Postpartum Infection

Postpartum Infection is a topic covered in the 5-Minute Emergency Consult.

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Basics

Description

  • Postpartum endometritis (PPE):
    • Early PPE
      • Develops within 48 hr
      • Most often complicating C-section
      • Occurs in 1–3% of uncomplicated vaginal deliveries
      • Classic triad: Fever, lower abdominal pain with uterine tenderness, foul-smelling lochia
    • Late PPE:
      • Develops 3 d–6 wk after delivery
      • Usually follows vaginal delivery
      • Risk of PPE as high as 85–95% in high-risk nonelective C-section patient
  • Complications of PPE (all are more common after C-section):
    • Pelvic thrombophlebitis
    • Pelvic abscess
    • Bacteremia
  • Risk factors for PPE:
    • C-section
    • Prolonged labor
    • Prolonged rupture of membranes
    • Increased number of vaginal exams
    • Use of internal fetal monitoring
  • Septic pelvic thrombophlebitis is a diagnosis of exclusion with 2 distinct clinical presentations, either of which may present with postpartum pulmonary embolus:
    • Acute thrombosis:
      • Most common in right ovarian vein
      • Usually occurs in first 48 hr as acute, progressive lower abdominal pain
    • Enigmatic fever: “Picket fence” spiking fevers and tachycardia
  • Septic abortion:
    • Uncommon in developing countries
    • Usually an ascending infection through an open cervical os
    • Associated with:
      • Nonsterile techniques, instruments
      • Retained products of conception
  • Mastitis:
    • Ranges from mild breast redness to fever, systemic illness, and abscess
    • Common (1–30% of postpartum patients)
    • Occurs within 90 d postpartum
    • Peaks at 2–3 wk
    • Recurs in 4–8%
  • UTI/pyelonephritis:
    • Along with mastitis accounts for 80% of postpartum infections

Etiology

  • PPE: Polymicrobial infection result of ascending spread from lower genital tract:
    • Gram-positive aerobes:
      • Group A and B Streptococcus
      • Enterococcus spp
      • Gardnerella vaginalis
    • Gram-negative aerobes:
      • Escherichia coli
      • Enterobacter spp
    • Anaerobes:
      • Bacteroides spp
      • Peptostreptococcus spp
    • Other genital mycoplasmas common in late PPE:
      • Ureaplasma urealyticum
      • Mycoplasma hominids
      • Chlamydia trachomatis
  • Septic abortion: usually polymicrobial
    • E. coli
    • Bacteroides spp
    • Anaerobic gram-negative rods
    • Group B Streptococcus
    • Staphylococcus spp
    • Sexually transmitted organisms:
      • Neisseria gonorrhea
      • C. trachomatis
      • Trichomonas vaginalis
  • Mastitis
    • Staphylococcus epidermidis (most prevalent)
    • Staphylococcus aureus
    • Group A and B Streptococcus
    • E. coli
    • Bacteroides spp

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Basics

Description

  • Postpartum endometritis (PPE):
    • Early PPE
      • Develops within 48 hr
      • Most often complicating C-section
      • Occurs in 1–3% of uncomplicated vaginal deliveries
      • Classic triad: Fever, lower abdominal pain with uterine tenderness, foul-smelling lochia
    • Late PPE:
      • Develops 3 d–6 wk after delivery
      • Usually follows vaginal delivery
      • Risk of PPE as high as 85–95% in high-risk nonelective C-section patient
  • Complications of PPE (all are more common after C-section):
    • Pelvic thrombophlebitis
    • Pelvic abscess
    • Bacteremia
  • Risk factors for PPE:
    • C-section
    • Prolonged labor
    • Prolonged rupture of membranes
    • Increased number of vaginal exams
    • Use of internal fetal monitoring
  • Septic pelvic thrombophlebitis is a diagnosis of exclusion with 2 distinct clinical presentations, either of which may present with postpartum pulmonary embolus:
    • Acute thrombosis:
      • Most common in right ovarian vein
      • Usually occurs in first 48 hr as acute, progressive lower abdominal pain
    • Enigmatic fever: “Picket fence” spiking fevers and tachycardia
  • Septic abortion:
    • Uncommon in developing countries
    • Usually an ascending infection through an open cervical os
    • Associated with:
      • Nonsterile techniques, instruments
      • Retained products of conception
  • Mastitis:
    • Ranges from mild breast redness to fever, systemic illness, and abscess
    • Common (1–30% of postpartum patients)
    • Occurs within 90 d postpartum
    • Peaks at 2–3 wk
    • Recurs in 4–8%
  • UTI/pyelonephritis:
    • Along with mastitis accounts for 80% of postpartum infections

Etiology

  • PPE: Polymicrobial infection result of ascending spread from lower genital tract:
    • Gram-positive aerobes:
      • Group A and B Streptococcus
      • Enterococcus spp
      • Gardnerella vaginalis
    • Gram-negative aerobes:
      • Escherichia coli
      • Enterobacter spp
    • Anaerobes:
      • Bacteroides spp
      • Peptostreptococcus spp
    • Other genital mycoplasmas common in late PPE:
      • Ureaplasma urealyticum
      • Mycoplasma hominids
      • Chlamydia trachomatis
  • Septic abortion: usually polymicrobial
    • E. coli
    • Bacteroides spp
    • Anaerobic gram-negative rods
    • Group B Streptococcus
    • Staphylococcus spp
    • Sexually transmitted organisms:
      • Neisseria gonorrhea
      • C. trachomatis
      • Trichomonas vaginalis
  • Mastitis
    • Staphylococcus epidermidis (most prevalent)
    • Staphylococcus aureus
    • Group A and B Streptococcus
    • E. coli
    • Bacteroides spp

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