FEVER AFTER LABOR

1. FEVER AFTER LABOR Dianne MP Graham, MD, CCFP Kelowna, BC, Canada Based on WHO Document on Managing Complications In Pregnancy, 2000

2. WHAT ARE THE CAUSES OF POSTPARTUM FEVER & SEPSIS? • Endometritis, Pelvic Abscess, Peritonitis • Breast engorgement, Mastitis & Breast Abscess • Wound cellulitis, Wound Hematoma, Wound Abscess • Cystitis and Acute Pyelonephritis • Deep Vein Thrombosis • Pneumonia & Atelectasis • Uncomplicated & Severe Complicated Malaria • Typhoid & Hepatitis

3. ENDOMETRITIS • Endometritis is infection of the uterus after delivery and is a major cause of maternal death • Multiple factors contribute to this including poor sterile technique, excessive internal exams, prolonged labors • Delayed or inadequate treatment can lead to pelvic abscess, peritonitis, septic shock, deep vein thrombosis, pulmonary embolism, chronic pelvic infection with pain and or infertility

4. ENDOMETRITIS • Signs: Fever/chills, lower abdominal pain, purulent/foul smelling lochia, tender uterus • Less Frequent Signs: Increased bleeding & shock • Treatment: -Give a combination of drugs until patient is fever free for 48 hours: • -ampicillin 2 gm IV every 6 hours • -PLUS gentamycin 5 mg/kg body wt every 24 hr • -PLUS metronidazole 500 mg IV every 8 hours

5. ENDOMETRITIS TREATMENT • If fever continues 72 hours after starting antibiotics re-evaluate and revise diagnosis • Possible complications include pelvic abscess or peritonitis which may need further intervention • NOTE: Oral antibiotics are NOT necessary after stopping IV antibiotics

6. BREAST INFECTIONS • SIGNS: - breast pain and tenderness with onset often 3 to 4 weeks after delivery • -reddened, wedge-shaped area on breast • -usually only one breast involved • -fever often rapid onset and high >38.5 • TREATMEMT: cloxacillin 500 mg orally four times daily for ten days OR erythromycin 250 mg three times a day for ten days

7. MASTITIS • continue breast feeding • support breasts with binder or brassiere • apply cold compresses to breasts between feeds • give paracetamol 500 mg by mouth as needed • NOTE: Follow patient up in 3 days to ensure response

8. INFECTION OF PERINEAL AND ABDOMENAL WOUNDS • If there is pus or fluid open and drain the wound • Remove infected skin or subcutaneous sutures & debride the wound. Do not remove fascia sutures. • If there is an abscess without cellulitis antibiotics are not needed • Place a damp dressing in the wound & have the woman return to change dressing every 24 hours • Woman needs to maintain good hygiene & wear clean pads or cloths that she changes often

9. WOUND CELLULITIS • If there is fluid or pus open & drain the wound • Remove infected skin or subcutaneous sutures & debride the wound. Do not remove fascia sutures • If infection is superficial and does not involve deep tissues monitor for development of an abscess and give • - ampicillin 500 mg po QID for five days • - PLUS metronidazole 400 mg 3x daily for 5 days

10. SEVERE DEEP WOUND INFECTIONS OR NECROTIZING FASCIITIS • Always involves muscles and is causing necrosis • If not properly treated usually leads to fistulas with bladder, bowel or abdomen • Necrotizing fasciitis requires wide surgical debridement • If woman has necrotizing fasciitis admit to hospital for management and change dressings twice daily

11. MEDICAL TREATMENT OF NECROTIZING FASCIITIS OF WOUNDS • Give in combination with debriding necrotic tissue until patient is fever free for 48 hours: • - penicillin G 2 million units IV every 6 hours • - PLUS gentamicin 5 mg/kg body weight IV every 24 hours • - PLUS metronidazole 500 mg IV every 8 hours

12. NECROTIZING FASCIITIS TREATMENT • ONCE WOMAN IS FEVER FREE FOR 48 HOURS give: • ampicillin 500 mg by mouth four times daily for five days • PLUS metronidazole 400 mg by mouth three times per day for five days

13. ACUTE PYELONEPHRITIS • Is an infection of the upper urinary tract • Common signs: Dysuria, spiking fever/chills, increased urinary frequency & urgency of urination, abdominal pain • Less common signs: retro pubic/suprapubic pain, loin pain/tenderness, loss of appetite, nausea/vomiting

14. TREATMENT OF ACUTE PYELONEPHRITIS • Start IV fluids at 150 ml per hour • If available get urine and blood cultures first . If not treat with IV antibiotics until patient is fever free 48 hours • ampicillin 2 gm IV every 6 hours • PLUS gentamycin 5 mg/kg patient weight IV every 24 hours • Once patient is afebrile 48 hours give amoxicillin by mouth 1 gm 3X daily for 14 days

15. Pneumonia • Pneumonia is a radiological diagnosis. Suspect it and get a chest x-ray if possible for any unexplained fever. • Common signs: fever, difficulty breathing, cough with expectoration, chest pain, consolidation, rapid breathing, rhonchi/rales, throat congestion • Give erythromycin 500 mg 3X daily for seven days • Ampicillin 1 gm 3X daily for seven days is an alternative

16. UNCOMPLICATED MALARIA • Plasmodium falciparum and P. vivax cause the majority of diseases • Plasmodium falciparum in pregnant/post-partum women can cause severe disease and death if not recognized and treated early • Malaria should be considered the most likely diagnosis in a pregnant woman with fever who has been exposed to malaria • Confirm diagnosis with thin and thick slides or rapid antigen tests

17. SIGNS OF UNCOMPLICATED MALARIA • Fever • Chills/rigors • Headache • Muscle/joint pain • Enlarged spleen