Postpartum Fever

Postpartum Pyrexia

Presented by: Abduelah Almarzooq, Faisal Alkharji, Abdulmohsen Alhussain, Nawaf Alsaggaf. Supervised by: DR. Mona Ahmed

OVERVIEW

• Define postpartum pyrexia
• Identify the risk factors
• Conduct a detailed history and physical examination
• Formulate a differential diagnosis
• Plan appropriate investigations
• Propose a management plan
• Reference

Definition

Postpartum pyrexia is defined as a maternal temperature greater than 38.0 °C (100.4 °F) occurring on any two of the first ten days following delivery, excluding the first 24 hours postpartum.

Risk Factors

• Caesarean section (C-section).
• Premature rupture of membranes (PROM).
• Multiple vaginal examinations during labor.
• Manual removal of the placenta.
• Prolonged labor.
• Other contributors:
  • Urinary tract infections.
  • Surgical incision infections.

History & Physical Examination

History:

• Onset, duration, and pattern of fever.
• Associated symptoms: foul-smelling lochia, pelvic pain, dysuria, breast pain, wound discharge.
• Obstetric history (delivery type, complications).

Examination:

• Vital signs.
• Uterus: tenderness, subinvolution, abnormal lochia.
• Perineum/cesarean wound: erythema, discharge.
• Breasts: engorgement, mastitis, abscess.
• Urinary system: suprapubic tenderness.

Differential Diagnosis

The 7 Ws of Postpartum Pyrexia

Womb, Wound, Water

1. Womb (Endomyometritis)

   • What: Most common cause; a uterine infection, esp. post C-section.
   • When: Days 3-7.
   • Signs: Uterine tenderness, foul-smelling lochia. An early, high fever can be a red flag.

2. Wound (Infection)

   • What: Infection at a C-section, episiotomy, or laceration site.
   • When: Days 4-7.
   • Signs: Localized redness, warmth, purulent drainage.

3. Water (UTI)

   • What: Urinary tract infection, often from catheterization.
   • When: Days 1-3.
   • Signs: Painful urination, frequency. Flank pain suggests kidney infection.

Weaning & Wind

4. Weaning (Mastitis/Engorgement)

   • What: Breast issues from milk stasis.
   • Engorgement (Days 2-3): Low-grade fever.
   • Infectious Mastitis (After Day 7): High fever, chills, and a tender, red wedge on one breast.

5. Wind (Pulmonary Issues)

   • What: Atelectasis (collapsed lung) or pneumonia, esp. after general anesthesia.
   • When: First 72 hours.
   • Signs: Cough and shortness of breath.

Walking & Wonder Drugs

6. Walking (Thromboembolism)

   • What: Blood clots; a serious postpartum concern.
   • DVT (Days 5-10): Unilateral leg pain and swelling.
   • Septic Pelvic Thrombophlebitis: Rare; fever persists despite antibiotics.

7. Wonder Drugs (Drug Fever)

   • What: A diagnosis of exclusion from a medication reaction.
   • When: About a week after starting a new drug.
   • Signs: Fever resolves when the drug is stopped.

Other Considerations

• Viral Infections: Common illnesses (e.g., influenza, gastroenteritis).
• Malaria: Crucial with travel history to endemic areas.
• Rare Conditions: Such as a thyroid storm.

Investigations

• CBC
• ESR/CRP
• Blood cultures
• Urinalysis and urine culture
• High vaginal swab and endocervical swab
• Pelvic ultrasound (to rule out retained products or abscess)

Management

1. General Measures

• Stabilize (ABCs, IV access, fluids if unstable).
• Antipyretics (e.g., paracetamol).
• Adequate hydration.
• Encourage early ambulation.
• Continue breastfeeding unless contraindicated.

2. Antibiotics

• Endometritis (most common):
  • IV Clindamycin + Gentamicin until afebrile 24–48h, Add Ampicillin if Enterococcus suspected.
• Wound infection:
  • IV broad-spectrum
    • (Co-amoxiclav or Cefazolin + Metronidazole).
• UTI:
  • IV Ceftriaxone
• Mastitis/Breast abscess:
  • Oral Dicloxacillin/Flucloxacillin

3. Source control

• Drain abscesses (breast, wound).
• Debride necrotic/infected tissue.

4. Monitoring & Follow-Up

• Monitor vitals, urine output, and labs.
• Tailor antibiotics once cultures return.

REFERENCE

• AMBOSS
• Hacker & Moore’s ESSENTIALS OF OBSTETRICS & GYNECOLOGY