Postpartum Infections Clinical Presentation

The history and course of the delivery is important in the evaluation of postpartum patients.

• Ascertain if the delivery was vaginal or cesarean.
• Ascertain if premature rupture of the membranes occurred.
• Determine if the patient had any prenatal care.
• Determine if the patient was diagnosed or treated for any infections during pregnancy or during the antepartum period.
• Assess the patient's symptoms.
• Features vary depending on the source of infection and may include the following:

  • Flank pain, dysuria, and frequency of UTIs
  • Erythema and drainage from the surgical incision or episiotomy site, in cases of postsurgical wound infections
  • Respiratory symptoms, such as cough, pleuritic chest pain, or dyspnea, in cases of respiratory infection or septic pulmonary embolus
  • Fever and chills
  • Abdominal pain
  • Foul-smelling lochia
  • Breast engorgement in cases of mastitis

Focus the physical examination on identifying the source of fever and infection. A complete physical examination, including pelvic and breast examinations, is necessary. Findings may include the following:

• Endometritis

  • Endometritis may be characterized by lower abdominal tenderness on one or both sides of the abdomen, adnexal and parametrial tenderness elicited with bimanual examination, and temperature elevation (most commonly >38.3°C).
  • Some women have foul-smelling lochia without other evidence of infection. Some infections, most notably caused by group A beta-hemolytic streptococci, are frequently associated with scanty, odorless lochia.
• Wound infections

  • Patients with wound infections, or episiotomy infections, have erythema, edema, tenderness out of proportion to expected postpartum pain, and discharge from the wound or episiotomy site.
  • Drainage from wound site should be differentiated from normal postpartum lochia and foul-smelling lochia, which may be suggestive of endometritis.
• Mastitis: Patients with mastitis have very tender, engorged, erythematous breasts. Infection frequently is unilateral.
• Urinary tract infections: Patients with pyelonephritis or UTIs may have costovertebral angle tenderness, suprapubic tenderness, and an elevated temperature.
• Respiratory tract infections: Evaluate for tachypnea, rales, crackles, rhonchi, and consolidation.
• Septic pelvic thrombophlebitis: Patients with septic pelvic thrombophlebitis, although rare, may have palpable pelvic veins. These patients also have tachycardia that is out of proportion to the fever.

Causes and risk factors may include the following:

• Endometritis

  • Route of delivery is the single most important factor in the development of endometritis.^[6]
  • The risk of endometritis increases dramatically after cesarean delivery.^{[6, 7]}
  • However, there is some evidence that hospital readmission for management of postpartum endometritis occurs more often in those who delivered vaginally.^[7]
  • Other risk factors include prolonged rupture of membranes, prolonged use of internal fetal monitoring, anemia, and lower socioeconomic status.^[6]
  • Perioperative antibiotics have greatly decreased the incidence of endometritis.^[6]
  • In most cases of endometritis, the bacteria responsible are those that normally reside in the bowel, vagina, perineum, and cervix.
  • The uterine cavity is usually sterile until the rupture of the amniotic sac. As a consequence of labor, delivery, and associated manipulations, anaerobic and aerobic bacteria can contaminate the uterus.
• Wound infections

  • Most often, the etiologic organisms associated with perineal cellulitis and episiotomy site infections are Staphylococcus or Streptococcus species and gram-negative organisms, as in endometritis.
  • Vaginal secretions contain as many as 10 billion organisms per gram of fluid. Yet, infections develop in only 1% of patients who had vaginal tears or who underwent episiotomies.
  • Those who underwent cesarean delivery have a higher readmission rate for wound infection and complications than those who delivered vaginally.^[8]
• Genital tract infections

  • Increased risk related to the duration of labor (ie prolonged labor increases risk of infection), use of internal monitoring devices, and number of vaginal examinations.^[9]
  • Genital tract infections are generally polymicrobial.
  • Gram-positive cocci and Bacteroides and Clostridium species are the predominant anaerobic organisms involved. Escherichia coli and gram-positive cocci are commonly involved aerobes.
• Mastitis

  • The most common organism reported in mastitis is Staphylococcus aureus.
  • The organism usually comes from the breastfeeding infant's mouth or throat.
  • Thrombosis
  • Numerous factors cause pregnant and postpartum women to be more susceptible to thrombosis. Pregnancy is known to induce a hypercoagulable state secondary to increased levels of clotting factors. Also, venous stasis occurs in the pelvic veins during pregnancy.
  • Although relatively rare, septic pelvic thrombosis is occasionally observed in the postpartum patient, who might have fever.
• Urinary tract infections

  • Bacteria most frequently found in UTIs are normal bowel flora, including E coli and Klebsiella,Proteus, and Enterobacter species.
  • Any form of invasive manipulation of the urethra (eg, Foley catheterization) increases the likelihood of a UTI.
• General risk factors

  • History of cesarean delivery
  • Premature rupture of membranes
  • Frequent cervical examination (Sterile gloves should be used in examinations. Other than a history of cesarean delivery, this risk factor is most important in postpartum infection.)
  • Internal fetal monitoring
  • Preexisting pelvic infection including bacterial vaginosis
  • Diabetes
  • Nutritional status
  • Obesity