Puerperal pyrexia is defined as the presence of a fever in a woman, within fourteen days 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 World Health Organization (WHO) reported that 98% of these deaths occur in developing countries, where the leading cause of maternal mortality is perinatal infection.¹

There are many causes of such a fever, but in the days prior to antibiotics it was a sign which was very much dreaded as it had a very poor prognosis.² These days, with prompt recognition and treatment of the underlying cause, the outcome is considerably better.

Aetiology

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, anaerobes, Group A streptococcus spp., Staphylococcus spp. and Clostridium welchii (rare, but serious).

• Mastitis:
  • Painful, hard, red breast abscess.
  • Nipple trauma and cellulitis.
  • Usually caused by Staphylococcus spp.

• Painful, red suture line.
• Deep tenderness on palpation.
• Lochia pink/coloured.

• Caused by venous stasis.
• Painful, swollen calf.
• 5 cases of ovarian vein thrombophlebitis have been reported in France.⁶

• Pyrexia in a recently delivered mother may also be due to causes common to all, such as viral infection or chest infection.
• A case of glandular fever was recently reported.⁷

Presentation

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.

History

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?

Examination

• 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.

Investigations

• High vaginal swab.
• Urine culture and microscopy.
• Other swabs as felt necessary, e.g. wound swabs, throat swabs.
• FBC.
• Blood culture.
• Ultrasound scan may be required to assist diagnosis of retained products of conception.

Management

General measures

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.

Pharmacological

When prescribing drugs it is important to ascertain whether or not the mother is breast-feeding, as this may influence the choice of agent used:

• Analgesia may be required.
• Antibiotics should be commenced after taking specimens and should not be delayed until the results are available.
• A broad-spectrum antibiotic with activity against Gram-positive cocci, such as penicillin or erythromycin, may be used in the first instance and amended when the results are available or if there is no response.
• More than one antibiotic may be needed in some instances, e.g. if it is thought that anaerobes may be involved.
• If endometritis has been diagnosed, the patient should be referred to secondary care for inpatient intravenous treatment with clindamycin and gentamicin in the absence of contra-indications.⁸
• Intravenous agents may be required initially
• If the fever is prolonged then treatment with heparin should also be considered.⁹

Surgical

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.

Complications

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:

• 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.

Prognosis

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.

Prevention

• Scrupulous attention to hygiene should be used during all examinations and instrumentation during and after labour.
• Some centres advocate the use of prophylactic antibiotics during prolonged labour.²
• 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.¹⁰
• 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.

Document references

1. Maternal deaths worldwide drop by third, World Health Organization, 2010
2. Ledger WJ; Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. 2003 Dec;29(6):364-73. [abstract]
3. Simoes E, Kunz S, Bosing-Schwenkglenks M, et al; Association between method of delivery and puerperal infectious complications in the perinatal database of Baden-Wurttemberg 1998-2001. Gynecol Obstet Invest. 2005;60(4):213-7. Epub 2005 Jul 26. [abstract]
4. Caesarean section, NICE Clinical Guideline (2004)
5. Thromboembolic Disease in Pregnancy and the Puerperium: Acute Management, Royal College of Obstetricians and Gynaecologists (2007)
6. 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. [abstract]
7. Tibbitts GM, Vogt HB, Dimitrievich E; Infectious mononucleosis presenting as postpartum fever. S D J Med. 2004 May;57(5):185-8. [abstract]
8. French LM, Smaill FM; Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD001067. [abstract]
9. French L; Prevention and treatment of postpartum endometritis. Curr Womens Health Rep. 2003 Aug;3(4):274-9. [abstract]
10. Postnatal care: Routine postnatal care of women and their babies, NICE Clinical Guideline (2006)

Internet and further reading

• Maharaj D; Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007 Jun;62(6):393-9. [abstract]
• Maharaj D; Puerperal Pyrexia: a review. Part II. Obstet Gynecol Surv. 2007 Jun;62(6):400-6. [abstract]
• 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. [abstract]

Acknowledgements