Puerperal fever

Definition

The term puerperal infection refers to a bacterial infection following childbirth. 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, or sepsis, is a rare, but potentially fatal complication.

Description

Puerperal infection affects an estimated 1-8% of new mothers in the United States. Given modern medical treatment and antibiotics, 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 5-10 times that high.

Deaths related to puerperal infection are very rare in the industrialized world. It is estimated 3 in 100,000 births result in maternal death due to infection. However, the death rate in developing nations may be 100 times higher.

Postpartum fever may arise from several causes, not necessarily infection. If the fever is 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 septic thrombophlebitis, a blood 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 prenatal nutrition.

Causes & symptoms

The primary symptom of puerperal infection is a fever at any point between birth and 10 days postpartum. A temperature of 100.4°F (38°C) on any two days during this period, or a fever of 101.6°F (38.6 °C) 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 synergistically--that 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 an abscess. The major symptoms of a genital tract infection include fever, malaise, abdominal pain, 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 include urinary tract infections, wound infections, septic thrombophlebitis, and mastitis. 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. An episiotomy and a cesarean section carry the risk of a wound infection. Such infections are suggested by a fever and pus-like discharge, inflammation, and swelling at wound sites.

Diagnosis

Fever 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. A urinalysis may also be ordered, especially if the symptoms are indicative of a urinary tract infection.

If the fever and other symptoms resist antibiotic therapy, an ultrasound examination or computed tomography scan (CT scan) is done to locate potential abscesses or blood clots in 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, a chest x ray may also be ordered.

Treatment

Antibiotic therapy is the backbone of puerperal infection 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.

Antibiotics taken together are effective against a wide range of bacteria, but may not be capable of clearing up the infection alone, especially if an abscess or blood clot is present. Heparin is combined with the antibiotic therapy in order to break apart blood clots. Heparin is used for 5-7 days, and may be followed by warfarin for the following month. If the infection is complicated, it may be necessary to surgically drain the infected site. Infected episiotomies can be opened and allowed to drain, but abscesses and blood clots may require surgery.

Prognosis

Antibiotic therapy and other treatment measures are virtually always successful in curing puerperal infections.

Prevention

Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. With some procedures, such as cesarean section, a doctor may administer prophylactic antibiotics as a preemptive strike against infectious bacteria.

Key Terms

Abscess

A pus-filled area with definite borders.

Blood clot

A dense mat formed by certain components of the blood stream to prevent blood loss.

Cesarean section

Incision through the abdomen and uterus to facilitate delivery.

Computed tomography scan (CT scan)

Cross-sectional x- rays of the body are compiled to create a three-dimensional image of the body's internal structures.

Episiotomy

Incision of the vulva (external female genitalia) during vaginal delivery to prevent tissue tearing.

Heparin

A blood component that controls the amount of clotting. It can be used as a drug to reduce blood clot formation.

Heparin challenge test

A medical test to evaluate how readily the blood clots.

Magnetic resonance imaging (MRI)

An imaging technique that uses a large circular magnet and radio waves to generate signals from atoms in the body. These signals are used to construct images of internal structures.

Postpartum

Referring to the time period following childbirth.

Prophylactic

Measures taken to prevent disease.

Sepsis

The presence of viable bacteria in the blood or body tissues.

Septic

Referring to the presence of infection.

Thrombophlebitis

An inflammation of veins accompanied by the formation of blood clots.

Ultrasound examination

A medical test in which high frequency sound waves are directed at a particular internal area of the body. As the sound waves are reflected by internal structures, a computer uses the data to construct an image of the structures.

Warfarin

A drug that reduces the ability of the blood to clot.

Further Reading

For Your Information

Books

• Charles, Jonathan, and David Charles. "Postpartum Infection." In Obstetric and Perinatal Infections, edited by David Charles. St. Louis: Mosby-Year Book, Inc., 1993.
• Rivlin, Michel E. "Puerperal Infections." In Manual of Clinical Problems in Obstetrics and Gynecology, 4th edition. Edited by Michel E. Rivlin and Rick W. Martin. Boston: Little, Brown and Company, 1994.

  Periodicals

• Hamadeh, Ghassan, Cindy Dedmon, and Paul D. Mozley. "Postpartum Fever." American Family Physician 52 no. 2 (August 1995): 531.

Gale Encyclopedia of Medicine. Gale Research, 1999.