Updated: 2/1/2020

Postpartum Fever

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  • Snapshot
    • A 24-year-old primigravid woman underwent a cesarean section secondary to failed induction of labor at 39 weeks gestation. The cesarean delivery was uncomplicated and a healthy 8-pound girl was delivered. On post-partum day 3, the nurse reports the patient's temperature is 38.7°C (101.7°F). On physical examination, the surgical site is clean, the patient has mid-line abdominal tenderness and purulent lochia. A CBC is ordered, and the patient is found to have a white blood count of 16,000 cells/mm^3.
  • Introduction
    • Overview
      • postpartum fever is defined as temperatures of 100.4°F(38.0°C) or higher
      • occurs on any 2 of the first 10 days postpartum outside of the first 24 hours.
      • can follow vaginal or cesarean birth
      • presumed infection
        • treated with antibiotics
  • Epidemiology
    • Incidence
      • estimated to occur in the U.S. in 1-8% of all births
      • higher incidence in cesarean delivery than vaginal delivery
    • Demographics
      • people of reproductive age who have recently delivered
    • Location
      • can be traced to many areas
        • surgical site infection
        • endometritis
        • septic pelvic thrombophlebitis
        • puerperal mastitis
        • urinary tract infections
        • perineal/episiotomy infections
        • pneumonia
    • Risk factors
      • maternal conditions
        • diabetes
        • obesity
        • anemia
        • immunosuppression
      • intrapartum
        • premature/prolonged rupture of membranes
        • prolonged labor
      • iatrogenic
        • cesarean birth (most significant)
        • use of fetal scalp electrode in labor
        • urinary catheter
        • frequent vaginal examinations
      • postpartum
        • retained products of conception
        • nipple trauma from breastfeeding
  • ETIOLOGY
    • Pathogenesis
      • related to source of infection
  • Presentation
    • Symptoms
      • fever on or after postpartum day 2
      • common symptoms
        • vary by location
          • postpartum day 1-2
            • urinary tract infection/pyelonephritis
              • malaise
              • costovertebral angle tenderness
              • increased urinary frequency
              • increased urinary urgency
              • dysuria
          • postpartum day 2-3
            • endometritis
              • uterine tenderness
              • foul-smelling (or purulent) lochia
            • pneumonia
              • cough
              • dyspnea
          • postpartum day 3-4
            • surgical site/wound infection
              • erythema or fluctuance at site
              • wound drainage
              • not responsive to antibiotics
          • postpartum day 5-6
            • septic pelvic thrombophlebitis
              • intermittent fevers
              • not responsive to antibiotics
          • postpartum day 7-21
            • mastitis
              • breast pain
              • breast tenderness
              • localized erythema
      • Physical exam
        • depends on site and nature of infection
  • Imaging
    • Radiographs
      • indications
        • symptoms of pneumonia
      • views
        • AP/lateral chest x-ray
  • Studies
    • Serum labs
      • CBC
      • CRP
      • blood culture
    • Cervical swab and culture
    • Urinalysis
    • Urine culture
    • Wound culture
  • Differential
    • Endometritis
      • key distinguishing factors
        • uterine tenderness
        • foul-smelling lochia
    • Pyelonephritis
      • key distinguishing factor
        • costovertebral angle tenderness
        • dysuria
        • increased urinary urgency/frequency
  • Treatment
    • Medical
      • empiric broad-spectrum intravenous antibiotics
        • clindamycin plus gentamicin
        • continue until 48 hours after fever resolution
      • supportive care
      • heparin therapy
        • for thrombophlebitis
    • Surgical
      • may be necessary depending on source
        • remove retained products of conception
        • drain infected wounds
  • Complications
    • Sepsis
      • incidence
        • high-income countries
          • 0.1-0.6/1,000 deliveries
      • risk factors
        • same as for postpartum fever
      • treatment
        • antibiotics
        • supportive care
    • Abscess
      • incidence
        • depends on site
      • risk factors
        • same as for postpartum fever
      • treatment
        • antibiotics
        • drainage
  • Prognosis
    • Most patients improve in 2-3 days with prompt treatment
    • Patients who develop sepsis have worse outcomes
    • Prophylactic antibiotics prior to cesarean delivery can reduce incidence

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