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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

- Risk factors for PPE: - C-section - Prolonged labor - Prolonged rupture of membranes - Increased number of vaginal exams - Use of internal fetal monitoring

- 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%

- 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

- Other genital mycoplasmas common in late PPE: - Ureaplasma urealyticum - Mycoplasma hominids - Chlamydia trachomatis

- Mastitis - Staphylococcus aureus - Group A and B hemolytic streptococci - E. coli - Bacteroides

- Careful birth history: - C-section - Length of labor - Complications - Exposure to STDs

- Fever from other sources - <6 hr: - Early streptococcal infection - Transfusion reaction - Thyroid crisis

  • Postpartum endometritis (PPE):Early PPEDevelops within 48 hrMost often complicating C-sectionOccurs in 1 " 3% of uncomplicated vaginal deliveriesClassic triad: Fever, lower abdominal pain with uterine tenderness, foul-smelling lochiaLate PPEDevelops 3 days " 6 wk after deliveryUsually follows vaginal deliveryRisk 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 thrombophlebitisPelvic abscessBacteremia
  • Risk factors for PPE:C-sectionProlonged laborProlonged rupture of membranesIncreased number of vaginal examsUse 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 veinUsually occurs in 1st 48 hr as acute, progressive lower abdominal painEnigmatic fever: "Picket fence " spiking fevers and tachycardia
  • Septic abortion:Uncommon in developing countriesUsually an ascending infection through an open cervical osAssociated with:Nonsterile techniques, instrumentsRetained products of conception
  • Mastitis:Ranges from mild breast redness to fever, systemic illness, and abscessCommon (1 " 30% of postpartum patients)Occurs within the 1st 3 mo postpartumPeaks at 2 " 3 wkRecurs 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 tractAnaerobic (up to 80%) and aerobic ( ¢ ¼70%):Gram-positive aerobes:Group A, B streptococciEnterococciGardnerella vaginalisGram-negative aerobes:Escherichia coliEnterobacterAnaerobes:BacteroidesPeptostreptococcusOther genital mycoplasmas common in late PPE:Ureaplasma urealyticumMycoplasma hominidsChlamydia trachomatis
  • Septic abortion:Usually polymicrobialE. coliBacteroidesAnaerobic gram-negative rodsGroup B streptococciStaphylococcusSTD:GonorrheaC. trachomatisTrichomonas
  • MastitisStaphylococcus aureusGroup A and B hemolytic streptococciE. coliBacteroides

Diagnosis

Signs and Symptoms

History

  • Careful birth history:C-sectionLength of laborComplicationsExposure to STDs
  • Pre-existing immunocompromise or disease
  • Endometritis:Fever and chillsAbdominal painFoul-smelling lochia
  • Septic abortion:Similar to endometritisFeverAbdominal painMay present with symptoms of shock including:Dyspnea (acute respiratory distress syndrome [ARDS], pulmonary edema)Bruising, bleeding (disseminated intravascular coagulation [DIC])
  • Mastitis:FeverBreast pain, engorgement, redness
  • Other sources of infection:Wound infection: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 infectionTransfusion reactionThyroid crisis
  • <48 hr:
  • <72 hr:
  • 3 " 5 days:MastitisBreast engorgementNecrotizing fasciitis
  • 3 " 7 days:MastitisSeptic thrombophlebitis
  • 7 " 14 days:
  • >2 wk:MastitisPulmonary 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 orCefoxitin: 2 g IV q6h orCefotetan: 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 orMetronidazole: 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

See Also (Topic, Algorithm, Electronic Media Element)

  • Mastitis
  • Urinary Tract Infection
  • Pyelonephritis

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