Fever During and After Childbirth

1
Fever During and After Childbirth

• Advances in Maternal and Neonatal Health

2
Session Objectives

• To discuss best practices for management of
  infection during and after childbirth,
  especially
• Amnionitis
• Metritis
• To describe strategies for prevention of
  infection
• To distinguish between prophylactic and
  therapeutic use of antibiotics

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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

4
Providing Prophylactic Antibiotics (continued)

• Should be given 30 minutes before procedure to
  allow adequate blood levels at time of procedure
• Except with cesarean section, 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 1,500 mL or more, give second dose

Gyssens 1999 Polk and Christmas 2000.
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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.
6
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.
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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 dosages 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)

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Principles of Treatment with Antibiotics

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

9
Fever During Pregnancy and Labor Differential
Diagnosis

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

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Acute Pyelonephritis

• Treat, because of risks of
• Preterm labor
• Sepsis
• Easy to treat
• Inexpensive

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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

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Acute Pyelonephritis Subsequent Prophylaxis

• Recurrence of acute pyelonephritis in the same
  gestation is reported to be 1018
• Suppressive therapy 2.7 will get another
  urinary tract infection
• No suppressive therapy 2030 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 1998 Duff 1996.
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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

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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

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Amnionitis Antibiotics

• Prompt intrapartum initiation (rather than delay
  until after childbirth) 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 et al 1988.
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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. colimajor causes of newborn sepsis
• Anaerobic coverage is not necessary (unless
  cesarean section performed)

Hauth et al 1985.
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Management of Amnionitis

• Give combination of antibiotics until childbirth
• 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.
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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

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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
  19801996
• Gleaned exposure data from antenatal care
  records, medical documents, questionnaire to
  mother

Czeizel et al 2000.
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Aminoglycosides During Pregnancy Results

• No detectable teratogenesis from parenteral
  gentamicin, streptomycin, tobramycin or oral
  neomycin

Czeizel et al 2000.
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Fever After Childbirth Differential Diagnosis

• Metritis
• Pelvic abscess
• Peritonitis
• Breast engorgement
• Mastitis
• Breast abscess
• Wound abscess, wound seroma or wound hematoma
• Wound cellulitis

• Cystitis
• Acute pyelonephritis
• Deep vein thrombosis
• Pneumonia
• Atelectasis
• Uncomplicated malaria
• Severe/complicated malaria
• Typhoid
• Hepatitis

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Obstetric and Medical Factors Affecting
Postpartum Sepsis

• Intervention during labor and childbirth
• 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.
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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.
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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

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Management of Metritis

• Start antibiotics
• Ampicillin every 6 hours
• Gentamicin every 24 hours
• Metronidazole every 8 hours
• Assess if retained placental fragments

• All the while
• Give fluids
• Transfuse blood as needed
• Give pain medication
• Continue close monitoring
• Watch for shock
• Watch for development of abscess

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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

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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.
28
Managing Metritis Results

• More treatment failure with regimens other than
  clindamycin and an aminoglycoside RR 1.37
  (1.101.70)
• 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 (0.301.20)
• No difference in nephrotoxicity, lower cost

French and Smaill 2000.
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Septic Shock

• IV antibiotics for sick patients
• Antibiotics for
• Gram (penicillin, ampicillin)
• Gram - (gentamicin)
• Anaerobes (metronidazole)
• Adequate doses of antibiotics are necessary
• Aggressive fluid resuscitation (23 L to start)
• Look for abscess, peritonitis or other condition
  requiring surgery
• IV antibiotics may be necessary for longer if
  bacteremia

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Prevention Strategies

• Infection prevention practices for every
  childbirth
• Minimum manipulation
• High-level disinfected or sterile gloves for
  examination
• Avoid unnecessary procedures (e.g., episiotomy)

• Three Cleans
• Clean hands
• Clean surface
• Clean blade
• Plus
• Clean tie
• Clean perineum
• Clean nails

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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 and
  presence of bacteremia

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References

• American College of Obstetricians and
  Gynecologists (ACOG). 1998. ACOG Educational
  Bulletin Antimicrobial Therapy for Obstetric
  Patients, March 1998. ACOG Washington, DC.
• Czeizel AE et al. 2000. A teratological study of
  aminoglycoside antibiotic therapy during
  pregnancy. Scand J Infect Dis 32 309313.
• 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) 823828.

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References (continued)

• Gyssens IC. 1999. Preventing postoperative
  infections Current treatment recommendations.
  Drugs 57(2) 175185.
• Hauth JC et al. 1985. Term maternal and neonatal
  complications of acute chorioamnionitis. Obstet
  Gynecol 66(1) 5962.
• Hopkins L and F Smaill. 2000. Antibiotic
  prophylaxis regimens and drugs for cesarean
  section (Cochrane Review), in The Cochrane
  Library. Issue 1. Update Software Oxford.
• Kwast B. 1991. Puerperal sepsis Its contribution
  to maternal mortality. Midwifery 7(3) 102106.
• Polk Jr. HC and AB Christmas. 2000. Prophylactic
  antibiotics in surgery and surgical wound
  infections. Am Surg 66 105111.
• Sweet RL and RS Gibbs. 1998. Infectious Diseases
  of the Female Genital Tract, 3rd ed. Williams
  Wilkins Baltimore, Maryland.