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Postpartum pyrexia
CASE-BASED LEARNING
Postpartum pyrexia
widespread practice, but it was only when antibiotics became widely available in the 1940’s that the mortality from genital tract sepsis began to decline rapidly. In the triennium 2006e2008, genital tract sepsis was, for the first time since the UK Confidential Enquiries into Maternal Deaths began in 1952, the commonest cause of Direct maternal death in the United Kingdom (Table 1). This is partly due to decreases in the numbers of deaths from other Direct causes, particularly thrombo-embolism, and partly due to a genuine rise in the number of deaths from sepsis, particularly sepsis due to Group A streptococcal infection. In 2006e2008, there were 26 Direct maternal deaths from genital tract sepsis; another three women died later but had developed sepsis around the time of delivery. Worldwide, puerperal sepsis remains a major cause of maternal mortality and is estimated to account for approximately 15% of all direct maternal deaths. Postpartum infections are also an important cause of maternal morbidity. The incidence of severe infections and ‘near miss’ events is much higher than the number of deaths, although accurate figures are hard to find because of the variety of definitions used and the difficulty of obtaining data from the community as many postpartum infections occur after discharge from hospital. The global incidence of puerperal sepsis is estimated to be 4.4% of live births. The Scottish Confidential Audit of Severe Maternal Morbidity showed a 0.11 per 1000 births rate of septicaemic shock in the triennium 2006e2008. The 2011 NICE Guideline on Caesarean Section (CS) recommends routine antibiotic prophylaxis to reduce the incidence of infections such as endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a caesarean section. A 2 year study of severe maternal sepsis in the UK was initiated by UKOSS in June 2011.
Kevin G Glackin Margaret Ann Harper
Abstract Postpartum pyrexia is a common condition that is sometimes associated with serious maternal morbidity and occasional mortality. Most cases are due to underlying genital tract infection, but there are a wide variety of other possible causes that may not always be clinically obvious. A comprehensive history and physical examination should always be carried out. Initial investigation should focus on thorough assessment of the genital tract, including swabs and ultrasound examination. However, a wide range of further investigations may be needed to determine the cause of the pyrexia. Use of an early warning chart for observations is important to detect early changes in a patient’s condition. Serious infection can develop insidiously and patients can deteriorate very rapidly, so immediate high dose broad-spectrum intravenous antibiotic treatment without waiting for microbiology results can be lifesaving. Early recognition, consultant involvement, appropriate investigation and prompt treatment are keys to successful management.
Keywords Group A Streptococcus; postpartum infection; postpartum pyrexia; puerperal infection; puerperal sepsis; Streptococcus pyogenes
Introduction Postpartum pyrexia is common and is usually due to bacterial infection of the breast, urinary or genital tracts. Although most cases are easily treated with routine management including antibiotics, serious maternal morbidity and occasional mortality can occur. Postpartum or puerperal pyrexia are general terms and exact definitions vary (Box 1). A temperature rise above 38 C (100.4 F) maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion is often used (ICD-10).
Aetiology Postpartum pyrexia may have a wide variety of underlying causes. These may be broadly divided into those directly related to pregnancy e.g. breast or uterine infection (Box 2), and coincidental causes unrelated to pregnancy e.g. malaria (Box 3). The cause of the raised temperature is usually easily discovered, but can be elusive. The potential consequences of persistent or relapsing maternal infection are serious so the search for a cause must be pursued vigorously and prompt effective treatment given. Most cases of postpartum pyrexia are related to the recent pregnancy and labour. After delivery, the placental bed, caesarean section and episiotomy wounds, cervical and vaginal lacerations are all susceptible to bacterial infection. Organisms may be acquired by contamination from an external source or endogenously from the woman’s own genital tract. Prolonged rupture of membranes, prolonged labour, operative vaginal delivery, caesarean section, pre-existing vaginal infection or history of Group B streptococcal (GBS) infection, postpartum haemorrhage, wound haematoma, retained pieces of placenta, membranes or intrauterine clot, or retained swabs all increase the risk of postpartum infection. Pregnancy itself affects the immune system, and conditions such as anaemia, impaired glucose tolerance or diabetes mellitus reduce resistance to infection. Obesity, an increasing problem in the developed world, is a risk factor for sepsis, as is multiparity.
Incidence Maternal mortality is the most serious outcome of postpartum pyrexia. Puerperal sepsis, which often occurred in major epidemics, was the leading cause of maternal death in the developed world in the eighteenth, nineteenth and early twentieth centuries. Semmelweiss demonstrated significant improvements in 1846e1847 by the introduction of careful hand washing between attending each patient; this gradually became
Kevin G Glackin MB ChB BAO MRCOG DFSRH is a Specialty Trainee (ST7) in Obstetrics and Gynaecology at Altnagelvin Hospital, Londonderry, UK. Conflicts of interest: none declared. Margaret Ann Harper OBE MD FRCOG FRCPI FFSRH is a Consultant in Obstetrics and Gynaecology at Royal-Jubilee Maternity Service, Belfast, UK. Conflicts of interest: none declared.
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feel generally unwell, shivery, feverish, or complain of rigors, headache, nausea, vomiting, diarrhoea, heavy or offensive lochia, dysuria, abdominal, renal angle or other pain. There may be several symptoms relating to more than one system. Although pregnancy is over, the underlying reason for the raised temperature may originate in events that occurred before or during labour. Therefore as much information as possible about the recent pregnancy and delivery should be obtained and the following questions considered: Was there any vaginal or urinary tract infection during pregnancy? Was a cervical suture inserted during pregnancy? Is there any history of Group B streptococcal (GBS) infection? What was the time between rupture of membranes and delivery? Was the temperature elevated during labour? If CS was performed, was it an elective procedure or after a long labour? Have there been any problems with a perineal or CS wound? Was there excessive bleeding at the time of delivery? Was there any difficulty with delivery of the placenta or membranes? Has the lochia been unusually heavy, discoloured or smell offensive? Is there any abdominal pain or tenderness? Is there any pain on micturition? Is the baby breast or bottle fed? Is there any history of cracked nipples or mastitis? Has the baby any evidence of infection? Are any other family members affected by similar symptoms? In hospital, the patient’s obstetric and midwifery notes should be reviewed. In the community, the hospital discharge note should include all relevant clinical information but this does not always happen. If necessary, the hospital may be contacted for
Definitions of postpartum pyrexia and puerperal sepsis C
C
C
Although often used to describe any infection of the genital tract after delivery, puerperal infection (or postpartum pyrexia, puerperal pyrexia or puerperal fever) was considered by the World Health Organization (WHO) Technical Working Group (1992) as a more general term that includes not only infections due to genital tract sepsis, but also all extra-genital infections and incidental infections. The International Classification of Diseases (ICD-10) defines postpartum (puerperal) sepsis as a temperature rise above 38 C (100.4 F) maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion. The WHO Technical Working Group (1992) defined puerperal sepsis as infection of the genital tract occurring at any time between the rupture of membranes or labour, and the 42nd day postpartum in which two or more of the following are present: Pelvic pain Fever i.e. oral temperature 38.5 C (101.3 F) or higher on any occasion Abnormal vaginal discharge e.g. presence of pus Abnormal smell/foul odour or discharge Delay in the rate of reduction of size of the uterus (<2 cm/day during the first 8 days).
Box 1
History A thorough, systematic history is essential to elicit any risk factors for infection and all relevant symptoms and will usually provide a good idea of the source of infection. The patient may
Direct deaths associated with genital tract sepsis and rate per 100,000 maternities; United Kingdom: 1985e2008 Triennium
1985e87 1988e90 1991e93 1994e96 1997e99 2000e02 2003e05 2006e08
Sepsis in early pregnancya
3 8 4 0 6 2 5 7
Puerperal sepsis
2 4 4 11 2 5 3 7
Sepsis after surgical procedures
2 5 5 3 1 3 2 4
Sepsis before or during labour
2 0 2 1 7 1 8 8
All Direct deaths counted in this chapter Number
Late Direct deathsb Rate
9 17 15 16 18 13 18 26
0.40 0.72 0.65 0.73 0.85 0.65 0.85 1.13
95 percent CI
Number
0.21 0.45 0.39 0.45 0.54 0.38 0.54 0.77
0.75 1.15 1.07 1.18 1.34 1.11 1.35 1.67
0 0 0 0 2 0 3 3
a
Early pregnancy deaths include those following miscarriage, ectopic pregnancy and other causes. Late deaths are not counted in this chapter or included in the numerator. Reproduced with kind permission of the Centre for Maternal and Child Enquiries (CMACE) from Lewis G (Ed.) Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 (suppl 1):1e203. b
Table 1
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This history illustrates that a woman can deteriorate rapidly. This woman had a risk factor for sepsis in the history of PPROM. The time scale from developing first signs to progressing to a lifethreatening state can be very short. Prompt assessment and treatment are essential. It is important to check temperature, examine the lochia and check for other sources of infection including the breasts. It is important to examine the legs and chest for signs of thromboembolism which may also manifest in pyrexia. It is important to consider how long the membranes ruptured before delivery. Pre-term pre-labour rupture of membranes is associated with infection and should raise the index of suspicion. In postpartum pyrexia, attention should be paid to all symptoms, not only those related to the genital tract. Pain in the upper abdomen, head, chest or legs, presence of a rash, alteration in mental state or level of consciousness, presence of cough or haemoptysis, or any other symptom, should prompt further enquiry, consideration of other non-pregnancy related diagnoses and appropriate investigation. It is important to keep an open mind and not assume causes without reviewing all the evidence, taking all the symptoms and clinical findings into consideration, and being prepared to change the provisional diagnosis if new factors come to light. Severe sepsis can cause systemic symptoms or confusional states that may mislead the clinician, as illustrated by one case in the triennial Report ‘Why Mothers Die 2000e2002’ of a woman with a persistent tachycardia (130e170 bpm) and increasingly bizarre behaviour after delivery, who was mistakenly and tragically assumed to be having panic attacks because she had a known history of these. She was admitted to a psychiatric hospital and, although rapidly transferred to the local general hospital, died soon afterwards. Autopsy revealed an infected necrotic uterus.
Postpartum pyrexia: causes related to pregnancy Genital tract causes Endometritis Infection of myometrium or parametrium Pelvic abscess Caesarean wound infection Infection of episiotomy or vaginal or cervical tears Non-genital tract causes Urinary tract e cystitis or pyelonephritis Breast infection e mastitis or breast abscess Respiratory infection including pneumonia Venous thromboembolism Septic thrombophlebitis Infection of cannula sites including epidural cannulae
Box 2
further information. Good communication between hospital and community carers is emphasized in the Maternal Mortality Report ‘Saving Mothers’ Lives 2003e20050 . Case 1 A multiparous woman was admitted with pre-term pre-labour rupture of membranes (PPROM) at 32 weeks’ gestation. She was commenced on oral erythromycin and given intramuscular corticosteroids. Two days after admission the fetal heart was absent. Labour was induced and she delivered a stillborn baby. Two days following delivery she developed a pyrexia. Blood cultures were taken and she was commenced on intravenous antibiotics. Within 24 hours she deteriorated, developing shortness of breath, tachycardia and continued pyrexia. She was investigated for suspected pulmonary embolus, which was excluded, but deteriorated further and was admitted to the Intensive Care Unit (ICU). She was treated for a lower respiratory tract infection and adult respiratory distress syndrome (ARDS). Blood cultures were positive for coliforms.
Is it necessary to monitor maternal temperature after delivery? In hospital, monitoring of maternal temperature measurement during labour and after vaginal delivery or caesarean section is routine, but is not usually done after the woman returns home. The 2006 NICE Guideline on Postnatal Care advises that routine assessment of temperature is unnecessary in the absence of any signs or symptoms of infection, but should be taken and documented if infection is suspected. The Guideline also recommends that if the temperature is above 38.0 C, measurement should be repeated within 4e6 hours and if still elevated, or there are other observable symptoms and measurable signs of sepsis, further evaluation and emergency action should be taken.
Postpartum pyrexia: causes unrelated to pregnancy Appendicitis Cholecystitis Pancreatitis Respiratory tract infections Cerebral abscess Rheumatic endocarditis Myocarditis Infectious diseases e.g. malaria, tuberculosis, HIV/AIDS Malignant disease e.g. lymphomas Parasitic infection Drug fever Other
Examination of patients with postpartum pyrexia The abdomen should be examined for tenderness and masses and the uterus palpated to assess its size and tenderness. If present, the abdominal wound should be inspected for signs of infection, haematoma or dehiscence, and the bowel sounds auscultated. The lochia and perineal wound, if present, should be inspected for evidence of infection. The breasts should be examined for any redness, tenderness, localized masses or cracked nipples. The heart sounds should be auscultated and lung fields checked for any signs of infection. The legs should be inspected for signs of deep venous thrombosis such as tenderness along the course of the deep veins or unilateral oedema of the
Box 3
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was found to have pyrexia of 39 C associated with rigors but no other symptoms. On examination of the breasts by the midwife, one breast was tender, red and hot. The woman had thought this was to be expected as she was breastfeeding. A diagnosis of mastitis was made and the woman was commenced on oral antibiotics. A full physical examination is indicated in assessment of a woman with postpartum pyrexia. Breast infection is a pregnancy related cause of pyrexia but often not immediately considered as it is outside the genital tract. In addition, women may not volunteer breast symptoms as they may consider pain or engorgement in the breast to be normal. Breast infections can be difficult to treat and it is important to prescribe adequate dosage of an antibiotic, such as flucloxacillin 500 mg orally qid, and to continue treatment for 10e14 days to ensure that infection has been eradicated.
lower leg. If there are any other signs or symptoms such as sore throat or lymphadenopathy, appropriate examination should be performed.
Investigations The initial blood and microbiological investigations that should be performed in a woman presenting with postpartum pyrexia are listed in Box 4. Even if microbiological tests are negative, swabs, blood and urine cultures should be repeated at intervals if the patient remains unwell. Ultrasound of abdomen and pelvis is indicated to assess uterine size and involution and look for any retained products of conception. Most cases of postpartum pyrexia are pregnancy related, but if investigations have ruled this out and pyrexia persists despite appropriate treatment, then other causes need to be considered. Advice about possible causes and appropriate further investigations from physicians, microbiologists, specialists in infectious diseases or other specialists may be helpful. Additional investigations may include blood films, antinuclear antibodies and rheumatoid factor, tests for infections such as hepatitis, HIV, tuberculosis, cytomegalovirus, glandular fever and Q-fever, chest and abdominal X-rays, ECG, Doppler examination of leg and pelvic veins and V/Q scan to look for evidence of venous thromboembolism, CT abdomen which may detect intra-abdominal or renal abscesses, or transoesophageal echocardiography to detect bacterial vegetations on the heart valves. Rheumatic heart disease used to be the commonest underlying cause of indirect maternal death but is now rare in the UK. Nevertheless, rheumatic fever is still common in other parts of the world and women recently arrived from developing countries may have this condition. Two maternal deaths occurred from infectious endocarditis in the triennium 2003e2005.
Management of postpartum pyrexia Postpartum pyrexia requires prompt intervention. In the community, urgent assessment is appropriate, with referral for hospital assessment and admission if the patient is generally distressed or unwell, or has pyrexia of 38 C or more, or is breathless, or has sustained tachycardia, or has severe diarrhoea or vomiting, or has chest, abdominal, uterine, renal angle or other pain. In hospital, immediate observations of temperature, pulse, blood pressure, respiratory rate, quality and amount of lochia, pain score, and level of consciousness should be made, and then repeated at regular intervals appropriate to the patient’s condition. It is sometimes difficult to know whether a patient is seriously ill. Routine use of a comprehensive obstetric early warning scoring chart will show changes in the patient’s condition and help the earlier recognition of women who have, or are developing, a critical illness. This is one of the ‘Top ten’ key recommendations in the triennial Reports of the Confidential Enquiries into Maternal Deaths in the United Kingdom for 2003e2005 and 2006e2008. If a patient is more seriously ill, or shocked, tachycardic, hypotensive (systolic BP <90 mmHg), breathless or otherwise distressed, thinking of the ‘Sepsis Six’ is an aid to prompt management. This refers to six simple steps that can be performed easily by non-specialist staff within 1 hour of recognizing severe sepsis: Give 100% oxygen Take blood cultures Give intravenous antibiotics Start intravenous fluid resuscitation Check haemoglobin and lactate Insert urinary catheter and measure hourly urine output. Initial investigations including microbiology should be carried out as soon as possible. Treatment with a combination of high dose broad-spectrum intravenous antibiotics such as co-amoxiclav and metronidazole should be started immediately, within an hour of admission, without waiting for microbiology results. This is because sepsis can have a very rapid and fulminating course, and adequate early intravenous antibiotic treatment may be lifesaving. The onset of septicaemia in a previously healthy young woman is often insidious, but as the disease advances her clinical condition may deteriorate very rapidly and she may
Case 2 A young woman in her second pregnancy had a spontaneous normal delivery in the midwifery-led-unit and went home after 8 hours. The community midwife visited her on day 3, when she
Initial investigations for postpartum pyrexia Blood tests Full blood count (white cell count) C-reactive protein. Blood cultures (aerobic and anaerobic) Blood gases, lactate and coagulation screen if patient is clinically unwell Urea and electrolytes Liver function tests Serum amylase D-dimer Microbiology High and low vaginal swabs Urine microscopy and culture Throat, wound, rectal swab or other swabs may be indicated Sputum culture if productive cough Breast milk if mastitis suspected Box 4
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collapse suddenly. If there is no response to the initial antibiotic regimen within 24e48 hours, or the patient’s condition worsens, the antibiotics should be changed, and gentamicin or similar antibiotic added. It is very helpful to seek advice from a consultant microbiologist. The Reports of the UK Confidential Enquiries into Maternal Deaths emphasize the importance of seeking consultant advice as soon as possible after the patient is recognized to be seriously ill. It is important to involve consultant anaesthetists, the critical care team, consultant microbiologist, and members of other disciplines such as radiology, surgery or haematology as appropriate depending on the situation. The need for high dependency or critical care should be anticipated and if possible planned in advance as a bed may not be immediately available. Even if there is no critical care bed, appropriate resuscitation and intensive care can be commenced in other settings. The cause of pyrexia should be elucidated and the appropriate treatment for the underlying condition commenced as soon as possible. This may include laparotomy and surgical drainage of abscesses.
penicillin 3 g as soon as possible after onset of labour then 1.5 g 4-hourly until delivery, or clindamycin 900 mg 8-hourly for those allergic to penicillin; although if chorioamnionitis is suspected, broad-spectrum antibiotic therapy including an agent active against GBS should replace GBS-specific antibiotic prophylaxis. The placenta and membranes should always be examined carefully after delivery to ensure that they are complete. All swabs, needles and instruments used should be checked and accounted for at the end of any procedure, including repair of episiotomy and all other vaginal procedures. The 2011 NICE Caesarean Section Guideline recommends that a single dose of a prophylactic broad-spectrum antibiotic, such as ampicillin or a first generation cephalosporin, be offered to all women having a CS. The 2007 RCOG Green-top Guideline about the management of a third- or fourth- degree perineal tear recommends the use of broad-spectrum antibiotics, including metronidazole, to reduce the incidence of postoperative infections and wound dehiscence. The 2011 RCOG Green-top Guideline about operative vaginal delivery notes that there is insufficient evidence to make recommendations regarding prophylactic antibiotics, however, good standards of hygiene and aseptic technique are recommended. Although there are no randomized controlled trials of the use of prophylactic antibiotics for manual removal of retained placenta after vaginal birth, a 2009 Cochrane Database Review suggests following WHO advice of a single dose of metronidazole 500 mg intravenously plus either ampicillin 2 g or cefazolin 1 g intravenously.
Case 3 A 26-year-old woman at 28 weeks’ gestation in her first pregnancy was admitted following diagnosis of intrauterine death (IUD). Labour was induced and she delivered a stillborn baby. Within 24 hours of delivery she developed pyrexia and shortness of breath. Blood cultures were obtained and she was commenced on broad spectrum intravenous antibiotics. She was admitted to the High Dependency Unit (HDU) following further deterioration including respiratory distress. Blood cultures were positive for Group A Streptococcus. The triennial Report of The Confidential Enquiry into Maternal Death in the UK for 2006e2008 reports 13 deaths from beta-haemolytic Streptococcus Lancefield Group A (Streptococcus pyogenes). This compares with eight deaths for 2003e2005 and three deaths in 2000e2002. This organism has historically been associated with puerperal sepsis but maternal mortality was reduced following the advent of antibiotics and antisepsis. This recent re-emergence of cases has prompted the need for antenatal education regarding personal hygiene and specific advice to women to avoid inadvertent contamination of the perineum by washing hands before using the toilet, changing sanitary pads/ tampons, etc. Contamination is more likely when the woman or close family, particularly children, have sore throat and/or respiratory symptoms.
Conclusion Postpartum pyrexia is a significant finding which requires a full history and examination, thorough investigation, close observation and prompt treatment. Most cases are due to genital tract sepsis but some are due to a wide variety of other causes. A range of further investigations may be required and advice from senior colleagues in other specialities, particularly microbiology, haematology, anaesthesia and critical care should be sought at an early stage. A
FURTHER READING Bacterial sepsis following pregnancy. Green-top Guideline No. 64b. Royal College of Obstetricians and Gynaecologists, April 2012. Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118(suppl 1): 1e203. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv 2007; 62: 393e9. Maharaj D. Puerperal pyrexia: a review. Part II. Obstet Gynecol Surv 2007; 62: 400e6. Palaniappan N, Menezes M, Willson P. Group A streptococcal puerperal sepsis: management and prevention. The Obstetrician & Gynaecologist 2012; 14: 9e16. Sinha P, Otify M. Genital tract sepsis: early diagnosis, management and prevention. The Obstetrician & Gynaecologist 2012; 14: 106e14. UKOSS e UK Obstetric Surveillance System. https://www.npeu.ox.ac.uk/ ukoss.
Prevention of postpartum genital tract infection Strict attention to hygiene, frequent hand washing, and aseptic precautions for all procedures performed during labour and delivery are essential. Frequent vaginal examinations should be avoided, as they increase the risk of introducing infection to the genital tract. When membranes rupture prior to the onset of labour, manual vaginal examination should be avoided altogether although a sterile speculum may be used to examine the cervix, exclude cord prolapse and take a swab for bacteriological examination. The 2003 RCOG Green-top Guideline about GBS disease recommends that when there is a history of GBS infection, intravenous antibiotic prophylaxis should be given with
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Practice points C
C
C
C
A complete history, full physical examination, blood and urine cultures, and swabs from the vagina, any wound, and throat if symptomatic, are essential in cases of postpartum pyrexia. Regular frequent observations should be made and the use of an Early Warning Score Chart will help to detect early changes in the patient’s condition. Patients with systemic infection can deteriorate very rapidly so it is essential to commence high dose broad-spectrum intravenous antibiotics immediately without waiting for results of microbiological investigations. If the cause of pyrexia is not quickly obvious, a variety of further investigations will be needed and advice should be sought from senior colleagues in other disciplines.
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Postpartum pyrexia
widespread practice, but it was only when antibiotics became widely available in the 1940’s that the mortality from genital tract sepsis began to decline rapidly. In the triennium 2006e2008, genital tract sepsis was, for the first time since the UK Confidential Enquiries into Maternal Deaths began in 1952, the commonest cause of Direct maternal death in the United Kingdom (Table 1). This is partly due to decreases in the numbers of deaths from other Direct causes, particularly thrombo-embolism, and partly due to a genuine rise in the number of deaths from sepsis, particularly sepsis due to Group A streptococcal infection. In 2006e2008, there were 26 Direct maternal deaths from genital tract sepsis; another three women died later but had developed sepsis around the time of delivery. Worldwide, puerperal sepsis remains a major cause of maternal mortality and is estimated to account for approximately 15% of all direct maternal deaths. Postpartum infections are also an important cause of maternal morbidity. The incidence of severe infections and ‘near miss’ events is much higher than the number of deaths, although accurate figures are hard to find because of the variety of definitions used and the difficulty of obtaining data from the community as many postpartum infections occur after discharge from hospital. The global incidence of puerperal sepsis is estimated to be 4.4% of live births. The Scottish Confidential Audit of Severe Maternal Morbidity showed a 0.11 per 1000 births rate of septicaemic shock in the triennium 2006e2008. The 2011 NICE Guideline on Caesarean Section (CS) recommends routine antibiotic prophylaxis to reduce the incidence of infections such as endometritis, urinary tract and wound infections, which occur in about 8% of women who have had a caesarean section. A 2 year study of severe maternal sepsis in the UK was initiated by UKOSS in June 2011.
Kevin G Glackin Margaret Ann Harper
Abstract Postpartum pyrexia is a common condition that is sometimes associated with serious maternal morbidity and occasional mortality. Most cases are due to underlying genital tract infection, but there are a wide variety of other possible causes that may not always be clinically obvious. A comprehensive history and physical examination should always be carried out. Initial investigation should focus on thorough assessment of the genital tract, including swabs and ultrasound examination. However, a wide range of further investigations may be needed to determine the cause of the pyrexia. Use of an early warning chart for observations is important to detect early changes in a patient’s condition. Serious infection can develop insidiously and patients can deteriorate very rapidly, so immediate high dose broad-spectrum intravenous antibiotic treatment without waiting for microbiology results can be lifesaving. Early recognition, consultant involvement, appropriate investigation and prompt treatment are keys to successful management.
Keywords Group A Streptococcus; postpartum infection; postpartum pyrexia; puerperal infection; puerperal sepsis; Streptococcus pyogenes
Introduction Postpartum pyrexia is common and is usually due to bacterial infection of the breast, urinary or genital tracts. Although most cases are easily treated with routine management including antibiotics, serious maternal morbidity and occasional mortality can occur. Postpartum or puerperal pyrexia are general terms and exact definitions vary (Box 1). A temperature rise above 38 C (100.4 F) maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion is often used (ICD-10).
Aetiology Postpartum pyrexia may have a wide variety of underlying causes. These may be broadly divided into those directly related to pregnancy e.g. breast or uterine infection (Box 2), and coincidental causes unrelated to pregnancy e.g. malaria (Box 3). The cause of the raised temperature is usually easily discovered, but can be elusive. The potential consequences of persistent or relapsing maternal infection are serious so the search for a cause must be pursued vigorously and prompt effective treatment given. Most cases of postpartum pyrexia are related to the recent pregnancy and labour. After delivery, the placental bed, caesarean section and episiotomy wounds, cervical and vaginal lacerations are all susceptible to bacterial infection. Organisms may be acquired by contamination from an external source or endogenously from the woman’s own genital tract. Prolonged rupture of membranes, prolonged labour, operative vaginal delivery, caesarean section, pre-existing vaginal infection or history of Group B streptococcal (GBS) infection, postpartum haemorrhage, wound haematoma, retained pieces of placenta, membranes or intrauterine clot, or retained swabs all increase the risk of postpartum infection. Pregnancy itself affects the immune system, and conditions such as anaemia, impaired glucose tolerance or diabetes mellitus reduce resistance to infection. Obesity, an increasing problem in the developed world, is a risk factor for sepsis, as is multiparity.
Incidence Maternal mortality is the most serious outcome of postpartum pyrexia. Puerperal sepsis, which often occurred in major epidemics, was the leading cause of maternal death in the developed world in the eighteenth, nineteenth and early twentieth centuries. Semmelweiss demonstrated significant improvements in 1846e1847 by the introduction of careful hand washing between attending each patient; this gradually became
Kevin G Glackin MB ChB BAO MRCOG DFSRH is a Specialty Trainee (ST7) in Obstetrics and Gynaecology at Altnagelvin Hospital, Londonderry, UK. Conflicts of interest: none declared. Margaret Ann Harper OBE MD FRCOG FRCPI FFSRH is a Consultant in Obstetrics and Gynaecology at Royal-Jubilee Maternity Service, Belfast, UK. Conflicts of interest: none declared.
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feel generally unwell, shivery, feverish, or complain of rigors, headache, nausea, vomiting, diarrhoea, heavy or offensive lochia, dysuria, abdominal, renal angle or other pain. There may be several symptoms relating to more than one system. Although pregnancy is over, the underlying reason for the raised temperature may originate in events that occurred before or during labour. Therefore as much information as possible about the recent pregnancy and delivery should be obtained and the following questions considered: Was there any vaginal or urinary tract infection during pregnancy? Was a cervical suture inserted during pregnancy? Is there any history of Group B streptococcal (GBS) infection? What was the time between rupture of membranes and delivery? Was the temperature elevated during labour? If CS was performed, was it an elective procedure or after a long labour? Have there been any problems with a perineal or CS wound? Was there excessive bleeding at the time of delivery? Was there any difficulty with delivery of the placenta or membranes? Has the lochia been unusually heavy, discoloured or smell offensive? Is there any abdominal pain or tenderness? Is there any pain on micturition? Is the baby breast or bottle fed? Is there any history of cracked nipples or mastitis? Has the baby any evidence of infection? Are any other family members affected by similar symptoms? In hospital, the patient’s obstetric and midwifery notes should be reviewed. In the community, the hospital discharge note should include all relevant clinical information but this does not always happen. If necessary, the hospital may be contacted for
Definitions of postpartum pyrexia and puerperal sepsis C
C
C
Although often used to describe any infection of the genital tract after delivery, puerperal infection (or postpartum pyrexia, puerperal pyrexia or puerperal fever) was considered by the World Health Organization (WHO) Technical Working Group (1992) as a more general term that includes not only infections due to genital tract sepsis, but also all extra-genital infections and incidental infections. The International Classification of Diseases (ICD-10) defines postpartum (puerperal) sepsis as a temperature rise above 38 C (100.4 F) maintained over 24 hours or recurring during the period from the end of the first to the end of the 10th day after childbirth or abortion. The WHO Technical Working Group (1992) defined puerperal sepsis as infection of the genital tract occurring at any time between the rupture of membranes or labour, and the 42nd day postpartum in which two or more of the following are present: Pelvic pain Fever i.e. oral temperature 38.5 C (101.3 F) or higher on any occasion Abnormal vaginal discharge e.g. presence of pus Abnormal smell/foul odour or discharge Delay in the rate of reduction of size of the uterus (<2 cm/day during the first 8 days).
Box 1
History A thorough, systematic history is essential to elicit any risk factors for infection and all relevant symptoms and will usually provide a good idea of the source of infection. The patient may
Direct deaths associated with genital tract sepsis and rate per 100,000 maternities; United Kingdom: 1985e2008 Triennium
1985e87 1988e90 1991e93 1994e96 1997e99 2000e02 2003e05 2006e08
Sepsis in early pregnancya
3 8 4 0 6 2 5 7
Puerperal sepsis
2 4 4 11 2 5 3 7
Sepsis after surgical procedures
2 5 5 3 1 3 2 4
Sepsis before or during labour
2 0 2 1 7 1 8 8
All Direct deaths counted in this chapter Number
Late Direct deathsb Rate
9 17 15 16 18 13 18 26
0.40 0.72 0.65 0.73 0.85 0.65 0.85 1.13
95 percent CI
Number
0.21 0.45 0.39 0.45 0.54 0.38 0.54 0.77
0.75 1.15 1.07 1.18 1.34 1.11 1.35 1.67
0 0 0 0 2 0 3 3
a
Early pregnancy deaths include those following miscarriage, ectopic pregnancy and other causes. Late deaths are not counted in this chapter or included in the numerator. Reproduced with kind permission of the Centre for Maternal and Child Enquiries (CMACE) from Lewis G (Ed.) Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 (suppl 1):1e203. b
Table 1
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This history illustrates that a woman can deteriorate rapidly. This woman had a risk factor for sepsis in the history of PPROM. The time scale from developing first signs to progressing to a lifethreatening state can be very short. Prompt assessment and treatment are essential. It is important to check temperature, examine the lochia and check for other sources of infection including the breasts. It is important to examine the legs and chest for signs of thromboembolism which may also manifest in pyrexia. It is important to consider how long the membranes ruptured before delivery. Pre-term pre-labour rupture of membranes is associated with infection and should raise the index of suspicion. In postpartum pyrexia, attention should be paid to all symptoms, not only those related to the genital tract. Pain in the upper abdomen, head, chest or legs, presence of a rash, alteration in mental state or level of consciousness, presence of cough or haemoptysis, or any other symptom, should prompt further enquiry, consideration of other non-pregnancy related diagnoses and appropriate investigation. It is important to keep an open mind and not assume causes without reviewing all the evidence, taking all the symptoms and clinical findings into consideration, and being prepared to change the provisional diagnosis if new factors come to light. Severe sepsis can cause systemic symptoms or confusional states that may mislead the clinician, as illustrated by one case in the triennial Report ‘Why Mothers Die 2000e2002’ of a woman with a persistent tachycardia (130e170 bpm) and increasingly bizarre behaviour after delivery, who was mistakenly and tragically assumed to be having panic attacks because she had a known history of these. She was admitted to a psychiatric hospital and, although rapidly transferred to the local general hospital, died soon afterwards. Autopsy revealed an infected necrotic uterus.
Postpartum pyrexia: causes related to pregnancy Genital tract causes Endometritis Infection of myometrium or parametrium Pelvic abscess Caesarean wound infection Infection of episiotomy or vaginal or cervical tears Non-genital tract causes Urinary tract e cystitis or pyelonephritis Breast infection e mastitis or breast abscess Respiratory infection including pneumonia Venous thromboembolism Septic thrombophlebitis Infection of cannula sites including epidural cannulae
Box 2
further information. Good communication between hospital and community carers is emphasized in the Maternal Mortality Report ‘Saving Mothers’ Lives 2003e20050 . Case 1 A multiparous woman was admitted with pre-term pre-labour rupture of membranes (PPROM) at 32 weeks’ gestation. She was commenced on oral erythromycin and given intramuscular corticosteroids. Two days after admission the fetal heart was absent. Labour was induced and she delivered a stillborn baby. Two days following delivery she developed a pyrexia. Blood cultures were taken and she was commenced on intravenous antibiotics. Within 24 hours she deteriorated, developing shortness of breath, tachycardia and continued pyrexia. She was investigated for suspected pulmonary embolus, which was excluded, but deteriorated further and was admitted to the Intensive Care Unit (ICU). She was treated for a lower respiratory tract infection and adult respiratory distress syndrome (ARDS). Blood cultures were positive for coliforms.
Is it necessary to monitor maternal temperature after delivery? In hospital, monitoring of maternal temperature measurement during labour and after vaginal delivery or caesarean section is routine, but is not usually done after the woman returns home. The 2006 NICE Guideline on Postnatal Care advises that routine assessment of temperature is unnecessary in the absence of any signs or symptoms of infection, but should be taken and documented if infection is suspected. The Guideline also recommends that if the temperature is above 38.0 C, measurement should be repeated within 4e6 hours and if still elevated, or there are other observable symptoms and measurable signs of sepsis, further evaluation and emergency action should be taken.
Postpartum pyrexia: causes unrelated to pregnancy Appendicitis Cholecystitis Pancreatitis Respiratory tract infections Cerebral abscess Rheumatic endocarditis Myocarditis Infectious diseases e.g. malaria, tuberculosis, HIV/AIDS Malignant disease e.g. lymphomas Parasitic infection Drug fever Other
Examination of patients with postpartum pyrexia The abdomen should be examined for tenderness and masses and the uterus palpated to assess its size and tenderness. If present, the abdominal wound should be inspected for signs of infection, haematoma or dehiscence, and the bowel sounds auscultated. The lochia and perineal wound, if present, should be inspected for evidence of infection. The breasts should be examined for any redness, tenderness, localized masses or cracked nipples. The heart sounds should be auscultated and lung fields checked for any signs of infection. The legs should be inspected for signs of deep venous thrombosis such as tenderness along the course of the deep veins or unilateral oedema of the
Box 3
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was found to have pyrexia of 39 C associated with rigors but no other symptoms. On examination of the breasts by the midwife, one breast was tender, red and hot. The woman had thought this was to be expected as she was breastfeeding. A diagnosis of mastitis was made and the woman was commenced on oral antibiotics. A full physical examination is indicated in assessment of a woman with postpartum pyrexia. Breast infection is a pregnancy related cause of pyrexia but often not immediately considered as it is outside the genital tract. In addition, women may not volunteer breast symptoms as they may consider pain or engorgement in the breast to be normal. Breast infections can be difficult to treat and it is important to prescribe adequate dosage of an antibiotic, such as flucloxacillin 500 mg orally qid, and to continue treatment for 10e14 days to ensure that infection has been eradicated.
lower leg. If there are any other signs or symptoms such as sore throat or lymphadenopathy, appropriate examination should be performed.
Investigations The initial blood and microbiological investigations that should be performed in a woman presenting with postpartum pyrexia are listed in Box 4. Even if microbiological tests are negative, swabs, blood and urine cultures should be repeated at intervals if the patient remains unwell. Ultrasound of abdomen and pelvis is indicated to assess uterine size and involution and look for any retained products of conception. Most cases of postpartum pyrexia are pregnancy related, but if investigations have ruled this out and pyrexia persists despite appropriate treatment, then other causes need to be considered. Advice about possible causes and appropriate further investigations from physicians, microbiologists, specialists in infectious diseases or other specialists may be helpful. Additional investigations may include blood films, antinuclear antibodies and rheumatoid factor, tests for infections such as hepatitis, HIV, tuberculosis, cytomegalovirus, glandular fever and Q-fever, chest and abdominal X-rays, ECG, Doppler examination of leg and pelvic veins and V/Q scan to look for evidence of venous thromboembolism, CT abdomen which may detect intra-abdominal or renal abscesses, or transoesophageal echocardiography to detect bacterial vegetations on the heart valves. Rheumatic heart disease used to be the commonest underlying cause of indirect maternal death but is now rare in the UK. Nevertheless, rheumatic fever is still common in other parts of the world and women recently arrived from developing countries may have this condition. Two maternal deaths occurred from infectious endocarditis in the triennium 2003e2005.
Management of postpartum pyrexia Postpartum pyrexia requires prompt intervention. In the community, urgent assessment is appropriate, with referral for hospital assessment and admission if the patient is generally distressed or unwell, or has pyrexia of 38 C or more, or is breathless, or has sustained tachycardia, or has severe diarrhoea or vomiting, or has chest, abdominal, uterine, renal angle or other pain. In hospital, immediate observations of temperature, pulse, blood pressure, respiratory rate, quality and amount of lochia, pain score, and level of consciousness should be made, and then repeated at regular intervals appropriate to the patient’s condition. It is sometimes difficult to know whether a patient is seriously ill. Routine use of a comprehensive obstetric early warning scoring chart will show changes in the patient’s condition and help the earlier recognition of women who have, or are developing, a critical illness. This is one of the ‘Top ten’ key recommendations in the triennial Reports of the Confidential Enquiries into Maternal Deaths in the United Kingdom for 2003e2005 and 2006e2008. If a patient is more seriously ill, or shocked, tachycardic, hypotensive (systolic BP <90 mmHg), breathless or otherwise distressed, thinking of the ‘Sepsis Six’ is an aid to prompt management. This refers to six simple steps that can be performed easily by non-specialist staff within 1 hour of recognizing severe sepsis: Give 100% oxygen Take blood cultures Give intravenous antibiotics Start intravenous fluid resuscitation Check haemoglobin and lactate Insert urinary catheter and measure hourly urine output. Initial investigations including microbiology should be carried out as soon as possible. Treatment with a combination of high dose broad-spectrum intravenous antibiotics such as co-amoxiclav and metronidazole should be started immediately, within an hour of admission, without waiting for microbiology results. This is because sepsis can have a very rapid and fulminating course, and adequate early intravenous antibiotic treatment may be lifesaving. The onset of septicaemia in a previously healthy young woman is often insidious, but as the disease advances her clinical condition may deteriorate very rapidly and she may
Case 2 A young woman in her second pregnancy had a spontaneous normal delivery in the midwifery-led-unit and went home after 8 hours. The community midwife visited her on day 3, when she
Initial investigations for postpartum pyrexia Blood tests Full blood count (white cell count) C-reactive protein. Blood cultures (aerobic and anaerobic) Blood gases, lactate and coagulation screen if patient is clinically unwell Urea and electrolytes Liver function tests Serum amylase D-dimer Microbiology High and low vaginal swabs Urine microscopy and culture Throat, wound, rectal swab or other swabs may be indicated Sputum culture if productive cough Breast milk if mastitis suspected Box 4
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collapse suddenly. If there is no response to the initial antibiotic regimen within 24e48 hours, or the patient’s condition worsens, the antibiotics should be changed, and gentamicin or similar antibiotic added. It is very helpful to seek advice from a consultant microbiologist. The Reports of the UK Confidential Enquiries into Maternal Deaths emphasize the importance of seeking consultant advice as soon as possible after the patient is recognized to be seriously ill. It is important to involve consultant anaesthetists, the critical care team, consultant microbiologist, and members of other disciplines such as radiology, surgery or haematology as appropriate depending on the situation. The need for high dependency or critical care should be anticipated and if possible planned in advance as a bed may not be immediately available. Even if there is no critical care bed, appropriate resuscitation and intensive care can be commenced in other settings. The cause of pyrexia should be elucidated and the appropriate treatment for the underlying condition commenced as soon as possible. This may include laparotomy and surgical drainage of abscesses.
penicillin 3 g as soon as possible after onset of labour then 1.5 g 4-hourly until delivery, or clindamycin 900 mg 8-hourly for those allergic to penicillin; although if chorioamnionitis is suspected, broad-spectrum antibiotic therapy including an agent active against GBS should replace GBS-specific antibiotic prophylaxis. The placenta and membranes should always be examined carefully after delivery to ensure that they are complete. All swabs, needles and instruments used should be checked and accounted for at the end of any procedure, including repair of episiotomy and all other vaginal procedures. The 2011 NICE Caesarean Section Guideline recommends that a single dose of a prophylactic broad-spectrum antibiotic, such as ampicillin or a first generation cephalosporin, be offered to all women having a CS. The 2007 RCOG Green-top Guideline about the management of a third- or fourth- degree perineal tear recommends the use of broad-spectrum antibiotics, including metronidazole, to reduce the incidence of postoperative infections and wound dehiscence. The 2011 RCOG Green-top Guideline about operative vaginal delivery notes that there is insufficient evidence to make recommendations regarding prophylactic antibiotics, however, good standards of hygiene and aseptic technique are recommended. Although there are no randomized controlled trials of the use of prophylactic antibiotics for manual removal of retained placenta after vaginal birth, a 2009 Cochrane Database Review suggests following WHO advice of a single dose of metronidazole 500 mg intravenously plus either ampicillin 2 g or cefazolin 1 g intravenously.
Case 3 A 26-year-old woman at 28 weeks’ gestation in her first pregnancy was admitted following diagnosis of intrauterine death (IUD). Labour was induced and she delivered a stillborn baby. Within 24 hours of delivery she developed pyrexia and shortness of breath. Blood cultures were obtained and she was commenced on broad spectrum intravenous antibiotics. She was admitted to the High Dependency Unit (HDU) following further deterioration including respiratory distress. Blood cultures were positive for Group A Streptococcus. The triennial Report of The Confidential Enquiry into Maternal Death in the UK for 2006e2008 reports 13 deaths from beta-haemolytic Streptococcus Lancefield Group A (Streptococcus pyogenes). This compares with eight deaths for 2003e2005 and three deaths in 2000e2002. This organism has historically been associated with puerperal sepsis but maternal mortality was reduced following the advent of antibiotics and antisepsis. This recent re-emergence of cases has prompted the need for antenatal education regarding personal hygiene and specific advice to women to avoid inadvertent contamination of the perineum by washing hands before using the toilet, changing sanitary pads/ tampons, etc. Contamination is more likely when the woman or close family, particularly children, have sore throat and/or respiratory symptoms.
Conclusion Postpartum pyrexia is a significant finding which requires a full history and examination, thorough investigation, close observation and prompt treatment. Most cases are due to genital tract sepsis but some are due to a wide variety of other causes. A range of further investigations may be required and advice from senior colleagues in other specialities, particularly microbiology, haematology, anaesthesia and critical care should be sought at an early stage. A
FURTHER READING Bacterial sepsis following pregnancy. Green-top Guideline No. 64b. Royal College of Obstetricians and Gynaecologists, April 2012. Centre for Maternal and Child Enquiries (CMACE). Saving mothers’ lives: reviewing maternal deaths to make motherhood safer: 2006e08. The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011; 118(suppl 1): 1e203. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv 2007; 62: 393e9. Maharaj D. Puerperal pyrexia: a review. Part II. Obstet Gynecol Surv 2007; 62: 400e6. Palaniappan N, Menezes M, Willson P. Group A streptococcal puerperal sepsis: management and prevention. The Obstetrician & Gynaecologist 2012; 14: 9e16. Sinha P, Otify M. Genital tract sepsis: early diagnosis, management and prevention. The Obstetrician & Gynaecologist 2012; 14: 106e14. UKOSS e UK Obstetric Surveillance System. https://www.npeu.ox.ac.uk/ ukoss.
Prevention of postpartum genital tract infection Strict attention to hygiene, frequent hand washing, and aseptic precautions for all procedures performed during labour and delivery are essential. Frequent vaginal examinations should be avoided, as they increase the risk of introducing infection to the genital tract. When membranes rupture prior to the onset of labour, manual vaginal examination should be avoided altogether although a sterile speculum may be used to examine the cervix, exclude cord prolapse and take a swab for bacteriological examination. The 2003 RCOG Green-top Guideline about GBS disease recommends that when there is a history of GBS infection, intravenous antibiotic prophylaxis should be given with
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Practice points C
C
C
C
A complete history, full physical examination, blood and urine cultures, and swabs from the vagina, any wound, and throat if symptomatic, are essential in cases of postpartum pyrexia. Regular frequent observations should be made and the use of an Early Warning Score Chart will help to detect early changes in the patient’s condition. Patients with systemic infection can deteriorate very rapidly so it is essential to commence high dose broad-spectrum intravenous antibiotics immediately without waiting for results of microbiological investigations. If the cause of pyrexia is not quickly obvious, a variety of further investigations will be needed and advice should be sought from senior colleagues in other disciplines.
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