Fever During and After Childbirth

Advances in Maternal and Neonatal Health

Session Objectives

Discuss best practices for management of infection during and after childbirth, especially:
 

Amnionitis Metritis

 

Describe strategies for prevention of infection Distinguish between prophylactic and therapeutic use of antibiotics

Fever During and After Childbirth

2

Providing Prophylactic Antibiotics

Help prevent infection, which can result from certain procedures, including:
     

Cesarean section Manual removal of placenta Correction of uterine inversion Repair of ruptured uterus Postpartum hysterectomy Prolonged rupture of membranes (Group B streptococcus)

If infection is suspected or diagnosed, therapeutic antibiotics are more appropriate

Fever During and After Childbirth

3

Fever During and After Childbirth 4 . to allow adequate blood levels at time of procedure Except at cesarean.    Gyssens 1999. give second dose.Providing Prophylactic Antibiotics (continued)  Should be given 30 minutes before procedure. Polk and Christmas 2000. give antibiotics when cord is clamped after delivery of newborn One dose is enough (as effective as 3 doses or 24 hours of antibiotics) If procedure is longer than 6 hours or blood loss is 1500 mL or more.

cost. urinary tract infection. wound infection. Fever During and After Childbirth 5 . adverse reactions. newborn outcomes   Hopkins and Smaill 2000. other serious infections.Providing Prophylactic Antibiotics for Cesarean Section: Objective and Design  Objective: To determine which antibiotic regimen is most effective in reducing infectious morbidity in women undergoing cesarean section Methods: 51 randomized controlled trials Outcomes: Fever.

at cord clamp) Hopkins and Smaill 2000.Providing Prophylactic Antibiotics for Cesarean Section: Results  Ampicillin and 1st generation cephalosporin have similar efficacy in reducing postoperative endometritis   No need for more broad spectrum agents or multiple doses Need randomized controlled trial to test optimal timing (pre-operative vs. Fever During and After Childbirth 6 .

give broad spectrum antibiotics Treat specific infection with specific antibiotics If response is poor after 48 hours:  Ensure adequate doses of antibiotics are being given  Re-evaluate woman for other infection or abscess  Treat based on reported microbial sensitivity  End point is when:    Woman is fever-free for 48 hours Clinical examination shows woman is improving Woman completes course of antibiotics (in all cases except metritis) Fever During and After Childbirth 7 .Providing Therapeutic Antibiotics    For general treatment of obstetrical infection or until diagnosis is made.

Principles of Treatment with Antibiotics    Adequate dosing Adequate duration Continued re-evaluation of the patient Fever During and After Childbirth 8 .

Fever During Pregnancy and Labor: Differential Diagnosis         Cystitis Acute pyelonephritis Septic abortion Amnionitis Pneumonia Malaria Typhoid Hepatitis Fever During and After Childbirth 9 .

because of risks of:   Preterm labor Sepsis   Easy to treat Inexpensive Fever During and After Childbirth 10 .Acute Pyelonephritis  Treat.

manage as indicated Check urine culture and sensitivity and give appropriate antibiotic If no culture available.Management of Acute Pyelonephritis   If in shock or preterm labor. give IV antibiotics until woman is feverfree for 48 hours:    Ampicillin every 6 hours PLUS gentamicin daily   Ensure adequate hydration by mouth or IV Give paracetamol by mouth for pain and to lower temperature Fever During and After Childbirth 11 .

Fever During and After Childbirth 12 .Acute Pyelonephritis: Subsequent Prophylaxis  Recurrence of acute pyelonephritis in the same gestation is reported to be 10–18% Suppressive therapy: 2.7% will get another urinary tract infection No suppressive therapy: 20–30% will get another urinary tract infection To prevent further infections. Duff 1996. give antibiotics once daily at bedtime for remainder of pregnancy and 2 weeks postpartum:      Trimethoprim/sulfamethoxazole Amoxicillin Sweet and Gibbs 1996.

9% of maternal deaths Postabortion care has had tremendous impact on reducing mortality.Septic Abortion   Cause of 12. particularly with use of manual vacuum aspiration Fever During and After Childbirth 13 .

Management of Septic Abortion  Begin antibiotics as soon as possible before evacuation:    Ampicillin every 6 hours PLUS gentamicin daily PLUS metronidazole every 8 hours   Continue until fever-free for 48 hours Manual vacuum aspiration Fever During and After Childbirth 14 .

Amnionitis: Antibiotics  Prompt intrapartum initiation (rather than delay until after delivery) of broad spectrum antibiotics results in:     Less newborn bacteremia Less newborn pneumonia Reduced maternal febrile morbidity Shorter duration of hospitalization  Treatment initiated intrapartum will not mask newborn infection Gibbs RS et al 1988. Fever During and After Childbirth 15 .

Fever During and After Childbirth 16 . coli – major causes of newborn sepsis   Anaerobic coverage is not necessary (unless cesarean section performed) Hauth et al 1985.Amnionitis: Antibiotics (continued)  Ampicillin and gentamicin   Broad coverage for wide variety of organisms Crosses placenta and achieves adequate concentrations in the fetus Excellent activity against group B streptococci and E.

Management of Amnionitis  Give combination of antibiotics until delivery:   Ampicillin every 6 hours PLUS gentamicin daily   If woman delivers vaginally. Fever During and After Childbirth 17 . discontinue antibiotics postpartum If woman has cesarean section:    Continue above antibiotics Add metronidazole every 8 hours Continue until fever-free for 48 hours ACOG 1998.

induce labor with oxytocin If cervix is unfavorable.Management of Amnionitis (continued)   If cervix is favorable. ripen with prostaglandins and infuse oxytocin or deliver by cesarean section Fever During and After Childbirth 18 .

Fever During and After Childbirth 19 .Aminoglycosides During Pregnancy: Objective and Design  Objective: To evaluate teratogenic potential of aminoglycosides Methods:   Selected cases of congenital anomalies from Hungarian congenital anomaly registry from 1980–1996 Gleaned exposure data from antenatal care records. medical documents. questionnaire to mother  Czeizel et al 2000.

tobramycin or oral neomycin Czeizel et al 2000.Aminoglycosides During Pregnancy: Results No detectable teratogenesis from parenteral gentamicin. streptomycin. Fever During and After Childbirth 20 .

Fever after Childbirth: Differential Diagnosis        Metritis Pelvic abscess Peritonitis Breast engorgement Mastitis Breast abscess Wound abscess. wound seroma or wound hematoma Wound cellulitis          Cystitis Acute pyelonephritis Deep vein thrombosis Pneumonia Atelectasis Uncomplicated malaria Severe/complicated malaria Typhoid Hepatitis 21  Fever During and After Childbirth .

pulmonary embolism. coagulopathy and septic shock may complicate the infection Remember that clostridium infections may be difficult to detect and occur where contamination with earth or cow dung is possible   Kwast 1991.Obstetric and Medical Factors Affecting Postpartum Sepsis   Intervention during labor and delivery Dangerous infections following prolonged and obstructed labor Thrombophlebitis. Fever During and After Childbirth 22 .

Health Service Factors Affecting Postpartum Sepsis  Majority of deaths occur between first and second week of puerperium and are linked to medical and midwifery/nursing staff factors:  Inadequate: – monitoring of temperature – bacteriological investigations – treatment with antibiotics or operative intervention Lack of: – asepsis and antisepsis – blood for transfusion – appropriate drugs  Kwast 1991. Fever During and After Childbirth 23 .

begin treatment immediately Fever During and After Childbirth 24 .Fever After Childbirth: General Management     Encourage bedrest Ensure adequate hydration by mouth or IV Decrease temperature with fan or tepid sponging If shock suspected.

Management of Metritis  Start antibiotics:   All the while:       Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours Give fluids Transfuse blood as needed Give pain medication Continue close monitoring Watch for shock Watch for development of abscess   Assess if retained placental fragments Fever During and After Childbirth 25 .

Antibiotics for Metritis  IV antibiotics:    Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours   Continue until fever-free for 48 hours No oral antibiotics after treatment:   Not proven to add any benefit Only add to expense Fever During and After Childbirth 26 .

drug reaction. costs   French and Smaill 2000. other complication (infectious). treatment failure. Fever During and After Childbirth 27 . Methods: 41 randomized controlled trials Outcomes: duration of fever.Managing Metritis: Objective and Design  Objective: To assess the effects of different regimens and their complications in the treatment of endometritis.

three-times daily: no difference in failure rates.60 (0.20) No difference in nephrotoxicity. Fever During and After Childbirth 28 .Managing Metritis: Results  More treatment failure with regimens other than clindamycin and an aminoglycoside RR 1.10–1.30–1. lower cost   French and Smaill 2000.70) Three studies looked at once-daily gentamicin vs.37 (1. but a trend toward fewer failures with once-daily dosing RR 0.

and  Anaerobes (metronidazole)  Adequate doses of antibiotics are necessary    Aggressive fluid resuscitation (2–3 liters to start) Look for abscess.(gentamicin). peritonitis or other condition requiring surgery IV antibiotics may be necessary for longer if bacteremia Fever During and After Childbirth 29 . ampicillin)  Gram .Septic Shock   IV antibiotics for sick patients Antibiotics for  Gram + (penicillin.

g.. episiotomy) Plus:     Clean tie Clean perineum Clean nails Fever During and After Childbirth 30 .Prevention Strategies  Infection prevention practices for every delivery:   Three Cleans:    Clean hands Clean surface Clean blade Minimum manipulation High-level disinfected or sterile gloves for examination Avoid unnecessary procedures (e.

Summary    Many causes of fever during and after childbirth Therapeutic antibiotics ONLY if disease is diagnosed Duration or treatment dependent on disease. whether or not cesarean section has occurred or presence of bacteremia Fever During and After Childbirth 31 .

292-300. Issue 4. 1988. Obstet Gynecol 72(6): 823–828. Update Software: Oxford. Czeizel AE et al. in The Cochrane Library. p. Churchill Livingstone: Edinburgh. Scand J Infect Dis 32: 309– 313. Antibiotic regimens for endometritis after delivery (Cochrane Review). Gabbe SG. in Obstetrics: Normal and Problem Pregnancy. 1996. 2000. 2000.References American College of Obstetricians and Gynecologists (ACOG) Educational Bulletin: Antimicrobial Therapy for Obstetric Patients. A randomized trial of intrapartum versus immediate postpartum treatment of women with intra-amniotic infection. Duff P. March 1998. Maternal and Perinatal Infections. A teratological study of aminoglycoside antibiotic therapy during pregnancy. Fever During and After Childbirth 32 . French LM and FM Smaill. Gibbs RS et al. 3rd ed. JR Niebyl and OL Simpson (eds). Scotland.

References (continued) Gyssens IC. in The Cochrane Library. Williams & Wilkins: Baltimore. Prophylactic antibiotics in surgery and surgical wound infections. Fever During and After Childbirth 33 . Update Software: Oxford. Midwifery 7(3): 102–106. Hopkins L and F Smaill. Maryland. Polk Jr. Puerperal sepsis: Its contribution to maternal mortality. 1999. Obstet Gynecol 66(1): 59–62. Term maternal and neonatal complications of acute chorioamnionitis. Antibiotic prophylaxis regimens and drugs for cesarean section (Cochrane Review). Am Surg 66: 105–111. 1985. 2000. Hauth JC et al. Preventing postoperative infections: Current treatment recommendations. Drugs 57(2): 175–185. 1998. Sweet RL and RS Gibbs. 3rd ed. HC and AB Christmas. Kwast B. Infectious Diseases of the Female Genital Tract. 1991. 2000.

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