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A15. Puerperal fever and sepsis

Puerperal fever (postpartum fever or childbed fever) refers to fever which occurs within the first 10 days postpartum. In most cases, fever is due to endometritis, but it can also be due to other causes. It’s most commonly seen after C-section but may occur following vaginal birth as well.

Most cases are mild and resolve quickly with antibiotics. Fever in the first day is especially common and often resolves spontaneously. However, some cases are severe and may cause sepsis.

Probably relevant to know is the history of Semmelweis, who discovered that handwashing with chlorinated lime between handling cadavers and assisting births significantly decreased the incidence of puerperal fever.

Etiology

  • Endometritis (most common)
  • Urinary tract infection
  • Surgical site infection (following C-section, episiotomy, rupture repair, etc.)
  • Mastitis
  • Septic pelvic thrombophlebitis

The following are risk factors for postpartum endometritis:

  • C-section
  • Retention of foetoplacental tissue
  • Bacterial vaginosis
  • Multiple vaginal examinations

Postpartum endometritis is often polymicrobial (from cervicovaginal flora).

Clinical features

The typical clinical features of postpartum endometritis (aside from fever) are uterine tenderness, tachycardia, midline lower abdominal pain, and purulent or foul-smelling discharge from the uterus.

Diagnosis and evaluation

Diagnosis is based on clinical features. In case sepsis is suspected, blood cultures should be taken. Ultrasound can determine whether there are retention products in the uterus. Gram stain and culture of the vaginal discharge can be used to guide antibiotic therapy.

Treatment

The treatment of postpartum endometritis is antibiotics, in Norway penicillin + clindamycin IV, however this varies from country to country. If retention products remain in the uterus, they should be removed by curettage.

Prevention

Routine antibiotic prophylaxis before C-section reduces the risk of postpartum fever. Bacterial vaginosis in pregnancy should also be treated.