Fever During and After Childbirth

Fever During Pregnancy and Labor: Differential Diagnosis Cystitis Acute pyelonephritis Septic abortion Amnionitis Pneumonia Malaria Typhoid Hepatitis

Acute Pyelonephritis Treat, because of risks of  Preterm labor Sepsis Easy to treat Inexpensive

Management of Acute Pyelonephritis: 

If in shock or preterm labor, manage as indicated Check urine culture and sensitivity and give appropriate antibiotic If no culture available, give IV antibiotics until woman is fever-free for 48 hours: Ampicillin every 6 hours PLUS gentamicin daily Ensure adequate hydration by mouth or IV Give paracetamol by mouth for pain and to lower temperature

Acute Pyelonephritis: Subsequent Prophylaxis: 

Recurrence of acute pyelonephritis in the same gestation is reported to be 10–18% Suppressive therapy: 2.7% will get another urinary tract infection No suppressive therapy: 20–30% will get another urinary tract infection To prevent further infections, give antibiotics once daily at bedtime for remainder of pregnancy and 2 weeks postpartum: Trimethoprim/sulfamethoxazole Amoxicillin Sweet and Gibbs 1996; Duff 1996.

Septic Abortion:

Cause of 12.9% of maternal deaths Postabortion care has had tremendous impact on reducing mortality, particularly with use of manual vacuum aspiration

Management of Septic Abortion: 

Begin antibiotics as soon as possible before evacuation: Ampicillin every 6 hours PLUS gentamicin daily PLUS metronidazole every 8 hours Continue until fever-free for 48 hours Manual vacuum aspiration

Amnionitis: Antibiotics: 

Prompt intrapartum initiation (rather than delay until after delivery) of broad spectrum antibiotics results in: Less newborn bacteremia Less newborn pneumonia Reduced maternal febrile morbidity Shorter duration of hospitalization Treatment initiated intrapartum will not mask newborn infection Gibbs RS et al 1988.

Ampicillin and gentamicin Broad coverage for wide variety of organisms Crosses placenta and achieves adequate concentrations in the fetus Excellent activity against group B streptococci and E. coli – major causes of newborn sepsis Anaerobic coverage is not necessary (unless cesarean section performed) Hauth et al 1985.

Management of Amnionitis: 

Give combination of antibiotics until delivery: Ampicillin every 6 hours PLUS gentamicin daily If woman delivers vaginally, discontinue antibiotics postpartum If woman has cesarean section: Continue above antibiotics Add metronidazole every 8 hours Continue until fever-free for 48 hours ACOG 1998.

If cervix is favorable, induce labor with oxytocin If cervix is unfavorable, ripen with prostaglandins and infuse oxytocin or deliver by cesarean section

Aminoglycosides During Pregnancy: 

Objective and Design:

To evaluate teratogenic potential of aminoglycosides Methods: Selected cases of congenital anomalies from Hungarian congenital anomaly registry from 1980–1996 Gleaned exposure data from antenatal care records, medical documents, questionnaire to mother Czeizel et al 2000.

Results:

Fever During and After Childbirth Aminoglycosides During Pregnancy: Results No detectable teratogenesis from parenteral gentamicin, streptomycin, tobramycin or oral neomycin Czeizel et al 2000.

Fever after Childbirth: 

Differential Diagnosis:

Metritis Pelvic abscess Peritonitis Breast engorgement Mastitis Breast abscess Wound abscess, wound seroma or wound hematoma Wound cellulitis Cystitis Acute pyelonephritis Deep vein thrombosis Pneumonia Atelectasis Uncomplicated malaria Severe/complicated malaria Typhoid Hepatitis

Obstetric and Medical Factors Affecting Postpartum Sepsis:

Sepsis Intervention during labor and delivery Dangerous infections following prolonged and obstructed labor Thrombophlebitis, pulmonary embolism, coagulopathy and septic shock may complicate the infection Remember that clostridium infections may be difficult to detect and occur where contamination with earth or cow dung is possible Kwast 1991.

Health Service Factors Affecting Postpartum Sepsis: 

Majority of deaths occur between first and second week of puerperium and are linked to medical and midwifery/nursing staff factors: Inadequate: monitoring of temperature bacteriological investigations treatment with antibiotics or operative intervention Lack of: asepsis and antisepsis blood for transfusion appropriate drugs Kwast 1991.

Fever After Childbirth: 

General Management:

Encourage bedrest Ensure adequate hydration by mouth or IV Decrease temperature with fan or tepid sponging If shock suspected, begin treatment immediately

Management of Metritis: 

Start antibiotics: Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours Assess if retained placental fragments All the while: Give fluids Transfuse blood as needed Give pain medication Continue close monitoring Watch for shock Watch for development of abscess

Antibiotics for Metritis: 

IV antibiotics: Ampicillin every 6 hours Gentamicin every 24 hours Metronidazole every 8 hours Continue until fever-free for 48 hours No oral antibiotics after treatment: Not proven to add any benefit Only add to expense

Managing Metritis:

Objective and Design:

To assess the effects of different regimens and their complications in the treatment of endometritis. Methods: 41 randomized controlled trials Outcomes: duration of fever, treatment failure, other complication (infectious), drug reaction, costs French and Smaill 2000.

Results:

More treatment failure with regimens other than clindamycin and an aminoglycoside RR 1.37 (1.10–1.70) Three studies looked at once-daily gentamicin vs. three-times daily: no difference in failure rates, but a trend toward fewer failures with once-daily dosing RR 0.60 (0.30–1.20) No difference in nephrotoxicity, lower cost French and Smaill 2000.

Septic Shock: 

IV antibiotics for sick patients Antibiotics for Gram + (penicillin, ampicillin) Gram - (gentamicin), and Anaerobes (metronidazole) Adequate doses of antibiotics are necessary Aggressive fluid resuscitation (2–3 liters to start) Look for abscess, peritonitis or other condition requiring surgery IV antibiotics may be necessary for longer if bacteremia

Prevention Strategies: 

Infection prevention practices for every delivery: Minimum manipulation High-level disinfected or sterile gloves for examination Avoid unnecessary procedures (e.g., episiotomy) Three Cleans: Clean hands Clean surface Clean blade Plus: Clean tie Clean perineum Clean nails.

by

Akshaya Srikanth

Pharm.D Intern

Hyderabad, India