Postpartum Fever

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

1520% of unscheduled cesarean deliveries

Risk Factors
Cesarean deliveries
Membranes ruptured for >6 hours

Multiple pelvic examinations

Chorioamnionitis

Increased duration of active labor

Internal fetal monitoring

Retained products of conception

Multiparity

Low socioeconomic status

Urethral catheterization

Previous UTI

Operative vaginal delivery

Obesity

Chronic lung disease

Smoking

Intubation

Nipple fissure

Breast-feeding

Breast engorgement

DM

Long operative duration

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

Breast infections arise from skin flora (see Mastitis)

Wound infections (see topics)

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

Pleuritic chest pain

Breast:
o

Pain

Erythema

Engorgement

Physical Exam
Vital signs:
o Appearance; pallor

Temperature

Pulse

BP (with orthostatic assessment)

Pulse oximetry

Pulmonary exam:
o

Rales

Rhonchi

Consolidation

Back:
o

Costovertebral angle tenderness

Breast (generally unilateral):

o

Erythema

Tenderness

Engorgement

Abdomen:
o

Bowel sounds

Fundal tenderness

Generalized abdomen, lower abdomen, or suprapubic tenderness

Wound:

Erythema

Local tenderness

Induration

Discharge

Pelvic exam:
o

Uterine tenderness

Adnexal/Parametrial tenderness

Foul-smelling lochia

Palpable mass

Palpable pelvic veins (rare)

Tests
Lab

CBC with differential

UA with culture and sensitivity test

Wound cultures

Blood cultures:

Septicemia

Refractory to routine antibiotics

Cervical or uterine cultures

Imaging
Pelvic US
CT

MRI

Differential Diagnosis
Infection
Endometritis
UTI

Mastitis

Pneumonia

Wound infection:
o

Abdominal (cesarean or postpartum sterilization) incision

Episiotomy

Pelvic abscess

Appendicitis

Hematologic
Thrombophlebitis
DVT

PE

Septic pelvic vein thrombosis

Metabolic/Endocrine
Thyroiditis
Drugs
Drug fever
Other/Miscellaneous
Atelectasis
P.353
Treatment
General Measures
Fluid management
Cardiac monitoring

Oxygen therapy, if necessary

Assess for signs of septic shock or septicemia.

Rule out intra-abdominal bleeding or wound hematoma.

Pregnancy-Specific Issues
Endometritis:
o Parenteral broad-spectrum antibiotics: IV treatment until 2448 hours
afebrile. Continuing treatment with oral antibiotics is not necessary.

Clindamycin/Gentamicin (Ampicillin is added if enterococcal

infection is suspected or if no improvement occurs by 48
hours.)

Clindamycin/Aztreonam

Metronidazole/Penicillin

Ampicillin/Gentamicin/Metronidazole

Mastitis:
o

Local measures:

Ice packs

Analgesics

Antibiotics:

Dicloxacillin

Nafcillin

Vancomycin (penicillin allergy)

Surgical drainage (local abscesses)

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

Reexpansion of the lung segments

Analgesia

Early ambulation

Pelvic abscess:

Drainage

Broad-spectrum antibiotics

Septic pelvic thrombophlebitis:

o

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

Metronidazole 500 mg PO/IV q6h

Cefotetan 12 g IV q12h

Cephalexin 500 mg PO q6h over 1014 days

Dicloxacillin 500 mg PO q6h

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.

If evidence of fascial dehiscence, surgical repair is required as emergency

procedure (See Wound Dehiscence and Disruption.).

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