Puerperal pyrexia is defined as the presence of a fever in a woman, within six weeks of giving birth, which is greater than or equal to 38°C.
Even in the 21st century, approximately 60,000 women die of pregnancy-related causes each year, the majority of these occurring in developing countries. In the UK, sepsis in the puerperium remains an important cause of maternal death. Sepsis from Group A beta-haemolytic streptococci (GAS) was responsible for 13 maternal deaths between 2006-2008.
Specific causes of puerperal pyrexia may include:
- Urinary tract infection:
- Frequency, dysuria, haematuria.
- Rigors from pyelonephritis.
- 95% caused by Escherichia coli, Proteus spp. and Klebsiella spp.
- Genital tract infection:
- Tender bulky uterus.
- Prolonged bleeding/pink or discoloured lochia.
- Painful inflamed perineum.
- May be caused by E. coli, other anaerobes, Group A streptococcus, Staphylococcus spp. and Clostridium welchii (rare, but serious).
- Painful, hard, red breast abscess.
- Nipple trauma and cellulitis.
- Usually caused by Staphylococcus spp.
- Postoperative infection following Caesarean section:
There is a significantly increased risk of postpartum septicaemia, wound problems and fever following lower segment Caesarean section (LSCS). In the UK there is an 8% risk of infection following LSCS, and antibiotic prophylaxis during the operation should be offered routinely. Prophylaxis reduces endometriosis by 66-75% and also reduces rate of wound infection. Presenting features may include:
- Painful, red suture line.
- Deep tenderness on palpation.
- Lochia pink/coloured.
- Deep venous thrombosis:
- Caused by venous stasis.
- Painful, swollen calf.
- Five cases of ovarian vein thrombophlebitis have been reported in France.
- Other infections:
- Pyrexia in a recently delivered mother may also be due to causes common to all, such as viral infection or chest infection.
- Glandular fever has also been reported.
The symptoms with which the mother presents may well provide some idea of the source of the infection or there may be many symptoms referring to more than one system, which will require a systematic method of determining the problem.
A full history should be taken, to include a full history of the delivery:
- When did the membranes rupture?
- Length of labour.
- Instrumentation used.
- Sutures required.
- Was the placenta complete?
- Was there any bleeding during or after delivery?
- Take the patient's temperature.
- Palpate the uterus to assess size and tenderness.
- Assess any perineal wounds and lochia.
- Examine the breasts.
- Examine the chest for signs of infection.
- Examine the abdomen.
- Examine the legs for possible thromboses.
- High vaginal swab.
- Urine culture and microscopy.
- Other swabs as felt necessary, eg wound swabs, throat swabs.
- Blood culture.
- Ultrasound scan may be required to assist diagnosis of retained products of conception.
Ice packs may be helpful for pain from perineal wounds or mastitis.
Rest and adequate fluid intake are required, particularly for mothers who continue to breast-feed.
The following signs and symptoms should prompt urgent referral for hospital assessment and, if the woman appears seriously unwell, by emergency ambulance:
- Pyrexia (greater than or equal to 38°C).
- Sustained tachycardia (≥90 beats/minute).
- Breathlessness (respiratory rate ≥20 breaths/minute).
- Abdominal or chest pain.
- Diarrhoea and/or vomiting.
- Uterine or renal angle pain and tenderness.
- The woman is generally unwell or seems unduly anxious or distressed.
Prophylaxis should be considered for close family members if Group A streptococcal infection is suspected.
Administration of intravenous broad-spectrum antibiotics within one hour of suspicion of severe sepsis, with or without septic shock, is recommended:
- Analgesia may be required. NB: non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for pain relief in cases of sepsis, as they impede the ability of polymorphs to fight GAS infection.
- Antibiotics should be commenced after taking specimens and should not be delayed until the results are available.
- A combination of either piperacillin/tazobactam or a carbapenem plus clindamycin provides one of the broadest ranges of treatment for severe sepsis.
- Meticillin-resistant Staphylococcus aureus (MRSA) may be resistant to clindamycin; hence, if the woman is or is highly likely to be MRSA-positive, vancomycin or teicoplanin may be added until sensitivity is known.
- Breast-feeding limits the use of some antimicrobials, hence the advice of a consultant microbiologist should be sought at an early stage.
- Intravenous immunoglobulin (IVIg) is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed. It has an immunomodulatory effect and in staphylococcal and streptococcal sepsis also neutralises the super-antigen effect of exotoxins. It also inhibits production of tumour necrosis factor and interleukins.
- If the fever is prolonged then treatment with heparin should also be considered.
Surgical intervention may be required if it is thought that an abscess has formed, as in this case the fever will not settle until the abscess has been incised and drained.
The possible complications of the infection will depend on the site, although several complications such as septicaemia, pulmonary embolus, disseminated intravascular coagulation and pneumonia are common to all. Severe sepsis with acute organ dysfunction has a mortality rate of 20-40%, rising to around 60% if septicaemic shock develops.
- Genital tract infection may lead to abscess formation, adhesions, peritonitis, haemorrhage and subsequent infertility if not treated early and aggressively.
- Urinary tract infection may progress to pyelonephritis and renal scarring if left untreated.
- Mastitis may lead to the formation of breast abscesses if treatment is not started early.
The majority of patients will make a full recovery with no lasting effects if treated speedily with appropriate antibiotic therapy and fluids.
However, the possibility of septicaemia and lasting sequelae or even death are still good reasons to treat all cases of puerperal pyrexia early and aggressively.
- Scrupulous attention to hygiene should be used during all examinations and use of instrumentation during and after labour.
- Some centres advocate the use of prophylactic antibiotics during prolonged labour.
- Catheterisation should be avoided where possible.
- Early mobilisation of delivered mothers will help to protect against venous thrombosis.
- New mothers should be helped to acquire the skills required for successful breast-feeding.
- Perineal wounds should be cleaned and sutured as soon as possible after delivery.
- All blood losses and the completeness of the placenta should be recorded at all deliveries.
Further reading & references
- Maharaj D; Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007 Jun;62(6):393-9.
- Maharaj D; Puerperal Pyrexia: a review. Part II. Obstet Gynecol Surv. 2007 Jun;62(6):400-6.
- Dunn PM; Oliver Wendell Holmes (1809-1894) and his essay on puerperal fever. Arch Dis Child Fetal Neonatal Ed. 2007 Jul;92(4):F325-7.
- Sepsis following Pregnancy, Bacterial; Royal College of Obstetricians and Gynaecologists (April 2012)
- Maternal deaths worldwide drop by third, World Health Organization, 2010
- Saving Mothers' Lives. Reviewing maternal deaths to make motherhood safer: 2006-2008; Centre for Maternal and Child Enquiries (CMACE), BJOG, Mar 2011
- Caesarean section, NICE Clinical Guideline (November 2011)
- Smaill FM, Gyte GM; Antibiotic prophylaxis versus no prophylaxis for preventing infection after Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007482.
- Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management; Royal College of Obstetricians and Gynaecologists (2007)
- Quarello E, Desbriere R, Hartung O, et al; Postpartum ovarian vein thrombophlebitis: report of 5 cases and review of the literature. J Gynecol Obstet Biol Reprod (Paris). 2004 Sep;33(5):430-40.
- Tibbitts GM, Vogt HB, Dimitrievich E; Infectious mononucleosis presenting as postpartum fever. S D J Med. 2004 May;57(5):185-8.
- Sepsis in Pregnancy, Royal College of Obstetricians and Gynaecologists (April 2012)
- Postnatal care: Routine postnatal care of women and their babies; NICE Clinical Guideline (2006)
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Dr Hayley Willacy
Dr Hayley Willacy
Dr John Cox