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 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)
- 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 afebrile
- Enoxaparin 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.