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Puerperal infection is a general term used to describe any bacterial infection of the genital tract after delivery. The earliest reference to puerperal infection is found in the works of Hippocrates from the 5th century bc, De Mulierum Morbis. He attributed the condition to retention of bowel contents. The history of puerperal infection is discussed in greater detail in previous editions of Williams Obstetrics.

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Along with preeclampsia and obstetrical hemorrhage, puerperal infection formed the lethal triad of causes of maternal deaths for many decades of the 20th century. Fortunately, because of effective antimicrobials, maternal deaths from infection have become uncommon. Berg and associates (2003) reported results from the Pregnancy Mortality Surveillance System, which contained 3201 maternal deaths in the United States from 1991 through 1997. Infection caused 13 percent of pregnancy-related deaths and was the fifth leading cause of death. In a similar analysis of the North Carolina population from 1991 through 1999, Berg and colleagues (2005) reported that 40 percent of infection-related maternal deaths were preventable.

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A number of factors can cause fever—a temperature of 38.0°C (100.4°F) or higher—in the puerperium. Most persistent fevers after childbirth are caused by genital tract infection. Filker and Monif (1979) reported that only about 20 percent of women febrile within the first 24 hours after giving birth vaginally were subsequently diagnosed with pelvic infection. This was in contrast to 70 percent of those undergoing cesarean delivery. It must be emphasized that spiking fevers of 39°C or higher that develop within the first 24 hours postpartum may be associated with virulent pelvic infection caused by group A streptococcus. Other common causes of puerperal fever are breast engorgement and pyelonephritis or occasionally respiratory complications after cesarean delivery (Maharaj, 2007).

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About 15 percent of women who do not breast feed develop postpartum fever from breast engorgement. This figure is lower in breast-feeding women (see Chap. 30, Breast Engorgement). Attributable fever rarely exceeds 39°C in the first few postpartum days and usually lasts less than 24 hours. Acute pyelonephritis has a variable clinical picture, and postpartum, the first sign of renal infection may be fever, followed later by costovertebral angle tenderness, nausea, and vomiting. Atelectasis is caused by hypoventilation and is best prevented by coughing and deep breathing on a fixed schedule following surgery. Fever associated with atelectasis is thought to follow infection by normal flora that proliferate distal to obstructing mucous plugs. Minor temperature elevations in the puerperium may also occasionally be caused by superficial or deep-venous thrombosis of the legs.

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Postpartum uterine infection has been called variously endometritis, endomyometritis, and endoparametritis. Because infection involves not only the decidua but also the myometrium and parametrial tissues, we prefer the inclusive term metritis with pelvic cellulitis.

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Predisposing Factors

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The route of delivery is the single most significant risk factor for the development of uterine ...

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