Fever During And After Childbirth

Fever During and After Childbirth Advances in Maternal and Neonatal Health

Session Objectives 

Discuss best practices for management of infection during and after childbirth, especially: 

Amnionitis



Metritis



Describe strategies for prevention of infection



Distinguish between prophylactic and therapeutic use of antibiotics

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Providing Prophylactic Antibiotics 



Help prevent infection, which can result from certain procedures, including: 

Cesarean section



Manual removal of placenta



Correction of uterine inversion



Repair of ruptured uterus



Postpartum hysterectomy



Prolonged rupture of membranes (Group B streptococcus)

If infection is suspected or diagnosed, therapeutic antibiotics are more appropriate

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Providing Prophylactic Antibiotics (continued) 

Should be given 30 minutes before procedure, to allow adequate blood levels at time of procedure



Except at cesarean, give antibiotics when cord is clamped after delivery of newborn



One dose is enough (as effective as 3 doses or 24 hours of antibiotics)



If procedure is longer than 6 hours or blood loss is 1500 mL or more, give second dose.

Gyssens 1999; Polk and Christmas 2000. Fever During and After Childbirth

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Providing Prophylactic Antibiotics for Cesarean Section: Objective and Design 

Objective: To determine which antibiotic regimen is most effective in reducing infectious morbidity in women undergoing cesarean section



Methods: 51 randomized controlled trials



Outcomes: Fever, wound infection, urinary tract infection, other serious infections, adverse reactions, cost, newborn outcomes

Hopkins and Smaill 2000. Fever During and After Childbirth

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Providing Prophylactic Antibiotics for Cesarean Section: Results 

Ampicillin and 1st generation cephalosporin have similar efficacy in reducing postoperative endometritis 

No need for more broad spectrum agents or multiple doses



Need randomized controlled trial to test optimal timing (pre-operative vs. at cord clamp)

Hopkins and Smaill 2000. Fever During and After Childbirth

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Providing Therapeutic Antibiotics 

For general treatment of obstetrical infection or until diagnosis is made, give broad spectrum antibiotics



Treat specific infection with specific antibiotics



If response is poor after 48 hours:



Ensure adequate doses of antibiotics are being given  Re-evaluate woman for other infection or abscess  Treat based on reported microbial sensitivity End point is when: 

  

Woman is fever-free for 48 hours Clinical examination shows woman is improving Woman completes course of antibiotics (in all cases except metritis) Fever During and After Childbirth

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Principles of Treatment with Antibiotics 

Adequate dosing



Adequate duration



Continued re-evaluation of the patient

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Fever During Pregnancy and Labor: Differential Diagnosis 

Cystitis



Acute pyelonephritis



Septic abortion



Amnionitis



Pneumonia



Malaria



Typhoid



Hepatitis

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Acute Pyelonephritis 

Treat, because of risks of: 

Preterm labor



Sepsis



Easy to treat



Inexpensive

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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 feverfree 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

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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. Fever During and After Childbirth

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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

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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

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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.

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Amnionitis: Antibiotics (continued) 



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.

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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.

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Management of Amnionitis (continued) 

If cervix is favorable, induce labor with oxytocin



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

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Aminoglycosides During Pregnancy: Objective and Design 

Objective: 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.

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Aminoglycosides During Pregnancy: Results No detectable teratogenesis from parenteral gentamicin, streptomycin, tobramycin or oral neomycin

Czeizel et al 2000.

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Fever after Childbirth: Differential Diagnosis 

Metritis



Cystitis



Pelvic abscess



Acute pyelonephritis



Peritonitis



Deep vein thrombosis



Breast engorgement



Pneumonia



Mastitis



Atelectasis



Breast abscess





Wound abscess, wound seroma or wound hematoma

Uncomplicated malaria



Severe/complicated malaria



Typhoid



Hepatitis



Wound cellulitis

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Obstetric and Medical Factors Affecting Postpartum 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.

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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.

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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

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Management of Metritis 

Start antibiotics: 

Ampicillin every 6 hours



Give fluids



Gentamicin every 24 hours



Transfuse blood as needed



Give pain medication



Continue close monitoring



Watch for shock



Watch for development of abscess





All the while:

Metronidazole every 8 hours

Assess if retained placental fragments

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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

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Managing Metritis: Objective and Design 

Objective: 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.

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Managing Metritis: 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.

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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

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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

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Summary 

Many causes of fever during and after childbirth



Therapeutic antibiotics ONLY if disease is diagnosed



Duration or treatment dependent on disease, whether or not cesarean section has occurred or presence of bacteremia

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References American College of Obstetricians and Gynecologists (ACOG) Educational Bulletin: Antimicrobial Therapy for Obstetric Patients, March 1998. p. 292-300. Czeizel AE et al. 2000. A teratological study of aminoglycoside antibiotic therapy during pregnancy. Scand J Infect Dis 32: 309– 313. Duff P. 1996. Maternal and Perinatal Infections, in Obstetrics: Normal and Problem Pregnancy, 3rd ed. Gabbe SG, JR Niebyl and OL Simpson (eds). Churchill Livingstone: Edinburgh, Scotland. French LM and FM Smaill. 2000. Antibiotic regimens for endometritis after delivery (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford. Gibbs RS et al. 1988. A randomized trial of intrapartum versus immediate postpartum treatment of women with intra-amniotic infection. Obstet Gynecol 72(6): 823–828. Fever During and After Childbirth

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References (continued) Gyssens IC. 1999. Preventing postoperative infections: Current treatment recommendations. Drugs 57(2): 175–185. Hauth JC et al. 1985. Term maternal and neonatal complications of acute chorioamnionitis. Obstet Gynecol 66(1): 59–62. Hopkins L and F Smaill. 2000. Antibiotic prophylaxis regimens and drugs for cesarean section (Cochrane Review), in The Cochrane Library. Update Software: Oxford. Kwast B. 1991. Puerperal sepsis: Its contribution to maternal mortality. Midwifery 7(3): 102–106. Polk Jr. HC and AB Christmas. 2000. Prophylactic antibiotics in surgery and surgical wound infections. Am Surg 66: 105–111. Sweet RL and RS Gibbs. 1998. Infectious Diseases of the Female Genital Tract, 3rd ed. Williams & Wilkins: Baltimore, Maryland. Fever During and After Childbirth

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