Puerperal Infectionhttp://medical-dictionary.thefreedictionary.com/Puerperal+InfectionDefinitionThe term puerperal infection refers to abacterial infectionfollowingchildbirth. The infection may also be referred to as puerperal or postpartum fever. The genital tract, particularly the uterus, is the most commonly infected site. In some cases infection can spread to other points in the body. Widespread infection, orsepsis, is a rare, but potentially fatal complication.DescriptionPuerperal infection affects an estimated 1-8% of new mothers in the United States. Given modern medical treatment andantibiotics, it very rarely advances to the point of threatening a woman's life. An estimated 2-4% of new mothers who deliver vaginally suffer some form of puerperal infection, but for cesarean sections, the figure is five-10 times that high.

Deaths related to puerperal infection are very rare in the industrialized world. It is estimated three in 100,000 births result in maternaldeathdue to infection. However, the death rate in developing nations may be 100 times higher.

Postpartumfevermay arise from several causes, not necessarily infection. Ifthe feveris related to infection, it often results from endometritis, an inflammation of the uterus. Urinary tract, breast, and wound infections are also possible, as well as septicthrombophlebitis, ablood clot-associated inflammation of veins. A woman's susceptibility to developing an infection is related to such factors as cesarean section, extended labor,obesity, anemia, and poor prenatalnutrition.Causes and symptomsThe primary symptom of puerperal infection is a fever at any point between birth and 10 days postpartum. A temperature of 100.4F (38C) on any two days during this period, or a fever of 101.6F (38.6C) in the first 24 hours postpartum, is cause for suspicion. An assortment of bacterial species may cause puerperal infection. Many of these bacteria are normally found in the mother's genital tract, but other bacteria may be introduced from the woman's intestine and skin or from a healthcare provider.

The associated symptoms depend on the site and nature of the infection. The most typical site of infection is the genital tract. Endometritis, which affects the uterus, is the most prominent of these infections. Endometritis is much more common if a small part of the placenta has been retained in the uterus. Typically, several species of bacteria are involved and may act synergisticallythat is, the bacteria's negative effects are multiplied rather than simply added together. Synergistic action by the bacteria can result in a stubborn infection such as anabscess. The majorsymptoms ofa genital tract infection include fever, malaise, abdominalpain, uterine tenderness, and abnormal vaginal discharge. If these symptoms do not respond to antibiotic therapy, an abscess or blood clot may be suspected.

Other causes of postpartum fever includeurinary tract infections, wound infections, septic thrombophlebitis, andmastitis. Mastitis, or breast infection, is indicated by fever, malaise, achy muscles, and reddened skin on the affected breast. It is usually caused by a clogged milk duct that becomes infected. Infections of the urinary tract are indicated by fever, frequent and painful urination,and back pain. Anepisiotomyand acesarean sectioncarry the risk of a wound infection. Such infections are suggested by a fever and pus-like discharge, inflammation, and swelling at wound sites.

DiagnosisFever is not an automatic indicator of puerperal infection. A new mother may have a fever owing to prior illness or an illness unconnected to childbirth. However, any fever within 10 days postpartum is aggressively investigated. Physical symptoms such as pain, malaise,loss of appetite, and others point to infection.

Many doctors initiate antibiotic therapy early in the fever period to stop an infection before it advances. A pelvic examination is done and samples are taken from the genital tract to identify the bacteria involved in the infection. The pelvic examination can reveal the extent of infection and possibly the cause. Blood samples may also be taken for blood counts and to test for the presence of infectious bacteria. Aurinalysismay also be ordered, especially if the symptoms are indicative of a urinarytract infection.

If the fever and other symptoms resist antibiotic therapy, an ultrasound examination orcomputed tomography scan(CT scan) is done to locate potential abscesses orblood clotsin the pelvic region.Magnetic resonance imaging(MRI) may be useful as well, in addition to a heparin challenge test if blood clots are suspected. If a lung infection is suspected, achest x raymay also be ordered.

TreatmentAntibiotic therapy is the backbone of puerperalinfection treatment. Initial antibiotic therapy may consist of clindamycin and gentamicin, which fight a broad array of bacteria types. If the fever and other symptoms do not respond to these antibiotics, a third, such as ampicillin, is added. Other antibiotics may be used depending on the identity of the infective bacteria and the possibility of an allergic reaction to certain antibiotics.

Postpartum Infectionhttp://emedicine.medscape.com/article/796892-overview

BackgroundPostpartum infections comprise a wide range of entities that can occur after vaginal and cesarean delivery or during breastfeeding. In addition to trauma sustained during the birth process or cesarean procedure, physiologicchanges during pregnancycontribute to the development of postpartum infections.[1]The typical pain that many women feel in the immediate postpartum period also makes it difficult to discern postpartum infection from postpartum pain.

Postpartum patients are frequently discharged within a couple days following delivery. The short period of observation may not afford enough time to exclude evidence of infection prior to discharge from the hospital. In one study, 94% of postpartum infection cases were diagnosed after discharge from the hospital.[2]Postpartum fever is defined as a temperature greater than 38.0C on any 2 of the first 10 days following delivery exclusive of the first 24 hours.[3]The presence of postpartum fever is generally accepted among clinicians as a sign of infection that must be determined and managed.

PathophysiologyLocal spread of colonized bacteria is the most common etiology for postpartum infection following vaginal delivery.Endometritisis the most common infection in the postpartum period. Other postpartum infections include (1) postsurgical wound infections, (2) perineal cellulitis, (3) mastitis, (4) respiratory complications from anesthesia, (5) retainedproducts of conception, (6)urinary tract infections(UTIs), and (7) septic pelvic phlebitis. Wound infection is more common withcesarean delivery.

EpidemiologyFrequencyUnited StatesOverall US rates for incidence and prevalence of postpartum infections is lacking. In a study by Yokoe et al in 2001, 5.5% of vaginal deliveries and 7.4% of cesarean deliveries resulted in a postpartum infection.[2]The overall postpartum infection rate was 6.0%. Endometritis accounted for nearly half of the infections in patients following cesarean delivery (3.4% of cesarean deliveries). Mastitis andurinary tract infectionstogether accounted for 5% of vaginal deliveries.[2]

Mortality/MorbidityIn most reviews, maternal death rates associated with infection range from 4-8%, or approximately 0.6 maternal deaths per 100,000 live births.A pregnancy-related mortality surveillance by theCenters for DiseaseControl and Prevention indicated infection accounted for about 11.6% of all deaths following pregnancy that resulted in a live birth, stillbirth, or ectopic.[4]

RaceThe risk of postpartum urinary tract infection is increased in the African American, Native American, and Hispanic populations.[5]

HistoryThe history and course of the delivery is important in the evaluation of postpartum patients. Ascertain if the delivery was vaginal or cesarean. Ascertain ifpremature rupture of the membranesoccurred. Determine if the patient had anyprenatal care. Determine if the patient was diagnosed or treated for any infectionsduring pregnancyor during the antepartum period. Assess the patient's symptoms. Features vary depending on the source of infection and may include the following: Flank pain, dysuria, and frequency of UTIs Erythema and drainage from the surgical incision or episiotomy site, in cases of postsurgical wound infections Respiratory symptoms, such as cough, pleuriticchest pain, or dyspnea, in cases of respiratory infection or septic pulmonary embolus Fever and chills Abdominal pain Foul-smelling lochia Breast engorgement in cases of mastitis

PhysicalFocus the physical examination on identifying the source of fever and infection. A complete physical examination, including pelvic and breast examinations, is necessary. Findings may include the following: Endometritis Endometritis may be characterized by lower abdominal tenderness on one or both sides of the abdomen, adnexal and parametrial tenderness elicited with bimanual examination, and temperature elevation (most commonly >38.3C). Some women have foul-smelling lochia without other evidence of infection. Some infections, most notably caused by group A beta-hemolytic streptococci, are frequently associated with scanty, odorless lochia. Wound infections Patients with wound infections, or episiotomy infections, have erythema, edema, tenderness out of proportion to expected postpartum pain, and discharge from the wound or episiotomy site. Drainage from wound site should be differentiated from normal postpartum lochia and foul-smelling lochia, which may be suggestive of endometritis. Mastitis: Patients with mastitis have very tender, engorged, erythematous breasts. Infection frequently is unilateral. Urinary tract infections: Patients with pyelonephritis or UTIs may have costovertebral angle tenderness, suprapubic tenderness, and an elevated temperature. Respiratorytract infections: Evaluate for tachypnea, rales, crackles, rhonchi,and consolidation. Septic pelvic thrombophlebitis: Patients with septic pelvic thrombophlebitis, although rare, may have palpable pelvic veins. These patients also have tachycardia that is out of proportion tothe fever.

CausesCauses and risk factors may include the following: Endometritis Route of delivery is the single most important factor in the development of endometritis.[6] The risk of endometritis increases dramatically after cesarean delivery.[6, 7] However, there is some evidence that hospital readmission for management of postpartum endometritis occurs more often in those who delivered vaginally.[7] Other risk factors include prolonged rupture of membranes, prolonged use of internal fetal monitoring, anemia, and lower socioeconomic status.[6] Perioperative antibiotics have greatly decreased the incidence of endometritis.[6] In most cases of endometritis, the bacteria responsible are those that normally reside in the bowel, vagina, perineum, and cervix. The uterine cavity is usually sterile until the rupture of the amniotic sac. As a consequence of labor, delivery, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus. Wound infections Most often, the etiologic organisms associated with perineal cellulitis and episiotomy site infections areStaphylococcusorStreptococcusspecies and gram-negative organisms, as in endometritis. Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet, infections develop in only 1% of patients who had vaginal tears or who underwent episiotomies. Those who underwent cesarean delivery have a higher readmission rate for wound infection and complications than those who delivered vaginally.[8] Genital tract infections Increased risk related to the duration of labor (ie prolonged labor increases risk of infection), use of internal monitoring devices, and number of vaginal examinations.[9] Genital tract infections are generally polymicrobial. Gram-positive cocci andBacteroidesandClostridiumspecies are the predominant anaerobic organisms involved.Escherichia coliand gram-positive cocci are commonly involved aerobes. Mastitis The most common organism reported in mastitis isStaphylococcus aureus. The organism usually comes from the breastfeeding infant's mouth or throat. Thrombosis Numerous factors cause pregnant and postpartum women to be more susceptible to thrombosis. Pregnancy is known to induce a hypercoagulable state secondary to increased levels of clotting factors. Also, venous stasis occurs in the pelvic veins during pregnancy. Although relatively rare, septic pelvic thrombosis is occasionally observed in the postpartum patient, who might have fever. Urinary tract infections Bacteria most frequently found in UTIs are normal bowel flora, includingE coliandKlebsiella,Proteus,andEnterobacterspecies. Any form of invasive manipulation of the urethra (eg, Foley catheterization) increases the likelihood of a UTI. General risk factors History of cesarean delivery Premature rupture of membranes Frequent cervical examination (Sterile gloves should be used in examinations. Other than a history of cesarean delivery, this risk factor is most important in postpartum infection.) Internal fetal monitoring Preexisting pelvic infection includingbacterial vaginosis Diabetes Nutritional status Obesity

Differential Diagnoses Appendicitis Breast abscess Cellulitis Deep vein thrombosis Pelvic Inflammatory Disease Pyelonephritis Tuboovarian Abscess Urinary Tract Infection, Female Vaginitis

Laboratory StudiesLaboratory studies are directed at elucidating the severity of illness as well as the etiology of the infection. Mild cases of mastitis usually do not require laboratory investigation. Wound infections and infections of the genital tract makes it more difficult to ascertain the extent of involvement. Laboratory studies should include the following: Complete blood count Electrolytes Blood cultures, if sepsis is suspected Urinalysis, with cultures and sensitivity tests Cervical or uterine cultures Wound cultures, if appropriate Lactate, if sepsis suspected Coagulation studies, if pelvic thrombosis,deep vein thrombosis, pulmonary embolism, or invasive treatment (eg, surgical procedure) is being considered

Imaging Studies Pelvic ultrasonography may be helpful in detecting retainedproducts of conception, pelvic abscess, or infected hematoma. Contrast-enhanced CT or MRI are useful in establishing the diagnosis of septic pelvic thrombosis.[10] In some cases, a contrast-enhanced CT examination of the abdomen and pelvis may be helpful if concurrent concern is present for other non-pregnancyrelated abdominal/pelvic sources of the infection (eg,appendicitis, colitis).

Prehospital CareThe most important aspect of prehospital care in a postpartum patient with a suspected infection is to ensure adequate fluid volume and to prevent sepsis and shock. Provide aggressive fluid management. Begin cardiac monitoring and administer oxygen.

Emergency Department CareED care is focused on identifying the source of the infection, followed by appropriate antimicrobial therapy and referral. Postpartum endometritis treatment In most cases, initial antimicrobial treatment is a combination of an aminoglycoside and clindamycin. Alternatively, an aminoglycoside plus metronidazole with or without ampicillin may also be used.[11] Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (eg, doxycycline, clindamycin). Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials. A review of trials for antibiotic regimens for the treatment of endometritis by French and Smaill in 2004 concluded that gentamicin in combination with clindamycin is appropriate for endometritis.[12] In general, the patient's condition rapidly improves after antibiotics are administered. Wound infection or episiotomy infection treatment Drainage, debridement, and irrigation may be required. Broad-spectrum antibiotics should be administered. Mastitis treatment Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or cloxacillin, or clindamycin in penicillin-allergic patients.[11] Use local measures, such asice packs, analgesics, and breast support.[11] The mother should be told to continue to breastfeed the baby. Continued breastfeeding prevents breast engorgement and subsequent pain. If abreast abscessis present, or breastfeeding is not possible, a breast pump should be used in lactating women.[11] Mastitis could lead to abscess formation, which may require surgical drainage. UTI treatment Administer fluids, if evidence of dehydration exists. Appropriate antibiotics should be used. These typically are trimethoprim-sulfamethoxazole, nitrofurantoin, ciprofloxacin, levofloxacin, or ofloxacin.[13, 14, 15] The above antibiotics (including fluoroquinolones) for UTI are considered safe by the AmericanAcademy of Pediatrics(AAP) for nursing infants, with no reported effects seen in infants who are breastfeeding.[13, 14] Although the AAP considers fluoroquinolones to be safe for breastfeeding mothers, they also recommend that the safest drug should be prescribed.[13]Fluoroquinolones are excreted in breast milk with unknown absorption by the infant. The potential for pediatric cartilage and joint damage were extrapolated from juvenile animal studies.[16, 17]For this reason, fluoroquinolones should not be first-line therapy and temporary discontinuation of breastfeeding should be considered.[16, 18] Trimethoprim-sulfamethoxazole and nitrofurantoin are to be avoided in mothers with breastfeeding infants with G-6-PD deficiency.[13, 14] When possible, the medication should be taken just after the patient has breastfed the infant to minimize drug exposure.[13] Fever and flank pain should raise suspicion for pyelonephritis, and inpatient hospital admission should be considered. Ampicillin and gentamicin may also be given to lactating mothers with no reported effects on breastfeeding infants.[13] Septic pelvic phlebitis treatment Broad-spectrum antibiotics should be administered. Initial choice of antibiotics should cover gram-positive, gram-negative, and anaerobic organisms. Ampicillin and gentamicin with metronidazole or clindamycin is a common regimen.[11, 10] Anticoagulation may be used, and it should be noted that there exist no universal guideline or recommendation for anticoagulation therapy in septic pelvic thrombosis. Initial bolus of 60 units/kg (4000 units maximum) followed by 12 units/kg/h (maximum of 1000 units/h) is recommended.[6]The aPTT is monitored for 2-3 times the normal value.[11, 10] Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg.[11, 10]

ConsultationsObstetric consultation must be obtained in cases of endometritis, postsurgical wound infections and cellulitis, retainedproducts of conception, and septic pelvic phlebitis. If an obstetrician/gynecologist is unavailable, seek consultation with a general surgeon.

Medication SummaryAntibiotics are the mainstay of treatment. Pain medications also are important, because patients often have discomfort. Patients withseptic pelvic thrombophlebitismust undergo anticoagulation therapy, and they should receive broad-spectrum antibiotics.

AntibioticsClass SummaryAntibiotic coverage forBacteroides,group B and A streptococci, Enterobacteriaceae organisms, andChlamydia trachomatisin endometritis is suggested. Wound and episiotomy site infections require broad-spectrum antibiotics as well, because of the polymicrobial nature of the local flora. Consider coverage primarily forStaphylococcus aureusinfection in postpartum mastitis.

CefoxitinSecond-generation cephalosporin indicated for gram-positive coccal and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin. Must be used with clindamycin or doxycycline and an aminoglycoside for the treatment of endometritis, for which it is adrug of choice. Particularly important in early postpartum (first 48 h) infections.

DoxycyclineInhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Must be used with other drugs for endometritis. Used often for outpatient therapy for late postpartum (48 h to 6 wk after delivery) treatment.

Gentamicin (Garamycin)Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used with an agent against gram-positive organisms in treatment of endometritis. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous and adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin may be given IV/IM.

ClindamycinInhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it binds preferentially to the 50S ribosomal subunit, causing bacterial growth inhibition. Must be used with other drugs in the treatment of endometritis. Second drug of choice, after dicloxacillin, in postpartum mastitis.

DicloxacillinBactericidal antibiotic that inhibitscell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. Primary drug of choice used for postpartum mastitis to coverS aureus.

MetronidazoleUsed with heparin and third-generation parenteral cephalosporin in the treatment of septic pelvic vein thrombophlebitis to cover streptococci andBacteroidesandEnterobacteriaceaespecies.

CephalexinFirst-generation cephalosporin used to coverS aureusin mastitis. Encourage the mother to continue breastfeeding to shorten duration of symptoms. Another DOC for postpartum mastitis

Further Inpatient CarePatients with early postpartum endometritis (especially after cesarean delivery) should be admitted, as should any patient with suspected septic pelvic vein thrombosis. Postsurgical wound infections may also require inpatient management, particularly if there is extensive involvement of surrounding soft tissues, intractable pain, and fever.

Further Outpatient CareAll patients with a postpartum infection should undergo follow-up with an obstetrician.

Complications Scarring Infertility Sepsis Septic shock DeathPrognosisThe prognosis for postpartum infections is good with prompt and appropriate therapy.

Patient EducationFor patient education resources, see thePregnancy and Reproduction Center, as well asPostpartum Perineal Care