Maria Angela S.

Rodriguez-Bandola, MD, FPOGS, FPIDSOG

Puerperal Clinical Associate Professor

University of the Philippines – Philippine General Hospital
Complications Department of Obstetrics and Gynecology
Infectious Diseases Division
Clinical Case

• You are making rounds on KT, a patient endorsed and managed by

your colleague.
• KT is a 36 year old primigravid who underwent primary cesarean
section 3 days prior. While waiting for discharge orders, she
develops fever of 38.9°C. KT had increasing lower abdominal pain
since last evening.
Clinical Case 1

• On chart review, she presented to the hospital at 39 weeks with

ruptured membranes, with cervical dilatation of 3 cm at 50%
effacement.
• She was given oxytocin to induce labor. Labor progressed slowly to
the active phase, and 12 hours later, cervix was 6 cm, fully effaced
with fetal head at station -1, but her labor remained protracted, and
had no progress for the next 4 hours.
• The fetus developed tachycardia and she underwent a low transverse
cesarean section.
• The surgery was uncomplicated. Delivered a live baby boy weighing
3500 grams, with Apgar score of 9, 9. She was given Cefazolin 2
grams at skin cutting.
Clinical Case 1
• As you make rounds, her BP=100/70, HR=108 bpm,
RR=22, with T= 38.7°C.
• Abdominal PE: intact wound, no discharge
• On IE, cervix is open with minimal foul-smelling
lochial discharge, uterus enlarged to 20 weeks, with
direct tenderness on the hypogastric area and slight
pain on bilateral adnexal areas, but no appreciable
masses.
What is your primary
working impression

• Speculum exam
Primary Working Impression

• Pregnancy Uterine, delivered, term, cephalic, live birth

• S/P Primary low segment cesarean section for dysfunctional
labor secondary to arrest in cervical dilatation secondary to
cephalopelvic disproportion at the inlet level
• Puerperal Sepsis probably secondary to endometritis (or
Postpartum Infection probably secondary to endometritis)
• G1P1 (1001)
 • Temperature of 38C occurring in
any 2 of the first 10 days
postpartum, exclusive of the 1st
24 hours
PUERPERAL • Exclusion of the first 24 hours
SEPSIS / • Observation that following
spontaneous vaginal delivery,
POSTPARTUM 6-8% of women will have
INFECTION isolated febrile spike in the
first 24 hours
• Only a quarter of these
individuals will develop overt
disease requiring antibiotics
PUERPERAL SEPSIS /
POSTPARTUM INFECTION
• FEVER as cardinal manifestation of puerperal
infection
• 2 consecutive temperatures > 38oC taken 4 hours
apart
• One temperature > 38.5oC
• 3 temperatures > 38oC in any 24 hr period
Puerperal Sepsis/Postpartum
Infection: Definition

Ø Standard puerperal morbidity is defined by the Joint Committee on

Maternal Welfare
- “Temperature of 38°C occurring in any 2 of the first 10 days postpartum,
exclusive of the 1st 24 hours
- Exclusion of the first 24 hours
- Observation that following spontaneous vaginal delivery, 6-8% of
women will have an isolated febrile spike in the first 24 hours
- Only a quarter of these individuals will develop overt disease requiring
antibiotics
Fever - cardinal manifestation of puerperal infection
Puerperal Sepsis/Postpartum
Infection: Definition

Ø Significant fever requiring work up include any of the

following (Monif, 2008):
• 2 consecutive temperatures > 38°C taken 4 hrs apart
• one temperature > 38.5°C
• 3 temperatures > 38°C in any 24 hr period
Ø Fever occurring during the puerperium which does not
satisfy the above criteria should be observed and
managed supportively
 Fever temp
Others
> 38oC
5 W of Wound infection:
puerperal Endometritis, CS
wound /
Breast
engorgement

sepsis /
episiotomy

postpartum Water (UTI) dehydration

infection
Wind: pneumonia,
distinct infection
atelectasis

Walk: severe
thrombophlebitis

Wonder drug
Puerperal Sepsis/Postpartum
Infection

Ø Diagnosis of postpartum endometritis highly considered

when fever is associated with one or more of the following:
• uterine tenderness
• foul smelling lochia or leukocytosis
• subinvolution of the uterus
• open cervix
GENITAL TRACT INFECTION

• Ascending genital tract infection

• Risk factors
• Poor nutrition
• Anemia
• Prolonged rupture of membranes
• Frequent vaginal examination during labor
• Chorioamnionitis
• Cesarean delivery
WILLIAMS 25th Ed.
GENITAL TRACT INFECTIONS

Increased risk of genital tract infections

Related to the duration of labor (i.e. prolonged labor increases
risk of infection), use of internal monitoring devices, number
of vaginal examination
POLYMICROBIAL
• Gram-positive cocci and Bacteroides and Clostridium species are
the predominant anaerobic organisms
• Escherichia coli and gram-positive cocci : commonly involved
aerobes
ENDOMETRITIS

• Route of delivery is the single most important risk factor

• Incidence of endometritis following vaginal delivery rarely
exceeds 2-3%
• Following cesarean section, incidence of endometritis ranges
from 10%. in low-risk patients (received antibiotic prophylaxis) to
95% in high-risk patients (without prophylactic antibiotics)
POLYMICROBIAL SEXUAL TRANSMITTED VIRULENT ORGANISMS
INFECTION
Gram (+) bacteria Clostridium perfringes
Chlamydia trachomatis
Gram (-) bacteria Staphylococcus
Neiserria gonorrhea
Anaerobes Streptococcus
Herpes Simplex virus
Mycoplasma
WOUND INFECTIONS

• Etiologic organisms associated with perineal cellulitis and

episiotomy site infections
• Staphylococcus or Streptococcus species, gram-negative
organisms
WILLIAMS 25th Ed.
MASTITIS

• Inflammation of the breast that may or may not involve a

bacterial infection
• Most common organism: Staphylococcus aureus
• Comes from the breastfeeding infant’s mouth or throat
• Presents with a hot, swollen, tender, wedge-shaped area on the
breast, fever, flu-like aches, systemic illness

Amir LH. The Academy of Breastfeeding Medicine Protocol Committee. Breastfeeding Medicine. 2014 Jun 1.
SEPTIC PELVIC THROMBOSIS

• Occasionally observed in the postpartum patient who might have

fever
URINARY TRACT INFECTION

• Most common organisms

• Normal bowel flora
• E. coli
• Klebsiella
• Proteus
• Enterobacter species
• May be caused by any form of invasive manipulation of the
urethra
• Foley catheterization
WILLIAMS 25th Ed.
ATELECTASIS

• Often used as an explanation for unexplained postoperative fever

• Both atelectasis and fever occur frequently after surgery
DRUG FEVER

• Fever can be the sole manifestation of an adverse drug reaction in 3-5%

of cases
• Hypersensitivity reactions
• Altered thermoregulatory mechanisms
• Reactions that are directly related to administration of the drug
• Reactions that are direct extensions of the pharmacologic action of
the drug
• Idiosyncratic reactions
• Antibiotic induced fever: Erythromycin, isoniazid, penicillin,
nitrofurantoin, procainamide, quinidine
WILLIAMS 25th Ed.
Puerperal Sepsis/Postpartum
Infection

• Other terms:
• Postpartum endometritis, endometritis, metritis,
endomyometritis and endomyoparametritis
• Endometritis: most commonly used term to describe
postpartum uterine infection
What diagnostic examination do you request for ?
What medications will you give?

MANAGEMENT
 • CBC: Leukocytosis 15-30,000 cells/Ul
• URINALYSIS
• CHEST X-RAY (if warranted)
• ENDOMETRIAL CULTURE
• No routinely performed
• Not cost effective
• ENDOCERVICAL CULTURE
• Test for gonorrhea or chlamydia if high
DIAGNOSTICS risk patient
• TRANSVAGINAL ULTRASOUND
• Confirm retained products, abscess or
hematoma formation
• CT scan or MRI
• May be performed in those with failure
response to antibiotic therapy
• Septic thrombophlebitis
 • Encourage bed rest
Puerperal
• Ensure adequate hydration by mouth or IV
Sepsis/Postpartum
Infection • Decrease temperature with fan or tepid
sponging
Management
• If shock suspected, begin treatment
immediately
PUERPERAL SEPSIS /
POSTPARTUM INFECTION
 • Gold standard: Clindamycin 900
BROAD mg IV q 8° + Gentamicin 240 mg
SPECTRUM IV OD
ANTIBIOTIC • May add Ampicillin (if
THERAPY enterococcus is suspected)
• 48-72 hrs
ANTIBIOTIC FAILURE

• Within 48-72 hours of antibiotic administration

• Pelvic abscess
• Septic pelvic thrombophlebitis
• Emergence of a resistant organism
• Continue treatment until patient is afebrile and asymptomatic for
24-36 hours
• Follow up oral antibiotics not needed
 Puerperal Sepsis/Postpartum Infection
Duration of Therapy

If bacteremia was
present as indicated If related to group
by a positive blood A streptococcal or
culture, oral staphylococcal
antibiotic therapy to infection --longer
complete a 7--day course of therapy
total course

Mackeen AD et al. Antibiotic regimens for postpartum endometritis.

Cochrane Database Syst Rev. 2015
MASTITIS

• Staphylococcus aureus
• Dicloxacillin 500 mg PO QID
• Erythromycin 500 PO QID

• Continue for 10-14 days

• Continue milk expression
BREAST ABSCESS

• SURGICAL DRAINAGE
• General anesthesia
• Incise along Langer skin lines
• Packing of cavity with gauze

• ULTRASOUND GUIDED NEEDLE ASPIRATION

• Local anesthesia
• 80-90% success rate
 THANK YOU FOR
YOUR ATTENTION.