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Postpartum Fever

- Choice of antibiotic therapy is dictated by source of infection and likely pathogenic organism (see pregnancy-specific issues): - Clindamycin 900 mg IV q8h - Clindamycin 300 " “450 mg PO q6h - Gentamicin 1.5 mg/kg q8h or 5 mg/kg q24h - Ampicillin 2 g IV q6h - Metronidazole 500 mg PO/IV q6h - Cefotetan 1 " “2 g IV q12h - Cephalexin 500 mg PO q6h - Dicloxacillin 500 mg PO q6h - Nafcillin 2 g IV q4h - Ampicillin/sulbactam 3 g IV q6h - Piperacillin/tazobactam 3.375 g IV q6h - Vancomycin 1 g IV q12h (1,3,6,7)

para>Endometritis

  • Parenteral broad-spectrum antibiotics: IV treatment until 24 " “48 hours afebrile. Continuing treatment with oral antibiotics is not necessary (1,3)[A].
  • Clindamycin plus gentamicin (Ampicillin is added if enterococcal infection is suspected or if no improvement occurs by 48 hours.)
  • Ampicillin/sulbactam
  • Piperacillin/tazobactam
  • Aztreonam (1,3)

Mastitis

  • Local measures
  • Analgesics
  • Outpatient antibiotics " ”dicloxacillin or cephalexin for 10 days or clindamycin if PCN-allergic
  • If MRSA suspected (history of MRSA or poor response to initial antibiotics), consider trimethoprim-sulfamethoxazole for 10 days.
  • Inpatient antibiotics if septic, seriously ill, or not tolerating PO " ”IV nafcillin, clindamycin or > vancomycin
  • If obvious fluctuance on exam or poor initial response to antibiotics, get stat US to look for abscess. Surgical drainage for local abscesses (7)[C]

UTI

  • Hydration
  • Antibiotic treatment

Wound infection

Pneumonia

  • Antibiotic treatment
  • Adequate oxygenation
  • Analgesia

Atelectasis

Pelvic abscess

SVT

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Medication

  • Choice of antibiotic therapy is dictated by source of infection and likely pathogenic organism (see pregnancy-specific issues):Clindamycin 900 mg IV q8hClindamycin 300 " “450 mg PO q6hGentamicin 1.5 mg/kg q8h or 5 mg/kg q24hAmpicillin 2 g IV q6hMetronidazole 500 mg PO/IV q6hCefotetan 1 " “2 g IV q12hCephalexin 500 mg PO q6hDicloxacillin 500 mg PO q6hNafcillin 2 g IV q4hAmpicillin/sulbactam 3 g IV q6hPiperacillin/tazobactam 3.375 g IV q6hVancomycin 1 g IV q12h (1,3,6,7)
  • For SVT, anticoagulation plus broad-spectrum antibiotics (see "Endometritis " ¯) needed (1)[C]Dalteparin 200 units/kg/day SQ qd or b.i.d. until 3 " “7 days afebrileEnoxaparin 1 mg/kg/dose b.i.d. till 3 " “7 days afebrile (1)

Issues for Referral

  • For mastitis, referral to surgeon comfortable with breast abscess, if abscess (7)[C]
  • For pelvic abscess, hematoma, or SVT, consultation with obstetrician/gynecologist (OB/GYN) needed (1)[C]

Surgery/Other Procedures

  • Wound exploration and probing at bedside or in operating room (OR) if hematoma/abscess is subfascial
  • Wound infection/seroma/infected hematoma that result in open incision should be assessed for possible wound closure.
  • If evidence of fascial dehiscence, surgical repair is required as emergency procedure.

Inpatient Considerations

Admission Criteria/Initial Stabilization

Sepsis treated with standard treatment " ”IV fluids to stabilize vitals, pressor support if needed ‚

IV Fluids

IV fluids needed if concern for sepsis ‚

Nursing

For mastitis, frequent breastfeeding/pumping (3 or more times a day) ‚

Discharge Criteria

  • Vitals stable
  • Afebrile times 24 " “48 hours
  • Ability to tolerate PO antibiotics for mastitis, wound cellulitis, endometritis does not require PO antibiotics, just stop IV antibiotics after 24 " “48 hours afebrile.
  • For SVT " ”cessation of IV antibiotics and anticoagulation after 3 " “7 days afebrile (1)

Ongoing Care

Follow-up Recommendations

All patients with a postpartum fever should undergo follow-up with an OB/GYN or family physician that practices obstetrics but ideally with the delivering physician (1). ‚

Patient Education

  • Explain rationale for diagnostic studies to identify source.
  • Explain treatment guided by underlying cause of fever.

Prognosis

Largely dependent on source of fever and resultant complications. For most patients, there is complete resolution of symptoms after appropriate treatment. ‚

References

1.Zheng ‚ T. Postpartum fever. In: Comprehensive Handbook: Obstetrics and Gynecology. 2nd ed. Paradise Valley, AZ: Phoenix Medical Press, LLC; 2012:64 " “65.2.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. ‚

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3.Larsen ‚ JW, Hager ‚ WD, Livengood ‚ CH, et al. Guidelines for the diagnosis, treatment and prevention of postoperative infections. Infect Dis Obstet Gynecol. 2003;11(1):65 " “70. ‚

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4.American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472 " “1483. ‚

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5.Elati ‚ A, Weeks ‚ A. Risk of fever after misoprostol for the prevention of postpartum hemorrhage: a meta-analysis. Obstet Gynecol. 2012;120(5):1140 " “1148. ‚

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6.Sarsam ‚ SE, Elliott ‚ JP, Lam ‚ GK. Management of wound complications from cesarean delivery. Obstet Gynecol Surv. 2005;60(7):462 " “473. ‚

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7.World Health Organization. Mastitis: cause and management. Geneva, Switzerland: World Health Organization; 2000.

Codes

ICD09

  • 672.04 Pyrexia of unknown origin during the puerperium, postpartum condition or complication
  • 647.94 Unspecified infection or infestation of mother, postpartum condition or complication
  • 675.24 Nonpurulent mastitis associated with childbirth, postpartum condition or complication
  • 674.34 Other complications of obstetrical surgical wounds, postpartum condition or complication
  • 667.14 Retained portions of placenta or membranes, without hemorrhage, postpartum condition or complication
  • 672.00 Pyrexia of unknown origin during the puerperium, unspecified as to episode of care or not applicable
  • 672.02 Pyrexia of unknown origin during the puerperium, delivered, with mention of postpartum complication

ICD10

  • O86.4 Pyrexia of unknown origin following delivery
  • O86.19 Other infection of genital tract following delivery
  • O91.12 Abscess of breast associated with the puerperium
  • O86.0 Infection of obstetric surgical wound
  • O73.1 Retained portions of placenta and membranes, w/o hemorrhage
  • O98.93 Unsp maternal infec/parastc disease comp the puerperium

SNOMED

  • 248451004 Postpartum fever (finding)
  • 199106001 Genitourinary tract infection in pregnancy - delivered (disorder)
  • 200381005 Obstetric non-purulent mastitis - delivered (disorder)
  • 24342007 Infection of cesarean section AND/OR perineal wound (disorder)
  • 371374003 retained products of conception (disorder)

Clinical Pearls

  • With endometritis " ”If no resolution of fever after 48 hours of broad-spectrum IV antibiotic, must get a CT scan of abdomen/pelvis to look for other causes (abscess, hematoma, SVT) (1)[C]
  • All mastitis patients sent home on PO antibiotics should be reevaluated in 48 " “72 hours. If no improvement, get breast US; consider MRSA coverage (7)[B].
  • Fever 1 " “2 hours after delivery, consider misoprostol as cause (if administered) " ”will be self-limiting.