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Post-Natal Care (NUCOG 12) » Notes
POSTPARTUM (PUERPERAL) PYREXIA
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POSTPARTUM (PUERPERAL) PYREXIA

  • 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

  • Urinary tract infection
  • Endometritis
  • Pelvic abscess
  • Septic pelvic vein thrombophlebitis

Breast

  • Breast engorgement
  • Mastitis

Wound

  • Wound infection – episiotomy, caesarean section wound, haematoma,

Chest

  • Respiratory tract infections

Non infective causes

  • Pulmonary embolism
  • DVT
  • 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

  • Symptoms of genital tract infections – offensive lochia, vaginal discharge, abdominal pain, diarrhoea
  • Symptoms of breast disease e.g. pain, redness
  • Symptoms of urinary tract infections  - frequency, dysuria, loin pain
  • Symptoms of respiratory infections - sore throat, cough, sputum
  • Symptoms of DVT / PE – calf pain / swelling; pleurytic chest pain & haemoptysis
  • Antenatal risk factors e.g. prolonged PROM
  • Intrapartum events – method of delivery, trauma to perineum, manual removal of placenta, caesarean section.

Examination

  • Pulse, BP, Temperature, respiratory rate
  • Examine chest, heart, skin to look for signs of infection
  • Examine abdomen – including abdominal wound, uterine / renal angle tenderness
  • Speculum / Bimanual exam – Look at episiotomy site, offensive lochia, cervical excitation, open Os, uterus – size, tenderness,
  • Legs – signs of DVT

Investigations

  • FBC, CRP
  • Blood cultures particularly at peak of pyrexia
  • Swabs – high vaginal, endocervical and Chlamydia swabs
  • MSU
  • Wound swabs
  • Chest x-ray & sputum for culture and sensitivity if chest infection suspected.
  • Ultrasound / CT scan – if indicated e.g. suspicion of pelvic abscess
  • Venous Dopplers – if DVT suspected

Treatment

  • Treat underlying cause
  • Uterine infection – treat with broad spectrum antibiotics
  • Respiratory/wound/ urinary tract infections – treat with appropriate antibiotics
  • Abscess – incision & drainage
  • Thrombophlebitis – treat with NSAIDs
  • Thrombosis – treat with anticoagulants
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