Puerperal feverPuerperal fever

IG: Sio Cheong IG: Sio Cheong UnUn

2011/4/42011/4/4

Puerperal feverPuerperal fever Puerperal fever, also known as postpartum Puerperal fever, also known as postpartum

fever or puerperal infectionfever or puerperal infection

Definition: temperatures in the Definition: temperatures in the postpartum feverpostpartum fever reach 100.4F(38.0C) or reach 100.4F(38.0C) or higher. The fevers occur on any two of the higher. The fevers occur on any two of the first 10 days postpartum, exclusive of the first 10 days postpartum, exclusive of the first 24 hours. first 24 hours.

Abortion or miscarriage isnAbortion or miscarriage isn’’t usually t usually associated with this infection and fever.associated with this infection and fever.  

Benign fever following Benign fever following vaginal delivery vaginal delivery

Benign single-day fevers: Benign single-day fevers:

Fever in the first 24 hours after Fever in the first 24 hours after delivery often resolves delivery often resolves spontaneously and cannot be spontaneously and cannot be explained by an identifiable explained by an identifiable infection. infection.

Benign fever following Benign fever following vaginal deliveryvaginal delivery

One retrospective cohort study of One retrospective cohort study of 2137 vaginal deliveries in 1996. 2137 vaginal deliveries in 1996. Patients were randomly selected Patients were randomly selected from the 25,687 vaginal deliveries from the 25,687 vaginal deliveries that took place between 1979 and that took place between 1979 and 1992 at The University of Iowa 1992 at The University of Iowa Hospitals and Clinics. The data were Hospitals and Clinics. The data were analyzed using odds ratios and analyzed using odds ratios and multiple logistic regression. multiple logistic regression.

CONCLUSIONS : Single-day fever CONCLUSIONS : Single-day fever was more likely to occur in was more likely to occur in primiparous women and in women primiparous women and in women who were monitored with a uterine who were monitored with a uterine pressure catheter. Most women with pressure catheter. Most women with benign single-day fevers had early benign single-day fevers had early low-grade fevers, whereas women low-grade fevers, whereas women with endometritis had higher fevers with endometritis had higher fevers that occurred later in the postpartum that occurred later in the postpartum period. period.

Fever is not an automatic indicator of Fever is not an automatic indicator of puerperal infection. A new mother puerperal infection. A new mother may have a fever owing to prior may have a fever owing to prior illness or an illness unconnected to illness or an illness unconnected to childbirth. However, any fever within childbirth. However, any fever within 10 days postpartum is aggressively 10 days postpartum is aggressively investigated. Physical symptoms such investigated. Physical symptoms such as pain, malaise, loss of appetite, and as pain, malaise, loss of appetite, and others point to infection. others point to infection.

Causes ( listed in order of decreasing Causes ( listed in order of decreasing frequency ) include endometritis (most frequency ) include endometritis (most common), urinary tract infection, common), urinary tract infection, pneumonia\atlectasis, wound infection, pneumonia\atlectasis, wound infection, and septic pelvic thrombophlebitis. and septic pelvic thrombophlebitis.

Septic risk factors for each etiologic Septic risk factors for each etiologic condition are listed in order of the condition are listed in order of the postpartum day(PPD) on which the postpartum day(PPD) on which the condition generally occurs.condition generally occurs.

Puerperal feverPuerperal fever

risk increases withrisk increases with ❑ ❑ prolonged and premature rupture of the prolonged and premature rupture of the

membranes membranes ❑ ❑ prolonged (more than 24 hours) labor prolonged (more than 24 hours) labor ❑ ❑ frequent or unsanitary vaginal examinations or frequent or unsanitary vaginal examinations or

unsanitary delivery unsanitary delivery ❑ ❑ retained products of conception retained products of conception ❑ ❑ hemorrhage hemorrhage ❑ ❑ maternal conditions, such as anemia, poor maternal conditions, such as anemia, poor

nutrition during pregnancy.nutrition during pregnancy. ❑ ❑ cesarean birth (20-fold increase in risk for cesarean birth (20-fold increase in risk for

puerperal infection). puerperal infection). ❑ ❑ genital or urinary tract infection prior to genital or urinary tract infection prior to

delivery. delivery. ❑ ❑ use of a fetal scalp electrode during labor. use of a fetal scalp electrode during labor. ❑ ❑ obesity. obesity. ❑ ❑ diabetes. diabetes. ❑ ❑ urinary catheterurinary catheter ❑ ❑ nipple trauma from breastfeedingnipple trauma from breastfeeding

The associated symptoms depend on The associated symptoms depend on the site and nature of the infection. the site and nature of the infection. The most typical site of infection is The most typical site of infection is the genital tract. Endometritis, the genital tract. Endometritis, which affects the uterus, is the most which affects the uterus, is the most prominent of these infections. prominent of these infections. Endometritis is much more common Endometritis is much more common if a small part of the placenta has if a small part of the placenta has been retained in the uterus. been retained in the uterus.

Physical examinationPhysical examination

A pelvic examination is done and A pelvic examination is done and samples are taken from the genital samples are taken from the genital tract to identify the bacteria tract to identify the bacteria involved in the infection. The pelvic involved in the infection. The pelvic examination can reveal the extent of examination can reveal the extent of infection and possibly the cause. infection and possibly the cause.

Laboratory Laboratory

Blood samples may also be taken for Blood samples may also be taken for blood counts , CRP, or blood culture. blood counts , CRP, or blood culture.

A urinalysis may also be ordered, A urinalysis may also be ordered, especially if the symptoms are especially if the symptoms are indicative of a urinary tract indicative of a urinary tract infection.infection.

Chest x-rayChest x-ray

Wound culture Wound culture

TreatmentTreatment Treatment of puerperal infection usually Treatment of puerperal infection usually

begins with I.V. infusion of broadspectrum begins with I.V. infusion of broadspectrum antibiotics and is continued for 48 hours antibiotics and is continued for 48 hours after fever is resolved.after fever is resolved.

Supportive care Supportive care Symptomatic treatmentSymptomatic treatment Surgery may be necessary to remove any Surgery may be necessary to remove any

remaining products of conception or to remaining products of conception or to drain local lesions, such as An infected drain local lesions, such as An infected episiotomy (incision made during episiotomy (incision made during delivery) may need to be opened and delivery) may need to be opened and drained.drained.

In the presence of thrombophlebitis, In the presence of thrombophlebitis, heparin therapy will be needed to provide heparin therapy will be needed to provide anticoagulation. anticoagulation.

CASECASE A 28-year-old primigravid underwent A 28-year-old primigravid underwent

a cesarean section secondary to a cesarean section secondary to having a breech presentation and having a breech presentation and rupture of membranes at 36 weeks rupture of membranes at 36 weeks gestation. The cesarean section was gestation. The cesarean section was uncomplicated, but on postpartum uncomplicated, but on postpartum day two the patient was having fever day two the patient was having fever (38.5C) and uterine tenderness. (38.5C) and uterine tenderness.

A diagnosis of postpartum A diagnosis of postpartum endometritis was made and the endometritis was made and the infection was treated with Mefoxine infection was treated with Mefoxine 1 g IV Q8H.1 g IV Q8H.

After 24 hours of antibiotics, the After 24 hours of antibiotics, the patient presented pain in the right patient presented pain in the right lower abdomen and loin, and her lower abdomen and loin, and her WBC count was 12000/mm3. She WBC count was 12000/mm3. She continued to spike fevers .continued to spike fevers .

Abd:soft,flat, tenderness on the right Abd:soft,flat, tenderness on the right abdomen,no rebound-tenderness, abdomen,no rebound-tenderness, McburneyMcburney’’s point (+/-),Murphys point (+/-),Murphy’’s s sign(-), kindey region percussion (-).sign(-), kindey region percussion (-).

Urinalysis was unremarkable.Urinalysis was unremarkable.

On postpartum day four, the On postpartum day four, the patientpatient’’s condition was no s condition was no improvement after antibiotic improvement after antibiotic treatment, and an abdominal CT treatment, and an abdominal CT scan was obtained. A right ovarian scan was obtained. A right ovarian vein thrombosis was noted on the vein thrombosis was noted on the imaging.imaging.

IMP: ovarian vein thrombophlebitis IMP: ovarian vein thrombophlebitis

The patient started therapeutic The patient started therapeutic enoxaparin(clexane). After 48 hours of enoxaparin(clexane). After 48 hours of anticoagulation, the patient was afebrile anticoagulation, the patient was afebrile and asymptomatic. The patient was and asymptomatic. The patient was discharged home after being discharged home after being anticoagulated with warfarin and after 6 anticoagulated with warfarin and after 6 weeks a CT scan was repeated. The weeks a CT scan was repeated. The right ovarian thrombosis was not right ovarian thrombosis was not present in the images and warfarin was present in the images and warfarin was discontinueddiscontinued

Prevention Prevention

Avoid the risk factorsAvoid the risk factors Keep the episiotomy site clean Keep the episiotomy site clean Careful attention to antiseptic Careful attention to antiseptic

procedures during childbirth is the procedures during childbirth is the basic underpinning of preventing basic underpinning of preventing infection. With some procedures, infection. With some procedures, such as cesarean section, a doctor such as cesarean section, a doctor may administer prophylactic may administer prophylactic antibiotics as a preemptive strike antibiotics as a preemptive strike against infectious bacteria. against infectious bacteria.

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