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