Postpartum infections
Postpartum infections, also known as childbed fever and puerperal fever, are any bacterial infections of the female reproductive tract following childbirth or miscarriage. Signs and symptoms usually include a fever greater than, chills, lower abdominal pain, and possibly odorous vaginal discharge. It usually occurs after the first 24 hours and within the first ten days following delivery.
The most common infection is that of the uterus and surrounding tissues known as puerperal sepsis, postpartum metritis, or postpartum endometritis. Risk factors include caesarean section, the presence of certain bacteria such as group B streptococcus in the vagina, premature rupture of membranes, multiple vaginal exams, manual removal of the placenta, and prolonged labour among others. Most infections involve a number of types of bacteria. Diagnosis is rarely helped by culturing of the vagina or blood. In those who do not improve, medical imaging may be required. Other causes of fever following delivery include breast engorgement, urinary tract infections, infections of an abdominal incision or an episiotomy, and atelectasis.
Due to the risks following caesarean section, it is recommended that all women receive a preventive dose of antibiotics such as ampicillin around the time of surgery. Treatment of established infections is with antibiotics, with most people improving in two to three days. In those with mild disease, oral antibiotics may be used; otherwise, intravenous antibiotics are recommended. Common antibiotics include a combination of ampicillin and gentamicin following vaginal delivery or clindamycin and gentamicin in those who have had a C-section. In those who are not improving with appropriate treatment, other complications such as an abscess should be considered.
In 2015, about 11.8 million maternal infections occurred. In the developed world about 1% to 2% develop uterine infections following vaginal delivery. This increases to 5% to 13% among those who have more difficult deliveries and 50% with C-sections before the use of preventive antibiotics. In 2015, these infections resulted in 17,900 deaths down from 34,000 deaths in 1990. They are the cause of about 10% of deaths around the time of pregnancy. The first known descriptions of the condition date back to at least the 5th century BCE in the writings of Hippocrates. These infections were a very common cause of death around the time of childbirth starting in at least the 18th century until the 1930s when antibiotics were introduced. In 1847, Hungarian physician Ignaz Semmelweiss decreased death from the disease in the First Obstetrical Clinic of Vienna from nearly 20% to 2% through the use of handwashing with calcium hypochlorite.
Signs and symptoms
Signs and symptoms usually include a fever greater than, chills, low abdominal pain, and possibly bad-smelling vaginal discharge. It usually occurs after the first 24 hours and within the first ten days following delivery.Causes
After childbirth, the female genital tract has a large bare surface, which is prone to infection. Infection may be limited to the cavity and wall of the uterus, or it may spread beyond to cause sepsis or other illnesses, especially when resistance has been lowered by long labour or severe bleeding. Puerperal infection is most common on the raw surface of the interior of the uterus after separation of the placenta, but pathogenic organisms may also affect lacerations of any part of the genital tract. By whatever portal, they can invade the bloodstream and lymph system to cause sepsis, cellulitis, and pelvic or generalized peritonitis. The severity of the illness depends on the virulence of the infecting organism, the resistance of the invaded tissues, and the general health of the woman. Organisms commonly producing this infection are Streptococcus pyogenes; staphylococci ; the anaerobic streptococci, which flourish in devitalized tissues such as may be present after long and injurious labour and unskilled instrumental delivery; Escherichia coli and Clostridium perfringens ; and Clostridium tetani.Risk factors
Causes include: endometritis, urinary tract infection, pneumonia/atelectasis, wound infection, and septic pelvic thrombophlebitis. Sepsis risk factors for each condition are listed in order of the postpartum day on which the condition generally occurs.- PPD 0: atelectasis risk factors include general anesthesia, cigarette smoking, and obstructive lung disease.
- PPD 1–2: urinary tract infection risk factors include multiple catheterization during labor, multiple vaginal examinations during labor, and untreated bacteriuria.
- PPD 2–3: endometritis risk factors include emergency cesarean section, prolonged membrane rupture, prolonged labor, and multiple vaginal examinations during labor.
- PPD 4–5: wound infection risk factors include emergency cesarean section, prolonged membrane rupture, prolonged labor, and multiple vaginal examinations during labor.
- PPD 5–6: septic pelvic thrombophlebitis risk factors include emergency cesarean section, prolonged membrane rupture, prolonged labor, and diffuse difficult vaginal childbirth.
- PPD 7–21: mastitis risk factors include nipple trauma from breastfeeding.
Diagnosis
- A temperature rise above maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion.
- Oral temperature of or more on any two of the first ten days postpartum.
- the specific target of infection: endometritis, metrophlebitis, and peritonitis.
- the severity of the infection: less serious infection or possibly life-threatening sepsis.
Differential diagnosis
Several other conditions can cause fevers following delivery, including: urinary tract infections, breast engorgement, atelectasis, and surgical incisions, among others.Management
Antibiotics have been used to prevent and treat these infections; however, the misuse of antibiotics is a serious problem for global health. It is recommended that guidelines be followed that outline when it is appropriate to give antibiotics and which antibiotics are most effective.Atelectasis: mild to moderate fever, no changes or mild rales on chest auscultation.
Management: pulmonary exercises, ambulation.
Urinary tract infection: high fever, malaise, costovertebral tenderness, positive urine culture.
Management: antibiotics as per culture sensitivity.
Endometritis: moderate fever, exquisite uterine tenderness, minimal abdominal findings.
Management: multiple agent IV antibiotics to cover polymicrobial organisms: clindamycin, gentamicin, and addition of ampicillin if no response, no cultures are necessary.
Wound infection: persistent spiking fever despite antibiotics, wound erythema or fluctuance, wound drainage.
Management: antibiotics for cellulitis, open and drain wound, saline-soaked packing twice a day, secondary closure.
Septic pelvic thrombophlebitis: persistent wide fever swings despite antibiotics, usually normal abdominal or pelvic exams.
Management: IV heparin for 7–10 days at rates sufficient to prolong the PTT to double the baseline values.
Mastitis: unilateral, localized erythema, edema, tenderness.
Management: antibiotics for cellulitis, open and drain the abscess if present.
Epidemiology
The number of cases of puerperal sepsis per year shows wide variations among published literature—this may be related to different definitions, recordings etc. Globally, bacterial infections are the cause of 10% of maternal deaths—this is more common in low income countries but is also a direct cause of maternal deaths in high-income countries.In the United States, puerperal infections are believed to occur in between 1% and 8% of all births. About three die from puerperal sepsis for every 100,000 births. The single most important risk factor is caesarean section. The number of maternal deaths in the United States is about 13 in 100,000. They make up about 11% of pregnancy-related deaths in the United States.
In the United Kingdom from 1985 to 2005, the number of direct deaths associated with genital tract sepsis per 100,000 pregnancies was 0.40–0.85. In 2003–2005, genital tract sepsis accounted for 14% of direct causes of maternal death.
Puerperal infections in the 18th and 19th centuries affected, on average, 6 to 9 women in every 1,000 births, killing two to three of them with peritonitis or sepsis. It was the single most common cause of maternal mortality, accounting for about half of all deaths related to childbirth, and was second only to tuberculosis in killing women of childbearing age. A rough estimate is that about 250,000–500,000 died from puerperal fever in the 18th and 19th centuries in England and Wales alone.
History
Although it had been recognized from as early as the time of the Hippocratic corpus that women in childbed were prone to fevers, the distinct name "puerperal fever" appears in historical records only from the early 18th century.The death rate for women giving birth decreased in the 20th century in developed countries. The decline may be partly attributed to improved environmental conditions, better obstetrical care, and the use of antibiotics. Another reason appears to be a lessening of the virulence or invasiveness of Streptococcus pyogenes. That organism is also the cause of scarlet fever, which declined over the same period but has seen a rise in the last decade worldwide, especially in Asia, with smaller outbreaks in the US and Canada. The UK reported 12,906 cases between September 2015 and April 2016, which is the largest outbreak since 1969.