Puerperal Infection

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Chapter 220 Puerperal Infection

INTRODUCTION

Description: Although the term puerperal infection can be used to describe any infection during or after labor, it generally applies to infection of the uterus and surrounding tissues after delivery. (See also Chorioamnionitis.) This can vary from mild to life-threatening in severity. Some of the most severe infections may appear within hours of delivery and are often opportunistic and not associated with reliable risk factors. Vigilance and aggressive diagnosis and treatment are required.
Prevalence: Estimated to occur in 1% to 8% of vaginal deliveries; approximately 15% if chorioamnionitis is present during labor. Following cesarean delivery: 10% to 20% if antibiotic prophylaxis is given during delivery, 50% to 90% without antibiotic prophylaxis in some series.
Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Colonization and infection of the tissues of the uterus, peritoneum, or surrounding organs. The most common organisms are group B streptococci; other facultative streptococci; Gardnerella vaginalis; and Escherichia coli, Bacteroides, and Peptostreptococcus species. Infection by clostridia or group A streptococci may result in rapidly progressive soft-tissue (subcutaneous tissue, muscle, or myometrial) infection. Abscesses usually contain both aerobic and anaerobic bacteria such as Bacteroides species (Bacteroides bivius, Bacteroides disiens, or Bacteroides fragilis). Approximately 50% of ascending uterine infections involve Chlamydia trachomatis.
Risk Factors: Cesarean delivery (10- to 20-fold increase), invasive procedures during labor, prolonged rupture of the membranes, prolonged labor, multiple examinations, retained placental fragments, urinary catheter, intravenous line(s), low socioeconomic or nutritional status, anemia, and chronic disease (diabetes).

CLINICAL CHARACTERISTICS

Signs and Symptoms

• Fever (90% >38.5°C by 24 hours) and tachycardia (often developing rapidly after delivery)
• Uterine tenderness (may be absent)
• Signs of septic or cardiovascular shock (hypotension, anxiety, disorientation, prostration)
• Impaired renal function (<20 mL/hour urine production)
• Altered white blood count (<1000 or ≥25,000)
• Hemolysis or hemoconcentration

DIAGNOSTIC APPROACH

Differential Diagnosis

• Urinary tract infections including pyelonephritis (5% of patients, classical signs are routinely absent, urinalysis shows large numbers of white blood cells, and cultures are positive)
• Wound infection
• Atelectasis or pneumonitis
• Infection in intravenous line or site, contaminated fluids
• Disturbed abscess (old tubo-ovarian or appendiceal abscess)
• Septic thrombophlebitis
• Necrotizing fasciitis
• Transfusion reaction (when applicable)
• Amniotic fluid or pulmonary embolism
• Cardiogenic shock (drugs, cardiac disease, aortic dissection)
• Toxic shock syndrome
• Mastitis (2% of patients)

Associated Conditions: Septic shock, adult respiratory distress syndrome, acute renal failure, and disseminated intravascular coagulation.

Workup and Evaluation

Laboratory: Complete blood count, endometrial culture obtained by protected swab (if amniotic fluid or endometrial culture obtained at the time of delivery [within 24 hours] is not available). Blood cultures (are positive in 15% to 25% of patients who are febrile but do not reflect the severity of the infection). Tissue culture (direct or by needle aspiration, when wound infections is suspected) and Gram stain.
Imaging: Ultrasonography may be useful in evaluating the possibility of pelvic abscess or gas formation. Computed tomography (CT) and magnetic resonance imaging (MRI) are useful for a more wide-ranging assessment.
Special Tests: Frozen-section histopathologic evaluation may be useful if necrotizing fasciitis is suspected.
Diagnostic Procedures: History, physical examination, cultures.

Pathologic Findings

Evidence of inflammation and/or necrosis (based on tissue involved and severity of infections).

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, fluid replacement or resuscitation, antipyretics and analgesics (after a diagnosis has been established). Close monitoring, including intensive care, may be required when infection is severe. Consultation with an infectious-disease specialist may be desirable. Low-grade (<38°C) or intermittent fevers may not require treatment when present in the first 24 hours.
Specific Measures: Aggressive antibiotic therapy. Based on response, removal of infected products (if present), surgical exploration, abscess drainage (percutaneous or open), debridement, or hysterectomy may be required. (Virtually all postpartum septic shock is caused by surgically treatable processes.) Because of the expanded blood and tissue volume at and after delivery, antibiotic dosages must be increased by 40% over those used outside of pregnancy.

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Diet: For patients who are acutely ill, nothing by mouth until condition is stabilized. For other patients, no specific dietary changes indicated.
Activity: Bed rest until patient’s condition is stable, then a progressive return to normal activity.
Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP006 (Cesarean Birth).

Drug(s) of Choice

Antibiotics should be administered to provide protection against gram-negative facultative and anaerobic bacteria. Moderate infections require double antibiotic treatment; severe infections should be treated with triple therapy: an aminoglycoside or first-generation cephalosporin (for facultative bacteria); clindamycin, imipenem-cilastatin, or metronidazole (anaerobic bacteria); and penicillin or ampicillin (clostridia and synergistic action with aminoglycosides on enterococci). β-Lactam antibiotics (penicillin or cephalosporin) should be given in dosages of 8 to 12 g/day.
Contraindications: See individual agents.
Precautions: Antibiotic dosages must be increased by up to 40% because of the altered physiologic state of pregnancy.
Interactions: See individual agents.

FOLLOW-UP

Patient Monitoring: When severe infections are present, intensive monitoring (including placement in an intensive care unit) may be required. This may include central venous access and monitoring, pulse oximetry, and careful (frequent if not continuous) blood pressure monitoring.
Prevention/Avoidance: Careful attention should be given to antisepsis, reduced numbers of vaginal examinations when the amniotic membranes have been ruptured, careful tissue handling during operative procedures, use of prophylactic antibiotics when risk factors are identified. Changing intravenous sites every 48 hours reduces the risk of infection. There is no evidence to support a role for vaginal antisepsis (chlorhexidine or similar) during labor or prior to cesarean delivery. There are insufficient data to evaluate the role of prophylactic antibiotics after manual removal of the placenta or operative delivery.
Possible Complications: Progression of infection, abscess formation, septic thrombophlebitis, septic shock, adult respiratory distress syndrome, renal failure, cardiovascular collapse, death. If septic shock occurs, mortality rates of 20% to 30% are common. Coagulopathy may develop. Necrotizing fasciitis is possible.
Expected Outcome: With timely diagnosis and appropriate therapy a complete recovery with no long-term sequelae should be expected. Approximately 90% of patients respond rapidly to antibiotic therapy (and/or percutaneous drainage of abscesses).

MISCELLANEOUS

ICD-9-CM Code: 670.0.

REFERENCES

Level I

Livingston JC, Llata E, Rinehart E, et al. Gentamicin and clindamycin therapy in postpartum endometritis: the efficacy of daily dosing versus dosing every 8 hours. Am J Obstet Gynecol. 2003;188:149.

Level II

Chongsomchai C, Lumbiganon P, Laopaiboon M. Prophylactic antibiotics for manual removal of retained placenta in vaginal birth. Cochrane Database Syst Rev. 2006. CD004904.

French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004. CD001067.

Hopkins L, Smaill F. Antibiotic regimens for management of intra-amniotic infection. Cochrane Database Syst Rev. 2002. CD003254.

Liabsuetrakul T, Choobun T, Peeyananjarassri K, Islam M. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2004. CD004455.

Lumbiganon P, Thinkhamrop J, Thinkhamrop B, Tolosa JE. Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV). Cochrane Database Syst Rev. 2004. CD004070.

Smaill F, Hofmeyr GJ. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev. 2002. CD000933.

Level III

American College of Obstetricians and Gynecologists. Prevention of early-onset group B streptococcal disease in newborns. ACOG Committee Opinion 279. Obstet Gynecol. 2002;100:1405.

American College of Obstetricians and Gynecologists. Prophylactic antibiotics in labor and delivery. ACOG Practice Bulletin 47. Obstet Gynecol. 2003;102:875.

American College of Obstetricians and Gynecologists. Premature rupture of membranes. ACOG Practice Bulletin 80. Obstet Gynecol. 2007;109:1007.

Casey BM, Cox SM. Chorioamnionitis and endometritis. Infect Dis Clin North Am. 1997;11:203.

Faro S. Postpartum endometritis. Clin Perinatol. 2005;32:803.

Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62:393.

Maharaj D. Puerperal pyrexia: a review. Part II. Obstet Gynecol Surv. 2007;62:400.

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