Postpartum Fever

Overview

Postpartum fever is defined as a temperature > 38. 7 C in the first 24 hours postpartum or > 38 C on any two of the first 10 days post-partum. The MCC of postpartum fever is endometritis.

Complicates approximately 5-7% of births

• Causes “After Unprotection Every Woman Should Marry*”***
  • Atelectasis
  • Urinary tract infection
  • Endometritis
  • Wound infections
  • Septic thrombophlebitis
  • Breast infection (Mastitis, breast abscess)
  • Drug fever (may occur at any time)
• Patient History
  • Days since delivery
  • Peripartum complications
    • PROM
    • Duration of labour
    • Antepartum infections
  • Mode of delivery
• Investigations
  • CBC
  • UA + culture
  • Blood culture

Atelectasis

Atelectasis is collapse of the alveoli d/t restricted breathing, It is associated with incisional pain, especially following wing C-section, causing restricted breathing and collapse of the lower lobes. Atelectasis does not necessarily cause fever. Dx is clinical

• Risk
  • Cigarette smoking
• Signs and Symptoms
  • Mild fever
  • Crackles on auscultation
• Treatment
  • Incentive spirometry
  • Ambulation

Urinary Tract Infection

UTI is an ascending infection of the bladder and/or upper urinary tract. Usually simple acute cystitis but may be a pyelonephritis.

• Risk
  • Catheterization
  • Vaginal exams (run the risk of introducing faecal flora into the urinary tract)
• Signs and symptoms
  • Dysuria
  • Pyelonephritis Sx
    • Fever
    • Ill-appearing
    • CVA tenderness
    • Flank tenderness
• Investigation
  • Urinalysis an dculture
• Treatment
  • TMP/SMX or Nitrofurantoin for acute cystitis

Endometritis

Endometritis is an ascending polymicrobial infection of the uterine lining that may invade the underlying wall (endomyometritis). MCC of post-partum fever.

• Patient History
  • C-section
  • Manual removal of the placenta after vaginal delivery
• Signs and symptoms
  • Fever
  • Tachycardia
  • Uterine tenderness
  • Foul smelling lochia
• Investigations
  • Pelvic sonography: r/o retained POC
• Treatment
  • Admit
  • IV Clindamycin + Gentamicin until afebrile for 24-48 hours

Wound infection

Infection of the skin surrounding the incision site or perineal laceration. Dx is clinical

• Patient History
  • Emergent C-section after prolonged ROM or Prolongedlabourr (not enough time for prophylactic antibiotic + Chorioamnionitis)
• Signs and symptoms of cellulitis
  • Local erythema
  • Warmth
  • Tenderness around the surgical site or laceration
• Signs and symptoms of abscesCellulitisis which does not respond to antibiotics
  • Celulitis which does not respond to antibiotics
  • Palpable collection of or drainage of pus from the wound
• Treatment
  • IV antibiotic
  • Drain abscess and pack wound

Septic Pelvic Thrombophlebitiss

Characterized by venous thrombosis, inflammation, and bacteremia. May be a complication of endometritis; causative organisms are similar.

• Signs and symptoms
  • Spiking fever (does not respond to antibiotics)
  • Illappearingg
  • Flank/lower abdominal pain
  • Lower abdominal mass (may be appreciated)
• Investigations
  • Pelvic CT
    • Lowdensityy lumen
    • Sharp enhancement of the wall of the vein
• Treatment
  • IV Heparin for 7 – 10 days
  • Monitor INR
  • CT broad-spectrum Abx

Mastitis and Breast Abscess

These are regional infections of the breast usually caused by skin flora or the oral floor of a breast-feeding infant. Differentiate from breast engorgement. Mastitis is unilateral and associated with fever. Dx clinical.

• Signs and symptoms
  • Unilateral breast erythema
  • Warm Tenderness
  • Tenderess
  • Mild fever
• Investigation
  • Sonography: for breast abscess
• Treatment
  • Dicloxacillin
  • CT breastfeeding or use a breast pump if not breastfeeding
  • IV antibiotics if unresponsive
  • FNA for breast abscess
  • Do not breastfeed if abscess