Postpartum Infection, Emergency Medicine

Basics

Description

Postpartum endometritis (PPE):
- Early PPE
  - Develops within 48 hr
  - Most often complicating C-section
  - Occurs in 1 " 3% of uncomplicated vaginal deliveries
  - Classic triad: Fever, lower abdominal pain with uterine tenderness, foul-smelling lochia
- Late PPE
  - Develops 3 days " 6 wk after delivery
  - Usually follows vaginal delivery
- Risk of PPE as high as 85 " 95% in high-risk nonelective C-section patient
Complications of PPE: All are more common after C-section:
- Pelvic thrombophlebitis
- Pelvic abscess
- Bacteremia
Risk factors for PPE:
- C-section
- Prolonged labor
- Prolonged rupture of membranes
- Increased number of vaginal exams
- Use of internal fetal monitoring
Septic pelvic thrombophlebitis is a diagnosis of exclusion with 2 distinct clinical presentations, either of which may present with postpartum pulmonary embolus:
- Acute thrombosis:
  - Most common in right ovarian vein
  - Usually occurs in 1st 48 hr as acute, progressive lower abdominal pain
- Enigmatic fever: "Picket fence " spiking fevers and tachycardia
Septic abortion:
- Uncommon in developing countries
- Usually an ascending infection through an open cervical os
- Associated with:
  - Nonsterile techniques, instruments
  - Retained products of conception
Mastitis:
- Ranges from mild breast redness to fever, systemic illness, and abscess
- Common (1 " 30% of postpartum patients)
- Occurs within the 1st 3 mo postpartum
- Peaks at 2 " 3 wk
- Recurs in 4 " 8%
UTI/pyelonephritis:
- Along with mastitis accounts for 80% of postpartum infections

Etiology

PPE:
- Polymicrobial infection result of ascending spread from lower genital tract
- Anaerobic (up to 80%) and aerobic ( ¢ ¼70%):
- Gram-positive aerobes:
  - Group A, B streptococci
  - Enterococci
  - Gardnerella vaginalis
- Gram-negative aerobes:
  - Escherichia coli
  - Enterobacter
- Anaerobes:
  - Bacteroides
  - Peptostreptococcus
- Other genital mycoplasmas common in late PPE:
  - Ureaplasma urealyticum
  - Mycoplasma hominids
  - Chlamydia trachomatis
Septic abortion:
- Usually polymicrobial
- E. coli
- Bacteroides
- Anaerobic gram-negative rods
- Group B streptococci
- Staphylococcus
- STD:
  - Gonorrhea
  - C. trachomatis
  - Trichomonas
Mastitis
- Staphylococcus aureus
- Group A and B hemolytic streptococci
- E. coli
- Bacteroides

Diagnosis

Signs and Symptoms

History

Careful birth history:
- C-section
- Length of labor
- Complications
- Exposure to STDs
Pre-existing immunocompromise or disease
Endometritis:
- Fever and chills
- Abdominal pain
- Foul-smelling lochia
Septic abortion:
- Similar to endometritis
- Fever
- Abdominal pain
- May present with symptoms of shock including:
  - Dyspnea (acute respiratory distress syndrome [ARDS], pulmonary edema)
  - Bruising, bleeding (disseminated intravascular coagulation [DIC])
Mastitis:
- Fever
- Breast pain, engorgement, redness
Other sources of infection:
- Wound infection:
  - Redness, pain, swelling
- UTI/pyelonephritis:
  - Fever, dysuria, frequency, flank pain

Physical Exam

Abdominal and/or uterine tenderness
Foul-smelling lochia
Unilateral tender, engorged, erythematous breast in cases of mastitis
Examine episiotomy infections
Suprapubic or costovertebral angle tenderness in cases of UTI/pyelonephritis

Essential Workup

Abdominal and pelvic exam
Cervical cultures for Chlamydia
Transcervical endometrial cultures

Diagnosis Tests & Interpretation

Lab

CBC
Urinalysis and culture
Blood cultures

Imaging

CT or MRI for ovarian vein thrombosis
US is sensitive for abscess or retained products of conception
Plain x-rays may show retained foreign bodies or free air in septic abortion.

Differential Diagnosis

Fever from other sources
<6 hr:
- Early streptococcal infection
- Transfusion reaction
- Thyroid crisis
<48 hr:
- Atelectasis
<72 hr:
- UTI
- Pneumonia
3 " 5 days:
- Mastitis
- Breast engorgement
- Necrotizing fasciitis
3 " 7 days:
- Mastitis
- Septic thrombophlebitis
7 " 14 days:
- Abscess
>2 wk:
- Mastitis
- Pulmonary embolism

Treatment

Pre-Hospital

ABCs
IV and IV fluids if signs of shock or impending shock

Initial Stabilization/Therapy

Manage airway and resuscitate as indicated:

Prompt evaluation of respiratory and hemodynamic status
Supplemental oxygen, cardiac monitor, and pulse oximetry, as needed
Venous access; support circulatory status with crystalloid and pressors, if needed

Ed Treatment/Procedures

IV antibiotics and close observation
Septic abortion is usually treated with dilatation and curettage and removal of any inciting agents
Monitor for signs of impending shock, circulatory failure, ARDS, and/or sepsis.
Heparin if suspicion or evidence of thrombophlebitis
Infected wound or abscess should be opened to establish drainage
Necrotizing fasciitis requires wide surgical debridement, parenteral antibiotics, and adjunctive hyperbaric oxygen therapy
Peritonitis requires imaging to evaluate cause

Medication

Per underlying infection. See corresponding chapters for complete list (consider safety in breast-feeding)
Endometritis

Cefoxitin: 2 g IV q6h or
Cefotetan: 2 g IV q12h or
Piperacillin/tazobactam: 3.375 g IV q6 " 8h or
Ampicillin/sulbactam: 1.5 " 3 g IV q6h or
Clindamycin: 600 " 900 mg IV q8h +
Gentamicin: 2 mg/kg load, then 1 " 1.5 mg/kg IV q8h

Septic Abortion

Triple antibiotics
Gram-positive coverage:
- Ampicillin/sulbactam: 1.5 " 3 g IV q6h or
- Cefoxitin: 2 g IV q6h or
- Cefotetan: 2 g IV q12h
Gram-negative coverage:
- Gentamicin: 2 mg/kg load, then 1 " 1.5 mg/kg IV q8h
Anaerobic coverage:
- Clindamycin: 600 " 900 mg IV q8h or
- Metronidazole: 500 mg IV q8h

Mastitis

Dicloxacillin: 250 mg q6h PO for 10 days
Mupirocin 2% ointment TID
Cephalexin: 500 mg q6h PO for 10 days
Clindamycin: 300 mg q6h PO for 10 days
Erythromycin: 500 mg q6h PO for 10 days
If MRSA positive: Vancomycin 1 g IV q12h

UTI/Pyelonephritis (Inpatient)

Ciprofloxacin: 400 mg IV q12h or
Ceftriaxone: 1 " 2 g IV q24h or
Piperacillin/tazobactam: 3.375 g IV q6 " 8h

Follow-Up

Disposition

Admission Criteria

Patients with endometritis or suspicion for septic pelvic thrombophlebitis should be admitted
Septic abortion

Discharge Criteria
Nontoxic, mildly symptomatic patient may be considered for outpatient management in consultation and close follow-up with obstetrics

Followup Recommendations

Close follow-up with obstetrician and/or primary care physician to evaluate treatment

Pearls and Pitfalls

Mastitis and UTI account for 80% of postpartum infections
C-section increases risk for PPE
Entertain broad differential with regard to source of infection
Early broad-spectrum antibiotics are often indicated

Additional Reading

Faro S. Postpartum endometritis. Clin Prenatal. 2005;32:803 " 814.
French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004;(4):CD001067.
Gorgas DL. Infections related to pregnancy. Emerg Med Clin North Am. 2008;26:345 " 366.
Gupta, K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Clin Infect Dis. 2010;52:103 " 120.
Levine BJ. EMRA Antibiotic Guide. 15th ed. EMRA; 2013.
Wong AW, Rosh AJ. Pregnancy, postpartum infections. http://emedicine.medscape.com/article/796892-overview

Codes

ICD9

670.00 Major puerperal infection, unspecified as to episode of care or not applicable
670.10 Puerperal endometritis, unspecified as to episode of care or not applicable
670.20 Puerperal sepsis, unspecified as to episode of care or not applicable
670.30 Puerperal septic thrombophlebitis, unspecified as to episode of care or not applicable
670.02 Major puerperal infection, delivered, with mention of postpartum complication
670.04 Major puerperal infection, postpartum condition or complication
670.0 Major puerperal infection, unspecified
670.12 Puerperal endometritis, delivered, with mention of postpartum complication
670.14 Puerperal endometritis, postpartum condition or complication
670.1 Puerperal endometritis
670.22 Puerperal sepsis, delivered, with mention of postpartum complication
670.24 Puerperal sepsis, postpartum condition or complication
670.2 Puerperal sepsis
670.32 Puerperal septic thrombophlebitis, delivered, with mention of postpartum complication
670.34 Puerperal septic thrombophlebitis, postpartum condition or complication
670.3 Puerperal septic thrombophlebitis
670.80 Other major puerperal infection, unspecified as to episode of care or not applicable
670.82 Other major puerperal infection, delivered, with mention of postpartum complication
670.84 Other major puerperal infection, postpartum condition or complication
670.8 Other major puerperal infection
670 Major puerperal infection

ICD10

O85 Puerperal sepsis
O86.4 Pyrexia of unknown origin following delivery
O86.12 Endometritis following delivery
O86.81 Puerperal septic thrombophlebitis
O86.19 Other infection of genital tract following delivery

SNOMED

200277008 Puerperal pyrexia of unknown origin (disorder)
22399000 Puerperal endometritis (disorder)
2858002 Puerperal septicemia (disorder)
83916000 Postpartum thrombophlebitis (disorder)
178280004 postnatal infection (disorder)
40125005 Major puerperal infection

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