Julia Faller, D.O., PGY1 Internal Medicine Lecture Series May 3, 2006 POSTPARTUM FEVER Julia Faller, D.O., PGY1 Internal Medicine Lecture Series May 3, 2006

Prelecture questions Puerperium is defined as: Onset of labour through delivery of the placenta Rupture of membranes through 2 weeks postpartum Delivery of the placenta through 6 weeks postpartum 37 weeks gestation through delivery of the placenta

Prelecture questions The most common cause of puerperal fever is: Endometritis UTI Pneumonia Septic pelvic thrombophlebitis

Prelecture questions The most common cause of fever following cesarean delivery is: Perineal cellulitis Abscess formation Atelectasis Endometritis

Puerperium Delivery of the placenta through 6 weeks 6 weeks back to normal state

Anatomic changes Uterus Postpartum bleeding Cervix Vagina Perineum Abdominal wall Ovaries Breasts

Postpartum Fever Infection most common Other causes

Postpartum infection 1-8% of deliveries 4-8% of maternal death Endometiritis most common cause

Risk Factors Cesarean PROM Frequent cervical exams Internal fetal monitoring Preexisting infection Diabetes Nutritional status Obesity

Types of Infection Endometitis Perineal cellulitis Mastitis Anesthesia complications Surgical wound infections UTI Septic pelvic phlebitis

History Type of delivery PROM Symptoms Pelvic exams Beta strep status

Physical Complete Breasts Pelvic Abdomen Back Lungs

Endometritis Ascending polymicrobial infection E. coli, Klebsiella and Proteus Uterus usually sterile Increased risk after cesarean Timing of infection Risk factors History and physical

Treatment of Endometritis IV antibiotics in hospital No consensus on antibiotics Cesarean prophylaxis

UTI Risk factors: E. coli and group B strep Bactrim, cipro, amoxil Type of delivery, tocolysis, induction, renal disease, preeclampsia, epidural, foley E. coli and group B strep Bactrim, cipro, amoxil

Mastitis Inflammation of the mammary gland Staphylococcus aureus 3% Abscess formation Fevers, chills, warmth, swelling, tender Ancef, erythromycin in pt with allergy

Wound Infection Various sites Risk factors Perineal—rare, vaginal flora Abdominal—vaginal flora and/or skin flora Risk factors Diabetes, HTN, obesity, anemia, chorioamnionitis, prolonged labor or ROM, abdominal twin delivery

Wound Infection History: inordinate amount of pain Physical: warm, tender, red, drainage Treatment: Perineal: sitz bath, symptomatic relief Abdominal: drainage, antibiotics

Septic Pelvic Thrombophlebitis Venous inflammation with thrombus formation in association with fevers unresponsive to abx therapy Risk factors: low SES, cesarean, prolonged ROM 1/2000

Septic Pelvic Thrombophlebitis History: often accompanies endometritis Lower abdominal pain Physical: resting tachycardia 50-70% have a palpable ropelike mass

Septic Pelvic Thrombophlebitis Treatment: IV heparin to an aPtt twice normal Long-term anticoagulation not required Continued antibiotic therapy Gentamicin and clindamycin Recent study

Questions Puerperium is defined as: A. Onset of labour through delivery of the placenta B. Rupture of membranes through 2 weeks postpartum C. Delivery of the placenta through 6 weeks postpartum D. 37 weeks gestation through delivery of the placenta

Questions The most common cause of puerperal fever is: A. Endometritis B. UTI C. Pneumonia D. Septic pelvic thrombophlebitis

Questions The most common cause of fever following cesarean delivery is: A. Perineal cellulitis B. Abscess formation C. Atelectasis D. Endometritis

Questions True or False: Atelectasis can cause fever