postpartum febrile morbidity oral temperature of ≥38.0 degrees Celsius (≥100.4 degrees Fahrenheit) on any 2 of the first 10 days postpartum, exclusive of the first 24 hours. The first 24 hours are excluded because low grade fever during this period is common and often resolves spontaneously, especially after vaginal birth.

Differential diagnosis Surgical site infection Endometritis Mastitis or breast abscess Pyelonephritis Aspiration pneumonia Unexplained fever (neuraxial anesthetic) Appendicitis Viral syndrome Pseudomembranous colitis

RISK FACTORS ●Preterm birth ●Operative vaginal delivery ●Post term pregnancy ●HIV infection ●Colonization with group B streptococcus ●Nasal carriage of Staphylococcus aureus ●Heavy vaginal colonization by Streptococcus agalactiae or Escherichia coli ●Bacterial vaginosis ●Maternal diabetes mellitus or severe anemia ● Cesarean delivery (myometrial necrosis at the suture line, and formation of hematomas and seromas). ●Chorioamnionitis ●Prolonged labor ●Prolonged rupture of membranes ●Multiple cervical examinations ●Internal fetal or uterine monitoring ●Large amount of meconium in amniotic fluid ●Manual removal of the placenta ●Low socioeconomic status

MICROBIOLOGY Postpartum endometritis is typically a polymicrobial infection Mixture of two to three aerobes and anaerobes from the genital tract. This was illustrated in a study of 55 women with well-defined puerperal endometritis who had endometrial cultures obtained with a triple-lumen catheter to reduce the risk of contamination from organisms on the cervix. None of the women had received prophylactic antibiotics.

MICROBIOLOGY More than one organism in 70 percent Bacteria and genital mycoplasmas in 61 percent Bacteria alone in 20 percent Genital mycoplasmas alone in 16 percent Anaerobes in 45 percent

MICROBIOLOGY Neisseria gonorrhoeae and Chlamydia trachomatis: Uncommon causes of postpartum endometritis Common causes of endometritis unrelated to pregnancy Group A streptococcus (GAS) infection : early-onset infection and high fever

Soft and subinvoluted uterus Excessive uterine bleeding CLINICAL FINDINGS Chills Headache Malaise Anorexia Soft and subinvoluted uterus Excessive uterine bleeding Postpartum fever Tachycardia Rise in temperature Midline lower abdominal pain Uterine tenderness Purulent lochia

White blood cell count Sonographic findings

Endometritis with toxic shock syndrome Group A streptococcus (GAS) (eg, Streptococcus pyogenes): Early-onset infection and high fever, hypotension , involvement of at least two other organ systems (renal, liver, or pulmonary insufficiency; coagulopathy; soft tissue necrosis; erythematous macular rash with desquamation) Staphylococcus: fever >38.9ºC, hypotension, diffuse erythroderma, desquamation (unless the patient dies before desquamation can occur), involvement of at least three organ systems, Onset may be early (within 24 hours of delivery) Clostridium sordellii :sudden onset of clinical shock: progressive, refractory hypotension ,massive and generalized tissue edema, hemoconcentration, a marked leukemoid reaction (total neutrophil count 66,000 to 93,600/mm3), absence of rash or fever, limited or no myonecrosis, rapidly lethal course.

ESTABLISHING THE MICROBIOLOGIC CAUSE Endometrial culture Cervical culture Blood culture (immunocompromised, septic, fails to respond to empiric therapy) In uncomplicated infections, it is not important to establish the microbiologic cause since empiric treatment with broad spectrum antibiotic is usually effective.

TREATMENT  Initial drug choice: ●Clindamycin 900 mg every eight hours PLUS ●Gentamicin 1.5 mg/kg every eight hours OR 5 mg/kg every 24 hours Renal insufficiency: Ampicillin-sulbactam 1.5 g every six hours or Clindamycin and a second-generation cephalosporin. Metronidazole with ampicillin and gentamicin

colonization with GBS: Addition of ampicillin to clindamycin plus gentamicin regimen or Ampicillin-sulbactam Duration : intravenous treatment until the patient is clinically improved (no fundal tenderness) and afebrile for at least 24 to 48 hours. Oral antibiotic therapy after successful parenteral treatment is not required

Oral and intramuscular regimens ●Clindamycin 600 mg orally every 6 hours plus gentamicin 4.5 mg/kg intramuscularly every 24 hours OR ●Amoxicillin-clavulanic acid 875 mg orally every 12 hours OR ●Cefotetan 2 g intramuscularly every 8 hours OR ●Meropenem or imipenem-cilastatin 500 mg intramuscularly every 8 hours OR ●Amoxicillin 500 mg plus metronidazole 500 mg orally every 8 hours

Oral antibiotic regimen is administered for a 14 day course Intramuscular antibiotic regimen : 48 to 72 hours of intramuscular therapy and then switch to an oral antibiotic to complete a seven day course

PREVENTION Antibiotic prophylaxis at cesarean delivery Antibiotic prophylaxis for vaginal delivery Women with bacterial vaginosis Spontaneous placental extraction Topical antimicrobials Vaginal lavage with chlorhexidine