Postpartum 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, physiologic changes during pregnancy contribute 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.

Pathophysiology
Local spread of colonized bacteria is the most common etiology for postpartum infection following vaginal delivery. Endometritis is 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) retained products of conception, (6) urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is more common with cesarean delivery.

Frequency
United States

Overall 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 and urinary tract infections together accounted for 5% of vaginal deliveries.2

Mortality/Morbidity
In 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 the Centers for Disease Control and Prevention indicated infection accounted for about 11.6% of all deaths following pregnancy that resulted in a live birth, stillbirth, or ectopic.4

Race
The risk of postpartum urinary tract infection is increased in the African American, Native American, and Hispanic populations.5

Clinical
History
The history and course of the delivery is important in the evaluation of postpartum patients.

Ascertain if the delivery was vaginal or cesarean. Ascertain if premature rupture of the membranes occurred. Determine if the patient had any prenatal care. Determine if the patient was diagnosed or treated for any infections during pregnancy or during the antepartum period. Assess the patient's symptoms. Features vary depending on the source of infection and may include the following:

o o o o o o o

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, pleuritic chest 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

Physical
Focus 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 o 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). o 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 o 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. o Drainage from wound site should be differentiated from normal postpartum lochia and foulsmelling 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. Respiratory tract 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 to the fever.

Causes
Causes and risk factors may include the following:

Endometritis o Route of delivery is the single most important factor in the development of endometritis. 6 o The risk of endometritis increases dramatically after cesarean delivery.6,7 o However, there is some evidence that hospital readmission for management of postpartum endometritis occurs more often in those who delivered vaginally.7 o Other risk factors include prolonged rupture of membranes, prolonged use of internal fetal monitoring, anemia, and lower socioeconomic status.6 o Perioperative antibiotics have greatly decreased the incidence of endometritis. 6 o In most cases of endometritis, the bacteria responsible are those that normally reside in the bowel, vagina, perineum, and cervix. o 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 are Staphylococcus or Streptococcus species and gram-negative organisms, as in endometritis. o 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. o Those who underwent cesarean delivery have a higher readmission rate for wound infection and complications than those who delivered vaginally.8 Genital tract infections o 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 o Genital tract infections are generally polymicrobial. o Gram-positive cocci and Bacteroides and Clostridium species are the predominant anaerobic organisms involved. Escherichia coli and gram-positive cocci are commonly involved aerobes. Mastitis o The most common organism reported in mastitis is Staphylococcus aureus. o The organism usually comes from the breastfeeding infant's mouth or throat. o Thrombosis o 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. o Although relatively rare, septic pelvic thrombosis is occasionally observed in the postpartum patient, who might have fever. Urinary tract infections o Bacteria most frequently found in UTIs are normal bowel flora, including E coli and Klebsiella, Proteus, and Enterobacter species. o Any form of invasive manipulation of the urethra (eg, Foley catheterization) increases the likelihood of a UTI. General risk factors o History of cesarean delivery o Premature rupture of membranes o 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.) o Internal fetal monitoring o Preexisting pelvic infection including bacterial vaginosis o Diabetes o Nutritional status o Obesity

Laboratory Studies
Laboratory 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

Treatment

Prehospital Care
The 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 Care

ED care is focused on identifying the source of the infection, followed by appropriate antimicrobial therapy and referral.

Postpartum endometritis treatment o 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 o Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (eg, doxycycline, clindamycin). o Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials. o 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 o In general, the patient's condition rapidly improves after antibiotics are administered. Wound infection or episiotomy infection treatment o Drainage, debridement, and irrigation may be required. o Broad-spectrum antibiotics should be administered. Mastitis treatment o Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or cloxacillin, or clindamycin in penicillin-allergic patients.11 o Use local measures, such as ice packs, analgesics, and breast support. 11 o The mother should be told to continue to breastfeed the baby. o Continued breastfeeding prevents breast engorgement and subsequent pain. o If a breast abscess is present, or breastfeeding is not possible, a breast pump should be used in lactating women.11 o Mastitis could lead to abscess formation, which may require surgical drainage. UTI treatment o Administer fluids, if evidence of dehydration exists. o Appropriate antibiotics should be used. These typically are trimethoprim-sulfamethoxazole, nitrofurantoin, ciprofloxacin, levofloxacin, or ofloxacin.13,14,15 o The above antibiotics (including fluoroquinolones) for UTI are considered safe by the American Academy of Pediatrics (AAP) for nursing infants, with no reported effects seen in infants who are breastfeeding.13,14 o 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 o 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 o 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 o 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 o 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 o Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg.11,10

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

Medication
Antibiotics are the mainstay of treatment. Pain medications also are important, because patients often have discomfort. Patients with septic pelvic thrombophlebitis must undergo anticoagulation therapy, and they should receive broad-spectrum antibiotics.

Antibiotics
Antibiotic coverage for Bacteroides, group B and A streptococci, Enterobacteriaceae organisms, and Chlamydia trachomatis in endometritis is suggested. Wound and episiotomy site infections require broadspectrum antibiotics as well, because of the polymicrobial nature of the local flora. Consider coverage primarily for Staphylococcus aureus infection in postpartum mastitis. Treatment includes encouragement of fluid intake and
antibiotics aimed at Staphylococcus aureus, the most common causative pathogen. Examples are dicloxacillin SOME TRADE
NAMES DYCILL DYNAPEN PATHOCIL Click for Drug Monograph

500 mg po q 6 h for 7 to 10 days and, for women allergic to penicillin, erythromycin SOME TRADE NAMES
ERY-TAB ERYTHROCIN Click for Drug Monograph

250 mg po q 6 h. If women do not improve and do not have an abscess, vancomycin SOME TRADE NAMES
VANCOCIN Click for Drug Monograph

1 g IV q 12 h or cefotetan SOME TRADE NAMES

CEFOTAN Click for Drug Monograph

1 to 2 g IV q 12 h to cover resistant organisms should be considered. Breastfeeding should be continued during treatment because treatment includes emptying the affected breast. Breast abscesses are treated mainly with incision and drainage. Antibiotics aimed at S. aureus are often used.

It is not clear whether antibiotics aimed at methicillin-resistant S. aureus are necessary for treatment of mastitis or breast abscess.

Cefoxitin

Second-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 a drug of choice. Particularly important in early postpartum (first 48 h) infections.

Dosing Interactions Contraindications Precautions

Adult

2 g IV q6-8h
Pediatric

80-160 mg/kg/d IV divided q4-6h; higher doses for more severe infections; not to exceed 12 g/d

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

Doxycycline

Inhibits 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.

Dosing Interactions Contraindications Precautions

Adult

100 mg PO/IV q12h for 14 d

Pediatric

<8 years: Contraindicated >8 years: 2-5 mg/kg/d PO/IV qd or divided bid

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

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.

Dosing Interactions Contraindications

Precautions

Adult

1 mg/kg IV q12h
Pediatric

<5 years: Not established >5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

Clindamycin

Inhibits 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.

Dosing Interactions Contraindications Precautions

Adult

450-900 mg IV/IM q8h or 300 mg PO q6h

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid or 8-20 mg/kg/d PO as hydrochloride, with 8-25 mg/kg/d as palmitate divided tid/qid

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

Dicloxacillin

Bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinaseproducing staphylococci. Primary drug of choice used for postpartum mastitis to cover S aureus.

Dosing Interactions Contraindications Precautions

Adult

500 mg PO q6h
Pediatric

<40 kg: 12.5 mg/kg/d PO q6h >40 kg: 125 mg PO q6h

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

Metronidazole

Used with heparin and third-generation parenteral cephalosporin in the treatment of septic pelvic vein thrombophlebitis to cover streptococci and Bacteroides and Enterobacteriaceae species.

Dosing Interactions

Contraindications Precautions

Adult

500 mg PO/IV q6h

Pediatric

15-30 mg/kg/d PO/IV divided bid/tid for 7 d

DosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicationsPrecautionsDosingInteractionsContraindicati onsPrecautions

Cephalexin

First-generation cephalosporin used to cover S aureus in mastitis. Encourage the mother to continue breastfeeding to shorten duration of symptoms. Another DOC for postpartum mastitis.

Dosing Interactions Contraindications Precautions

Adult

500 mg PO qid for 10-14 d

Pediatric

Not established

Imaging Studies

Pelvic ultrasonography may be helpful in detecting retained products 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).