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Postpartum Infections• Author: Andy W Wong, MD; Chief Editor: Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE more...

Updated: Dec 06, 2015

Background

Postpartum infections comprise a wide range of entities that can occur after vaginaland cesarean delivery or during breastfeeding. In addition to trauma sustainedduring the birth process or cesarean procedure, physiologic changes during

pregnancy contribute to the development of postpartum infections.[1] The typical painthat many women feel in the immediate postpartum period also makes it difficult todiscern postpartum infection from postpartum pain.

Postpartum patients are frequently discharged within a couple days followingdelivery. The short period of observation may not afford enough time to excludeevidence of infection prior to discharge from the hospital. In one study, 94% of

postpartum infection cases were diagnosed after discharge from the hospital.[2]

Postpartum fever is defined as a temperature greater than 38.0°C on any 2 of the

first 10 days following delivery exclusive of the first 24 hours.[3] The presence ofpostpartum fever is generally accepted among clinicians as a sign of infection thatmust be determined and managed.

Pathophysiology

Local spread of colonized bacteria is the most common etiology for postpartuminfection following vaginal delivery. Endometritis is the most common infection in thepostpartum period. Other postpartum infections include (1) postsurgical woundinfections, (2) perineal cellulitis, (3) mastitis, (4) respiratory complications fromanesthesia, (5) retained products of conception, (6) urinary tract infections (UTIs),and (7) septic pelvic phlebitis. Wound infection is more common with cesareandelivery. (A review study by Haas et al indicated that cleansing the vagina with apovidone-iodine solution immediately prior to cesarean delivery decreases the risk

for postoperative endometritis.[4] )

Etiology

Endometritis

The Route of delivery is the single most important factor in the development of

endometritis.[5] The risk of endometritis increases dramatically after cesarean

delivery.[5, 6] However, there is some evidence that hospital readmission formanagement of postpartum endometritis occurs more often in those who delivered

vaginally.[6]

Other risk factors include prolonged rupture of membranes, prolonged use of internal

fetal monitoring, anemia, and lower socioeconomic status.[5]

Perioperative antibiotics have greatly decreased the incidence of endometritis.[5]

In most cases of endometritis, the bacteria responsible are those that normallyreside in the bowel, vagina, perineum, and cervix.

The uterine cavity is usually sterile until the rupture of the amniotic sac. As aconsequence of labor, delivery, and associated manipulations, anaerobic andaerobic bacteria can contaminate the uterus.

Wound infections

Most often, the etiologic organisms associated with perineal cellulitis and episiotomysite infections are Staphylococcus or Streptococcus species and gram-negativeorganisms, as in endometritis.

Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet,infections develop in only 1% of patients who had vaginal tears or who underwentepisiotomies.

Those who underwent cesarean delivery have a higher readmission rate for wound

infection and complications than those who delivered vaginally.[7]

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Genital tract infections

Increased risk of genital tract infections is related to the duration of labor (ieprolonged labor increases risk of infection), use of internal monitoring devices, and

number of vaginal examinations.[8]

Genital tract infections are generally polymicrobial. Gram-positive cocciand Bacteroides and Clostridium species are the predominant anaerobic organismsinvolved. Escherichia coli  and gram-positive cocci are commonly involved aerobes.

Mastitis

The most common organism reported in mastitis is Staphylococcus aureus. Theorganism usually comes from the breastfeeding infant's mouth or throat.

Thrombosis may occur. Numerous factors cause pregnant and postpartum womento be more susceptible to thrombosis. Pregnancy is known to induce ahypercoagulable state secondary to increased levels of clotting factors. Also, venousstasis occurs in the pelvic veins during pregnancy.

 Although relatively rare, septic pelvic thrombosis is occasionally observed in thepostpartum patient, who might have fever.

Urinary tract infections

Bacteria most frequently found in UTIs are normal bowel flora, including Ecoli  and Klebsiella, Proteus, and Enterobacter  species.

 Any form of invasive manipulation of the urethra (eg, Foley catheterization)increases the likelihood of a UTI.

General risk factors

The following increase the risk for partpartum infections:

• History of cesarean delivery• Premature rupture of membranes• Frequent cervical examination (Sterile gloves should be used in

examinations. Other than a history of cesarean delivery, this risk factor ismost important in postpartum infection.)

• Internal fetal monitoring• Preexisting pelvic infection including bacterial vaginosis• Diabetes• Nutritional status• Obesity

In the aforementioned study by Bauer et al, of approximately 45 millionhospitalizations for delivery between 1998 and 2008, medical conditions that werefound to be independently associated with severe sepsis included congestive heartfailure, chronic kidney disease, chronic liver disease, and systemic lupus

erythematosus. An association with rescue cerclage was also found.[9]

Epidemiology

United States statistics

In a study by Yokoe et al in 2001, 5.5% of vaginal deliveries and 7.4% of cesarean

deliveries resulted in a postpartum infection.[2] The overall postpartum infection ratewas 6.0%. Endometritis accounted for nearly half of the infections in patientsfollowing cesarean delivery (3.4% of cesarean deliveries). Mastitis and urinary tract

infections together accounted for 5% of vaginal deliveries.[2]

 A study by Bauer et al indicated that in the United States from 1998 to 2008, ofapproximately 45 million hospitalizations for delivery, sepsis was a complication in 1out of every 3333 deliveries. The investigators also found that during the studyperiod, the risk for severe sepsis (1:10,823 deliveries) and sepsis-related death

(1:105,263 deliveries) increased.[9]

Race-related demographics

The risk of postpartum urinary tract infection is increased in the African American,

Native American, and Hispanic populations.[10]

Prognosis

The prognosis for postpartum infections is good with prompt and appropriatetherapy.

In most reviews, maternal death rates associated with infection range from 4-8%, orapproximately 0.6 maternal deaths per 100,000 live births.

 A pregnancy-related mortality surveillance by the Centers for Disease Control andPrevention indicated infection accounted for about 11.6% of all deaths following

pregnancy that resulted in a live birth, stillbirth, or ectopic.[11]

Complications

Complications include the following:

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• Scarring• Infertility• Sepsis• Septic shock• Death

Clinical Presentation

Contributor Information and Disclosures

 AuthorAndy W Wong, MD Resident Physician, Department of Emergency Medicine, Wayne State University, DetroitReceiving Hospital

 Andy W Wong, MD is a member of the following medical societies: American College of Emergency Physicians,Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Coauthor(s)Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department ofEmergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

 Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor BoardFrancisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center Collegeof Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Mark Zwanger, MD, MBA Assistant Professor, Department of Emergency Medicine, Jefferson Medical College ofThomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American College of EmergencyPhysicians

Disclosure: Nothing to disclose.

Chief EditorBruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE  Medical Director, Department of Emergency Medicine,Sentara Norfolk General Hospital; Associate Professor, Assistant Program Director, Core Academic Faculty,Department of Emergency Medicine, Eastern Virginia Medical School

Bruce M Lo, MD, CPE, RDMS, FACEP, FAAEM, FACHE is a member of the following medical societies: American Academy of Emergency Medicine, American Association for Physician Leadership, American College ofEmergency Physicians, American College of Healthcare Executives, American Institute of Ultrasound in Medicine,Emergency Nurses Association, Medical Society of Virginia, Norfolk Academy of Medicine, Society for AcademicEmergency Medicine

Disclosure: Nothing to disclose.

 Additional ContributorsAssaad J Sayah, MD, FACEP Chief, Department of Emergency Medicine; Senior Vice President, Primary andEmergency Care, Cambridge Health Alliance

 Assaad J Sayah, MD, FACEP is a member of the following medical societies: American College of EmergencyPhysicians, Massachusetts Medical Society, National Association of EMS Physicians

Disclosure: Nothing to disclose.

 AcknowledgementsElicia Kennedy, MD Clinical Assistant Professor, Department of Emergency Medicine, University of Arkansas forMedical Sciences.

Elicia Kennedy is a member of the following medical societies: American College of Emergency Physicians andSociety for Academic Emergency Medicine.

Disclosure: Nothing to disclose.

Andy W Wong, MD Resident Physician, Department of Emergency Medicine, Wayne State University, DetroitReceiving Hospital

 Andy W Wong, MD is a member of the following medical societies: American College of Emergency Physiciansand Emergency Medicine Residents Association

Disclosure: Nothing to disclose.

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