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

Fever During and After Childbirth 2

 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

Fever During and After Childbirth 3

 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 4
 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 5
 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 6
 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 7

Principles of Treatment with Antibiotics

 Adequate dosing
 Adequate duration
 Continued re-evaluation of the patient

Fever During and After Childbirth 8

 Fever During Pregnancy and Labor:
Differential Diagnosis

 Cystitis
 Acute pyelonephritis
 Septic abortion
 Amnionitis
 Pneumonia
 Malaria
 Typhoid
 Hepatitis

Fever During and After Childbirth 9

 Acute Pyelonephritis

 Treat, because of risks of:

 Preterm labor
 Sepsis
 Easy to treat
 Inexpensive

Fever During and After Childbirth 10

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

Fever During and After Childbirth 11

 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 12
 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

Fever During and After Childbirth 13

 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

Fever During and After Childbirth 14

 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. Fever During and After Childbirth 15

 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. Fever During and After Childbirth 16

 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. Fever During and After Childbirth 17

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

Fever During and After Childbirth 18

 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. Fever During and After Childbirth 19

 Aminoglycosides During
Pregnancy: Results

No detectable teratogenesis from parenteral gentamicin,

streptomycin, tobramycin or oral neomycin

Czeizel et al 2000. Fever During and After Childbirth 20

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

Fever During and After Childbirth 21

 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. Fever During and After Childbirth 22

 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 During and After Childbirth 23

 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

Fever During and After Childbirth 24

 Management of Metritis

 Start antibiotics: All the while:

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

Fever During and After Childbirth 25

 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

Fever During and After Childbirth 26

 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. Fever During and After Childbirth 27

 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. Fever During and After Childbirth 28

 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

Fever During and After Childbirth 29

 Prevention Strategies

 Infection prevention Three Cleans:

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

Fever During and After Childbirth 30

 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

Fever During and After Childbirth 31

 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 32

 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 33