia in the infant)
    • Trimethoprim Trimethoprim The sulfonamides are a class of antimicrobial drugs inhibiting folic acid synthesize in pathogens. The prototypical drug in the class is sulfamethoxazole. Although not technically sulfonamides, trimethoprim, dapsone, and pyrimethamine are also important antimicrobial agents inhibiting folic acid synthesis. The agents are often combined with sulfonamides, resulting in a synergistic effect. Sulfonamides and Trimethoprim–sulfamethoxazole ( ↑ risk of kernicterus)
  • In cases of pyelonephritis Pyelonephritis Pyelonephritis is infection affecting the renal pelvis and the renal parenchyma. This condition arises mostly as a complication of bladder infection that ascends to the upper urinary tract. Pyelonephritis can be acute or chronic (which results from persistent or chronic infections). Typical acute symptoms are flank pain, fever, and nausea with vomiting. T Pyelonephritis and Perinephric Abscess, IV antibiotics are typically required.

Septic pelvic phlebitis

  • Administration of broad-spectrum antibiotics 
  • Ampicillin + gentamicin + clindamycin is a common regimen.
  • Administration of anticoagulants Anticoagulants Anticoagulants are drugs that retard or interrupt the coagulation cascade. The primary classes of available anticoagulants include heparins, vitamin K-dependent antagonists (e.g., warfarin), direct thrombin inhibitors, and factor Xa inhibitors. 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 Anesthesia Anesthesiology is the field of medicine that focuses on interventions that bring a state of anesthesia upon an individual. General anesthesia is characterized by a reversible loss of consciousness along with analgesia, amnesia, and muscle relaxation. Anesthesiology: History and Basic Concepts
    • Surgery ( cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery)
  • Appropriate use of prophylactic antibiotics, for example:
    • Prior to cesarean delivery Cesarean Delivery Cesarean delivery (CD) is the operative delivery of ≥ 1 infants through a surgical incision in the maternal abdomen and uterus. Cesarean deliveries may be indicated for a number of either maternal or fetal reasons, most commonly including fetal intolerance to labor, arrest of labor, a history of prior uterine surgery, fetal malpresentation, and placental abnormalities. Cesarean Delivery (typically cefazolin +/– azithromycin)
    • After manual extraction of the placenta Placenta The placenta consists of a fetal side and a maternal side, and it provides a vascular communication between the mother and the fetus. This communication allows the mother to provide nutrients to the fetus and allows for removal of waste products from fetal blood. Placenta, Umbilical Cord, and Amniotic Cavity
  • 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 Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and/or fertility issues) 
  • Pulmonary embolism Pulmonary Embolism Pulmonary embolism (PE) is a potentially fatal condition that occurs as a result of intraluminal obstruction of the main pulmonary artery or its branches. The causative factors include thrombi, air, amniotic fluid, and fat. In PE, gas exchange is impaired due to the decreased return of deoxygenated blood to the lungs. Pulmonary Embolism 
  • DIC DIC Disseminated intravascular coagulation (DIC) is a condition characterized by systemic bodywide activation of the coagulation cascade. This cascade results in both widespread microvascular thrombi contributing to multiple organ dysfunction and consumption of clotting factors and platelets, leading to hemorrhage. Disseminated Intravascular Coagulation

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 Sepsis Organ dysfunction resulting from a dysregulated systemic host response to infection separates sepsis from uncomplicated infection. The etiology is mainly bacterial and pneumonia is the most common known source. Patients commonly present with fever, tachycardia, tachypnea, hypotension, and/or altered mentation. Sepsis and Septic Shock
  • 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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