AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Emergency physicians are increasingly concerned about postpartum patients who come to the ED with a fever or evidence of infection. The number of cases of infection can be expected to increase because of the earlier discharge of postpartum patients from the hospital. Any infection following delivery is classified as postpartum or puerperal infection.

Pathophysiology

Endometritis is the most common source of postpartum infection. Other sources of postpartum infections include (1) postsurgical wound infections, (2) perineal cellulitis, (3) mastitis, (4) respiratory complications from anesthesia, (5) retained products of conception, (6) urinary tract infections (UTIs), and (7) septic pelvic phlebitis.

Frequency

United States

Overall, postpartum infection is estimated to occur in 1-8% of all deliveries.

Mortality/Morbidity

In most reviews, maternal death rates associated with infection range from 4-8%, or approximately 0.6 maternal deaths per 100,000 live births.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

The history and course of the delivery is important in the evaluation of postpartum patients.

• Ascertain if the delivery was vaginal or cesarean.
• Ascertain if premature rupture of the membranes occurred.
• Assess the patient's symptoms.
• Features vary depending on the source of infection and may include the following:
• • Flank pain, dysuria, and frequency of UTIs
  • Erythema and drainage from the surgical incision or episiotomy site, in cases of postsurgical wound infections
  • Respiratory symptoms, such as cough, pleuritic chest pain, or dyspnea, in cases of respiratory infection or septic pulmonary embolus
  • Fever and chills
  • Abdominal pain
  • Foul-smelling lochia
  • Breast engorgement in cases of mastitis

Physical

Focus the physical examination on identifying the source of fever and infection. A complete physical examination, including pelvic and breast examinations, is necessary. Findings may include the following:

• Endometritis may be characterized by lower abdominal tenderness on one or both sides of the abdomen, adnexal and/or parametrial tenderness elicited with bimanual examination, temperature elevation (most commonly >38.3°C)
• Some women have foul-smelling lochia without other evidence of infection. Some infections, most notably caused by group A beta-hemolytic streptococci, are frequently associated with scanty, odorless lochia.
• Patients with wound infections, or episiotomy infections, have erythema, edema, tenderness, and discharge from the wound or episiotomy site.
• Patients with mastitis have very tender, engorged, erythematous breasts. Infection frequently is unilateral.
• Patients with pyelonephritis or UTIs may have tenderness at the costovertebral angle and an elevated temperature.
• Respiratory signs, such as rales, consolidation, or rhonchi in pneumonia, are possible.
• Patients with septic pelvic thrombosis, although rare, may have palpable pelvic veins. These patients also have tachycardia that is out of proportion to the fever.

Causes

Causes and risk factors may include the following:

• Endometritis
• • In most cases of endometritis, the bacteria responsible for pelvic infections are those that normally reside in the bowel, vagina, perineum, and cervix.
  • The uterine cavity is usually sterile until the rupture of the amniotic sac. As a consequence of labor, delivery, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus.
  • The risk of endometritis increases dramatically after cesarean delivery (10-20% of patients).
• Genital tract infections
• • Genital tract infections are generally polymicrobial.
  • Gram-positive cocci and Bacteroides and Clostridium species are the predominant anaerobic organisms involved. Escherichia coli and gram-positive cocci are commonly involved aerobes.
• Mastitis
• • The most common organism reported in mastitis is Staphylococcus aureus.
  • The organism usually comes from the breastfeeding infant's mouth or throat.
• Thrombosis
• • Numerous factors cause pregnant and postpartum women to be more susceptible to thrombosis. Pregnancy is known to induce a hypercoagulable state secondary to increased levels of clotting factors. Also, venous stasis occurs in the pelvic veins during pregnancy.
  • Although relatively rare, septic pelvic thrombosis is occasionally observed in the postpartum patient, who might have fever.
• Perineal cellulitis and episiotomy site infections
• • Most often, the etiologic organisms associated with perineal cellulitis and episiotomy site infections are Staphylococcus or Streptococcus species and gram-negative organisms, as in endometritis.
  • Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet, infections develop in only 1% of patients who had vaginal tears or who underwent episiotomies.
• Urinary tract infections
• • Bacteria most frequently found in UTIs are normal bowel flora, including E coli and Klebsiella, Proteus, and Enterobacter species.
  • Any form of invasive manipulation of the urethra (eg, Foley catheterization) increases the likelihood of a UTI.
• Risk factors
• • History of cesarean delivery
  • Premature rupture of membranes
  • Frequent cervical examination (Sterile gloves should be used in examinations. Other than a history of cesarean delivery, this risk factor is most important in postpartum infection.)
  • Internal fetal monitoring
  • Preexisting pelvic infection
  • Diabetes
  • Nutritional status
  • Obesity

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Endometritis
Mastitis
Retained products of conception
Septic pelvic phlebitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Complete blood count
• Blood cultures, if sepsis is suspected
• Urinalysis, with cultures and sensitivity tests
• Cervical or uterine cultures
• Wound cultures, if appropriate

Imaging Studies

• Pelvic ultrasonography may be helpful in detecting a pelvic abscess or infected hematoma. In some cases, a contrast computed tomography examination of the abdomen and pelvis may be helpful if concurrent concern is present for other non-pregnancy–related abdominal/pelvic sources of the infection (eg, appendicitis, colitis).

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Prehospital Care

The most important aspect of prehospital care in a postpartum patient with a suspected infection is to ensure adequate fluid volume and to prevent sepsis and shock.

• Provide aggressive fluid management.
• Begin cardiac monitoring and administer oxygen.

Emergency Department Care

ED care is focused on identifying the source of the infection, followed by appropriate antimicrobial therapy and referral.

• Postpartum endometritis treatment
• • Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (such as doxycycline or clindamycin).
  • Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials (cefoxitin with doxycycline or clindamycin).
  • A rapid response to antibiotics is the typical response in the treatment of postpartum endometritis.
• Mastitis treatment
• • Administer dicloxacillin, penicillinase-resistant penicillin, or clindamycin, and use local measures, such as ice packs, analgesics, and breast support.
  • The mother should be told to continue to breastfeed the baby, because breastfeeding is not harmful to the child.
  • Mastitis could lead to abscess formation, which may require surgical drainage.
• UTI treatment
• • Administer fluids, if evidence of dehydration exists.
  • Appropriate antibiotics may be used.
• Septic pelvic phlebitis treatment
• • Anticoagulation may be used.
  • Broad-spectrum antibiotics may be administered.
• Wound infection or episiotomy infection treatment
• • Drainage, debridement, and irrigation may be required.
  • Broad-spectrum antibiotics may be administered.

Consultations

Consult an obstetrician.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Antibiotics are the mainstay of treatment. Pain medications also are important, because patients often have discomfort. Patients with septic pelvic thrombophlebitis must undergo anticoagulation therapy, and they should receive broad-spectrum antibiotics.

Drug Category: Antibiotics

Antibiotic coverage for Bacteroides group B and A streptococci, Enterobacteriaceae organisms, and Chlamydia trachomatis in endometritis is suggested. Wound and episiotomy site infections need broad-spectrum antibiotics as well, because of the polymicrobial nature of the local flora. Consider coverage primarily for S aureus in postpartum mastitis.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Patients with early postpartum endometritis (especially after cesarean delivery) should be admitted, as should any patient with suspected septic pelvic vein thrombosis.

Further Outpatient Care

• All patients with a postpartum infection should undergo follow-up with an obstetrician.

Complications

• Scarring
• Infertility
• Sepsis
• Septic shock
• Death

Prognosis

• The prognosis is good with prompt and appropriate therapy.

Patient Education

• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Postpartum Perineal Care.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to diagnose
• Inappropriate antibiotics

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Atrash HK, Koonin LM, Lawson HW, Franks AL, Smith JC. Maternal mortality in the United States, 1979-1986. Obstet Gynecol. Dec 1990;76(6):1055-60. [Medline].
• Chaim W, Bashiri A, Bar-David J, et al. Prevalence and clinical significance of postpartum endometritis and wound infection. Infect Dis Obstet Gynecol. 2000;8(2):77-82. [Medline].
• Cohen J, Powderly W. Episiotomy infections and postabortion sepsis. In: Infectious Diseases. 2^nd ed. 2004:697-698.
• Cunningham FG, MacDonald PC, Gant NF. Infections and disorders of the puerperium. In: William's Obstetrics. 20^th ed. 1997:547-68.
• Del Priore G, Jackson-Stone M, Shim EK, et al. A comparison of once-daily and 8-hour gentamicin dosing in the treatment of postpartum endometritis. Obstet Gynecol. Jun 1996;87(6):994-1000. [Medline].
• Faro S. Postpartum endometritis. In: Obstetrics and Gynecologic Infectious Disease. 1994:427-36.
• French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2002;CD001067. [Medline].
• Gabbe, SG. Puerperal endometritis, serious sequelae of puerperal infection. In: Obstetrics: Normal and Problem Pregnancies. 4^th ed. 2002:1304-1308.
• Gibbs RS. Clinical risk factors for puerperal infection. Obstet Gynecol. May 1980;55(5 Suppl):178S-184S. [Medline].
• Gilstrap LC, Faro S. Postpartum endometritis. In: Infections in Pregnancy. 2^nd ed. 1997:65-78.
• Monga M, Oshiro BT. Puerperal infections. Semin Perinatol. Dec 1993;17(6):426-31. [Medline].
• Rochat RW, Koonin LM, Atrash HK, Jewett JF. Maternal mortality in the United States: report from the Maternal Mortality Collaborative. Obstet Gynecol. Jul 1988;72(1):91-7. [Medline].
• Sweet RL, Gibbs RS. Postpartum infection. In: Infectious Diseases of the Female Genital Tract. 3^rd ed. 1995:578-600.

Article Last Updated: Aug 8, 2007