postpartum febrile morbidity - PowerPoint Presentation

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postpartum febrile morbidity

oral temperature of

≥38.0

degrees Celsius (≥100.4 degrees Fahrenheit) on

any 2 of the first 10 days

postpartum, exclusive of the first 24

hours.

The first 24 hours are excluded because low grade fever during this period is common and often resolves spontaneously, especially after vaginal

birth.

Differential diagnosis 

Surgical site

infection

Endomet

r

itis

Mastitis

or breast

abscess

Pyelonephritis

Aspiration pneumonia

Unexplained

fever (

neuraxial

anesthetic)

Appendicitis

V

iral syndrome

Pseudomembranous colitis

●Preterm birth

●Operative vaginal delivery

●Post term pregnancy

●HIV infection

●Colonization with group B streptococcus ●Nasal carriage of Staphylococcus aureus●Heavy vaginal colonization by Streptococcus agalactiae or Escherichia coli●Bacterial vaginosis●Maternal diabetes mellitus or severe anemia● Cesarean delivery (myometrial necrosis at the suture line, and formation of hematomas and seromas).●Chorioamnionitis●Prolonged labor●Prolonged rupture of membranes●Multiple cervical examinations●Internal fetal or uterine monitoring●Large amount of meconium in amniotic fluid●Manual removal of the placenta●Low socioeconomic status

RISK FACTORS

MICROBIOLOGY

Postpartum

endometritis

is typically a polymicrobial infectionMixture of two to three aerobes and anaerobes from the genital tract. This was illustrated in a study of 55 women with well-defined puerperal endometritis who had endometrial cultures obtained with a triple-lumen catheter to reduce the risk of contamination from organisms on the cervix. None of the women had received prophylactic antibiotics.

MICROBIOLOGY

More than one

organism

in 70

percent Bacteria and genital mycoplasmas in 61 percent Bacteria alone in 20 percentGenital mycoplasmas alone in 16 percentAnaerobes in 45 percent

MICROBIOLOGY

Neisseria

gonorrhoeae

and Chlamydia

trachomatis: Uncommon causes of postpartum endometritisCommon causes of endometritis unrelated to pregnancyGroup A streptococcus (GAS) infection : early-onset infection and high fever

CLINICAL FINDINGS 

Chills

Headache

MalaiseAnorexiaSoft and subinvoluted uterusExcessive uterine bleedingPostpartum feverTachycardia Rise in temperatureMidline lower abdominal painUterine tenderness Purulent lochia

White blood cell

count

Sonographic

findings

Endometritis with toxic shock syndrome

Group A streptococcus (GAS) (

eg

, Streptococcus

pyogenes): Early-onset infection and high fever, hypotension , involvement of at least two other organ systems (renal, liver, or pulmonary insufficiency; coagulopathy; soft tissue necrosis; erythematous macular rash with desquamation)Staphylococcus: fever >38.9ºC, hypotension, diffuse erythroderma, desquamation (unless the patient dies before desquamation can occur), involvement of at least three organ systems, Onset may be early (within 24 hours of delivery)Clostridium sordellii :sudden onset of clinical shock: progressive, refractory hypotension ,massive and generalized tissue edema, hemoconcentration, a marked leukemoid reaction (total neutrophil count 66,000 to 93,600/mm3), absence of rash or fever, limited or no myonecrosis, rapidly lethal course.

ESTABLISHING THE MICROBIOLOGIC CAUSE

Endometrial culture 

Cervical culture

Blood

culture (immunocompromised, septic, fails to respond to empiric therapy)In uncomplicated infections, it is not important to establish the microbiologic cause since empiric treatment with broad spectrum antibiotic is usually effective.

TREATMENT 

Initial drug

choice:

●

Clindamycin 900 mg every eight hours PLUS●Gentamicin 1.5 mg/kg every eight hours OR 5 mg/kg every 24 hours Renal insufficiency:Ampicillin-sulbactam 1.5 g every six hours orClindamycin and a second-generation cephalosporin.Metronidazole with ampicillin and gentamicin

colonization with GBS:

Addition

of

ampicillin to clindamycin plus gentamicin regimen or Ampicillin-sulbactamDuration : intravenous treatment until the patient is clinically improved (no fundal tenderness) and afebrile for at least 24 to 48 hours. Oral antibiotic therapy after successful parenteral treatment is not required

Oral and intramuscular regimens 

●

Clindamycin

600 mg orally every 6 hours plus

gentamicin 4.5 mg/kg intramuscularly every 24 hours OR●Amoxicillin-clavulanic acid 875 mg orally every 12 hours OR●Cefotetan 2 g intramuscularly every 8 hours OR●Meropenem or imipenem-cilastatin 500 mg intramuscularly every 8 hours OR●Amoxicillin 500 mg plus metronidazole 500 mg orally every 8 hours

Oral

antibiotic regimen is

administered for a

14 day courseIntramuscular antibiotic regimen : 48 to 72 hours of intramuscular therapy and then switch to an oral antibiotic to complete a seven day course

PREVENTION

Antibiotic prophylaxis at cesarean delivery 

Antibiotic prophylaxis for vaginal delivery 

Women with bacterial vaginosis 

Spontaneous placental extraction Topical antimicrobials Vaginal lavage with chlorhexidine