POSTPARTUM (PUERPERAL) PYREXIA
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The definition of Puerperal pyrexia used for reporting rates of puerperal morbidity is a temperature of 38 C or more on any two of the first 10 days postpartum, or 38.7 C or more during the first 24 hrs postpartum.
Causes
Pelvic / Genito-urinary causes
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Urinary tract infection
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Endometritis
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Pelvic abscess
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Septic pelvic vein thrombophlebitis
Breast
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Breast engorgement
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Mastitis
Wound
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Wound infection – episiotomy, caesarean section wound, haematoma,
Chest
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Respiratory tract infections
Non infective causes
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Pulmonary embolism
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DVT
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Drug fevers
Uterine infection – usually polymicrobial in origin. Caused by organisms normally present in the normal vaginal flora that ascend into the upper genital tract. Common ones include group B streptococcus, anaerobic streptococci, aerobic and anaerobic gram negative bacilli. Haemolytic group A streptococcus generally causes severe infections and is a rising cause of maternal mortality in the UK.
Urinary tract infections – factors such as vaginal examinations in labour, catheterisations, asymptomatic bacteruria increase risk of UTIs. Pyelonephritis is particularly serious.
Management of Puerperal Pyrexia
History
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Symptoms of genital tract infections – offensive lochia, vaginal discharge, abdominal pain, diarrhoea
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Symptoms of breast disease e.g. pain, redness
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Symptoms of urinary tract infections - frequency, dysuria, loin pain
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Symptoms of respiratory infections - sore throat, cough, sputum
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Symptoms of DVT / PE – calf pain / swelling; pleurytic chest pain & haemoptysis
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Antenatal risk factors e.g. prolonged PROM
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Intrapartum events – method of delivery, trauma to perineum, manual removal of placenta, caesarean section.
Examination
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Pulse, BP, Temperature, respiratory rate
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Examine chest, heart, skin to look for signs of infection
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Examine abdomen – including abdominal wound, uterine / renal angle tenderness
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Speculum / Bimanual exam – Look at episiotomy site, offensive lochia, cervical excitation, open Os, uterus – size, tenderness,
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Legs – signs of DVT
Investigations
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FBC, CRP
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Blood cultures particularly at peak of pyrexia
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Swabs – high vaginal, endocervical and Chlamydia swabs
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MSU
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Wound swabs
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Chest x-ray & sputum for culture and sensitivity if chest infection suspected.
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Ultrasound / CT scan – if indicated e.g. suspicion of pelvic abscess
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Venous Dopplers – if DVT suspected
Treatment
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Treat underlying cause
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Uterine infection – treat with broad spectrum antibiotics
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Respiratory/wound/ urinary tract infections – treat with appropriate antibiotics
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Abscess – incision & drainage
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Thrombophlebitis – treat with NSAIDs
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Thrombosis – treat with anticoagulants
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