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Cristiano Jodicke MD
Basics
Description
Postpartum fever or puerperal fever is defined as an oral temperature of 38C
(100.4F) on 2 separate occasions at least 6 hours apart, or of >38.5C
(101.6F) at any time.
Postpartum fever is a sign that requires investigation to determine the specific
etiology, which will then dictate treatment.
Puerperal fever
Epidemiology
A complication in 24% of vaginal deliveries
515% of scheduled cesarean deliveries
Risk Factors
Cesarean deliveries
Membranes ruptured for >6 hours
Chorioamnionitis
Multiparity
Urethral catheterization
Previous UTI
Obesity
Smoking
Intubation
Nipple fissure
Breast-feeding
Breast engorgement
DM
Anemia
Immunosuppressive therapy
Immunodeficiency disorder
Corticoid therapy
Nutritional status
Pathophysiology
Pathophysiology depends on cause and site.
Pelvic infections associated with vaginal pathogens that then lead to ascending
genital tract infection
Diagnosis
Signs and Symptoms
History
Vaginal or cesarean delivery
Premature rupture of membranes
Pelvic pain
Foul-smelling lochia
Fever
Chills
Headache
Malaise
Anorexia
Urinary system:
Flank pain
Dysuria
Urgency
Frequency
Surgical incision/episiotomy:
Erythema
Induration
Drainage
Local pain
Respiratory system:
o
Cough
Dyspnea
Breast:
o
Pain
Erythema
Engorgement
Physical Exam
Vital signs:
o Appearance; pallor
Temperature
Pulse
Pulse oximetry
Pulmonary exam:
o
Rales
Rhonchi
Consolidation
Back:
o
Erythema
Tenderness
Engorgement
Abdomen:
o
Bowel sounds
Fundal tenderness
Wound:
Erythema
Local tenderness
Induration
Discharge
Pelvic exam:
o
Uterine tenderness
Adnexal/Parametrial tenderness
Foul-smelling lochia
Palpable mass
Tests
Lab
Wound cultures
Blood cultures:
Septicemia
Imaging
Pelvic US
CT
MRI
Differential Diagnosis
Infection
Endometritis
UTI
Mastitis
Pneumonia
Wound infection:
o
Episiotomy
Pelvic abscess
Appendicitis
Hematologic
Thrombophlebitis
DVT
PE
Metabolic/Endocrine
Thyroiditis
Drugs
Drug fever
Other/Miscellaneous
Atelectasis
P.353
Treatment
General Measures
Fluid management
Cardiac monitoring
Pregnancy-Specific Issues
Endometritis:
o Parenteral broad-spectrum antibiotics: IV treatment until 2448 hours
afebrile. Continuing treatment with oral antibiotics is not necessary.
Clindamycin/Aztreonam
Metronidazole/Penicillin
Ampicillin/Gentamicin/Metronidazole
Mastitis:
o
Local measures:
Ice packs
Analgesics
Antibiotics:
Dicloxacillin
Nafcillin
UTI:
o
Hydration
Antibiotic treatment
Wound infection:
o
Drainage
Debridement
Irrigation
Broad-spectrum antibiotics
Pneumonia:
o
Antibiotic treatment
Adequate oxygenation
Analgesia
Atelectasis:
o
Adequate oxygenation
Analgesia
Early ambulation
Pelvic abscess:
Drainage
Broad-spectrum antibiotics
Broad-spectrum antibiotics
Anticoagulation
Medication (Drugs)
Choice of antibiotic therapy is dictated by source of infection and likely pathogenic
organisms:
Clindamycin 900 mg IV q8h
Gentamicin 1.5 mg/Kg q8h or 5 mg/Kg q24h
Ampicillin 2g IV q6h
Cefotetan 12 g IV q12h
Nafcillin 2g IV q4h
Vancomycin 1g IV q12h
Surgery
Wound exploration and probing at bedside
Wound infection/seroma/infected hematoma that result in open incision should
be assessed for possible wound closure.
Followup
All patients with a postpartum fever should undergo follow-up with an
obstetrician/gynecologist, but ideally with the delivering obstetrician.
Bibliography
Bonnar J. Venous thromboembolism and pregnancy. Clin Obstet Gynecol.
1981;8:455473.
Chaim W, et al. Prevalence and clinical significance of postpartum endometritis and
wound infection. Infect Dis Obstet Gynecol. 2000;8(2):7782.
Cunningham FG, et al. Infections and disorders of the puerperium. In: William's
Obstetrics, 20th ed. New York: McGraw-Hill; 1997:547568.
Filker R, et al. The significance of temperature during the first 24 hours postpartum.
Obstet Gynecol. 1979;53:358361.
Gabbe SG. Puerperal endometritis, serious sequelae of puerperal infection. In:
Obstetrics: Normal and Problem Pregnancies, 4th ed. 2002:13041308.
Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol. 1980;55(5
Suppl):178S84S.
Gilstrap LC, et al. Postpartum endometritis. In: Infections in Pregnancy, 2nd ed.
1997:6578.
Larsen JW. Guidelines for the diagnosis, treatment and prevention of postoperative
infections. Infect Dis Obstet Gynecol. 2003;11:6570.
Mead PB. Postpartum endometritis. Contemp Ob Gyn. 1990;35:2934.
Seaward. International Multicentre Term Prelabor Rupture of Membranes Study:
Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients
with prelabor rupture of membranes at term. Am J Obstet Gynecol.
1997;177(5):10241029.
Suonio S.Int J Gynaecol Obstet. 1989;29(2):135142.
Sweet RL, et al. Postpartum infection. In: Infectious Diseases of the Female Genital
Tract, 3rd ed. 1995;578600.
Yonekura ML. Treatment of postcesarean endomyometritis. Clin Obstet Gynecol.
1988;31:488500.
Miscellaneous
Clinical Pearls
The classic description of the temporal sequence of postpartum fever involves:
Wind (lungatelectasis, pneumonia)
Water (urinary tract)
Wound (infection)
Wonder drugs (drug fever)
Abbreviations
DMDiabetes mellitus
DVTDeep venous thrombosis
PEPulmonary embolism
UTIUrinary tract infection
Codes
ICD9-CM
672.02 (if delivered on current visit)
672.04 (if delivered during the previous episode of care)
Patient Teaching
Prevention
Antibiotic prophylaxis before cesarean
Early ambulation
Good hemostasis
Excellent surgical technique
Incentive spirometry
Early urethral catheter removal