Key Clinical Questions
What are the common causes of postpartum fever?
What antibiotics are recommended for common postpartum infections?
What is the differential diagnosis for a postpartum headache?
When does a postpartum headache require radiologic imaging?
What are the common postpartum neuropathies?
The postpartum period, lasting 6 months, is a unique time during which there is a physiological return to the prepregnancy state. Night sweats, mood disturbance, urinary frequency, perineal and vaginal discomfort, and breast engorgement are all common complaints from postpartum women. Clinicians treating postpartum patients in the hospital setting must be able to differentiate these normal changes from disease states.
EPIDEMIOLOGY AND RISK STRATIFICATION
Low-grade fever frequently occurs in the first 24 hours after delivery. Postpartum fever is defined as a temperature of ≥ 38.0°C (100.4°F) on any two of the first 10 days postpartum exclusive of the first 24 hours. Infection is the leading cause of postpartum fever in the United States; the overall postpartum infection rate is around 6%, with the incidence in planned cesarean deliveries up to 10%, and higher in unplanned deliveries. Endometritis is the most common infection in the postpartum period, followed by urinary tract infection, lower genital tract infection, wound infection, pulmonary infection, thrombophlebitis, cholecystitis, and breast infections. Mastitis and abscess are rare in women who do not breastfeed but occur in 2% to 3% of breastfeeding women. A recent pregnancy also increases the risk for pneumonia, appendicitis, and cholecystitis.
EVALUATION AND INPATIENT MANAGEMENT
Postpartum endometritis is typically a polymicrobial infection with lower genital tract flora infecting the upper genital tract. The prevalence of endometritis has been greatly reduced with the standard use of antibiotic prophylaxis with cesarean deliveries. The risk of endometritis is increased by various factors listed in Table 222-1.
TABLE 222-1Risk Factors of Endometritis |Favorite Table|Download (.pdf) TABLE 222-1 Risk Factors of Endometritis
Prolonged rupture of membranes
Multiple vaginal examinations
Operative vaginal delivery
Cesarean section (especially nonelective)
Antepartum isolation of group B streptococci, Chlamydia, or mycoplasma
The criteria for diagnosis of endometritis include fever and uterine tenderness. Other signs and symptoms include foul lochia and chills. The postpartum uterus should be firm, nontender, and below the umbilicus; with endometritis a soft, subinvoluted uterus may lead to excessive vaginal bleeding.
When endometritis is suspected, laboratory or imaging data are rarely needed before initiating treatment. If despite treatment, a patient has persistent fever or unusually severe or localized pain, further studies may be helpful. A white blood cell with differential, blood cultures (which are positive in 10%-20% of patients), and endometrial cultures may be diagnostic and can help direct antimicrobial therapy. Endometrial cultures should be acquired with a double or ...