eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology

Pregnancy, Postpartum Infections

Andy W Wong, MD, Resident Physician, Department of Emergency Medicine, Wayne State University, Detroit Receiving Hospital
Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital

Updated: Aug 10, 2009

Introduction

Background

Postpartum infections comprise a wide range of entities that can occur after vaginal and cesarean delivery or during breastfeeding. In addition to trauma sustained during the birth process or cesarean procedure, physiologic changes during pregnancy contribute to the development of postpartum infections.¹ The typical pain that many women feel in the immediate postpartum period also makes it difficult to discern postpartum infection from postpartum pain.

Postpartum patients are frequently discharged within a couple days following delivery. The short period of observation may not afford enough time to exclude evidence of infection prior to discharge from the hospital. In one study, 94% of postpartum infection cases were diagnosed after discharge from the hospital.² Postpartum fever is defined as a temperature greater than 38.0°C on any 2 of the first 10 days following delivery exclusive of the first 24 hours.³ The presence of postpartum fever is generally accepted among clinicians as a sign of infection that must be determined and managed.

Pathophysiology

Local spread of colonized bacteria is the most common etiology for postpartum infection following vaginal delivery. Endometritis is the most common infection in the postpartum period. Other  postpartum infections include (1) postsurgical wound infections, (2) perineal cellulitis, (3) mastitis, (4) respiratory complications from anesthesia, (5) retained products of conception, (6) urinary tract infections (UTIs), and (7) septic pelvic phlebitis. Wound infection is more common with cesarean delivery.

Frequency

United States

Overall US rates for incidence and prevalence of postpartum infections is lacking. In a study by Yokoe et al in 2001, 5.5% of vaginal deliveries and 7.4% of cesarean deliveries resulted in a postpartum infection.² The overall postpartum infection rate was 6.0%. Endometritis accounted for nearly half of the infections in patients following cesarean delivery (3.4% of cesarean deliveries). Mastitis and urinary tract infections together accounted for 5% of vaginal deliveries.²

Mortality/Morbidity

In most reviews, maternal death rates associated with infection range from 4-8%, or approximately 0.6 maternal deaths per 100,000 live births.

A pregnancy-related mortality surveillance by the Centers for Disease Control and Prevention indicated infection accounted for about 11.6% of all deaths following pregnancy that resulted in a live birth, stillbirth, or ectopic.⁴

Race

The risk of postpartum urinary tract infection is increased in the African American, Native American, and Hispanic populations.⁵

Clinical

History

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

Physical

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 may be characterized by lower abdominal tenderness on one or both sides of the abdomen, adnexal and parametrial tenderness elicited with bimanual examination, 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.
• Patients with wound infections, or episiotomy infections, have erythema, edema, tenderness, and discharge from the wound or episiotomy site.
• Patients with mastitis have very tender, engorged, erythematous breasts. Infection frequently is unilateral.
• Patients with pyelonephritis or urinary tract infections (UTIs) may have tenderness at the costovertebral angle and an elevated temperature.
• Respiratory signs, such as rales, consolidation, or rhonchi in pneumonia, are possible.
• Patients with septic pelvic thrombosis, although rare, may have palpable pelvic veins. These patients also have tachycardia that is out of proportion to the fever.

Causes

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

Differential Diagnoses

Other Problems to Be Considered

Endometritis
Mastitis
Retained products of conception
Septic pelvic phlebitis

Workup

Laboratory Studies

Laboratory studies are directed at elucidating the severity of illness as well as the etiology of the infection. Mild cases of mastitis usually do not require laboratory investigation. Wound infections and infections of the genital tract makes it more difficult to ascertain the extent of involvement. Laboratory studies should include the following:

• Complete blood count
• Electrolytes
• Blood cultures, if sepsis is suspected
• Urinalysis, with cultures and sensitivity tests
• Cervical or uterine cultures
• Wound cultures, if appropriate
• Lactate, if sepsis suspected

Imaging Studies

• Pelvic ultrasonography may be helpful in detecting retained products of conception, pelvic abscess, or infected hematoma.
• Contrast-enhanced CT or MRI are useful in establishing the diagnosis of septic pelvic thrombosis.¹⁰
• In some cases, a contrast-enhanced CT examination of the abdomen and pelvis may be helpful if concurrent concern is present for other non-pregnancy–related abdominal/pelvic sources of the infection (eg, appendicitis, colitis).

Treatment

Prehospital Care

The most important aspect of prehospital care in a postpartum patient with a suspected infection is to ensure adequate fluid volume and to prevent sepsis and shock. 

• Provide aggressive fluid management.
• Begin cardiac monitoring and administer oxygen.

Emergency Department Care

ED care is focused on identifying the source of the infection, followed by appropriate antimicrobial therapy and referral. 

• Postpartum endometritis treatment
  • In most cases, initial antimicrobial treatment is a combination of an aminoglycoside and clindamycin. Alternatively, an aminoglycoside plus metronidazole with or without ampicillin may also be used.¹¹
  • Mild cases of endometritis after vaginal delivery may be treated with oral antimicrobial agents (eg, doxycycline, clindamycin).
  • Moderate-to-severe cases, including those involving cesarean deliveries, should be treated with parenteral broad-spectrum antimicrobials.
  • In general, the patient's condition rapidly improves after antibiotics are administered.
• Wound infection or episiotomy infection treatment
  • Drainage, debridement, and irrigation may be required.
  • Broad-spectrum antibiotics should be administered.   
• Mastitis treatment
  • Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or cloxacillin, or clindamycin in penicillin-allergic patients.¹¹
  • Use local measures, such as ice packs, analgesics, and breast support.¹¹
  • The mother should be told to continue to breastfeed the baby.
  • Continued breastfeeding prevents breast engorgement and subsequent pain.
  • If a breast abscess is present, or breastfeeding is not possible, a breast pump should be used in lactating women.¹¹
  • Mastitis could lead to abscess formation, which may require surgical drainage.
• UTI treatment
  • Administer fluids, if evidence of dehydration exists.
  • Appropriate antibiotics should be used. These typically are trimethoprim-sulfamethoxazole, nitrofurantoin, ciprofloxacin, levofloxacin, or ofloxacin.^12,13,14
  • The above antibiotics (including fluoroquinolones) for UTI are considered safe by the American Academy of Pediatrics (AAP) for nursing infants, with no reported effects seen in infants who are breastfeeding.^12,13   
  • Although the AAP considers fluoroquinolones to be safe for breastfeeding mothers, they also recommend that the safest drug should be prescribed.¹² Fluoroquinolones are excreted in breast milk with unknown absorption by the infant. The potential for pediatric cartilage and joint damage were extrapolated from juvenile animal studies.^15,16 For this reason, fluoroquinolones should not be first-line therapy and temporary discontinuation of breastfeeding should be considered.^15,17
  • Trimethoprim-sulfamethoxazole and nitrofurantoin are to be avoided in mothers with breastfeeding infants with G-6-PD deficiency.^12,13
  • When possible, the medication should be taken just after the patient has breastfed the infant to minimize drug exposure.¹²
  • Fever and flank pain should raise suspicion for pyelonephritis, and inpatient hospital admission should be considered. Ampicillin and gentamicin may also be given to lactating mothers with no reported effects on breastfeeding infants.¹²
• Septic pelvic phlebitis treatment
  • Broad-spectrum antibiotics should be administered. Initial choice of antibiotics should cover gram-positive, gram-negative, and anaerobic organisms. Ampicillin and gentamicin with metronidazole or clindamycin is a common regimen.^11,10
  • Anticoagulation may be used, and it should be noted that there exist no universal guideline or recommendation for anticoagulation therapy in septic pelvic thrombosis. Initial bolus of 60 units/kg (4000 units maximum) followed by 12 units/kg/h (maximum of 1000 units/h) is recommended.⁶ The aPTT is monitored for 2-3 times the normal value.^11,10
  • Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg.^11,10

Consultations

Obstetric consultation must be obtained in cases of endometritis, postsurgical wound infections and cellulitis, retained products of conception, and septic pelvic phlebitis. If an obstetrician/gynecologist is unavailable, seek consultation with a general surgeon.

Medication

Antibiotics are the mainstay of treatment. Pain medications also are important, because patients often have discomfort. Patients with septic pelvic thrombophlebitis must undergo anticoagulation therapy, and they should receive broad-spectrum antibiotics.

Antibiotics

Antibiotic coverage for Bacteroides, group B and A streptococci, Enterobacteriaceae organisms, and Chlamydia trachomatis in endometritis is suggested. Wound and episiotomy site infections require broad-spectrum antibiotics as well, because of the polymicrobial nature of the local flora. Consider coverage primarily for Staphylococcus aureus infection in postpartum mastitis.

Cefoxitin

Second-generation cephalosporin indicated for gram-positive coccal and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin. Must be used with clindamycin or doxycycline and an aminoglycoside for the treatment of endometritis, for which it is a drug of choice. Particularly important in early postpartum (first 48 h) infections.

Dosing

Adult

2 g IV q6-8h

Pediatric

80-160 mg/kg/d IV divided q4-6h; higher doses for more severe infections; not to exceed 12 g/d

Interactions

Probenecid may increase effects; concurrent use with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in previously diagnosed colitis

Doxycycline

Inhibits protein synthesis and thus bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Must be used with other drugs for endometritis. Used often for outpatient therapy for late postpartum (48 h to 6 wk after delivery) treatment.

Dosing

Adult

100 mg PO/IV q12h for 14 d

Pediatric

<8 years: Contraindicated
>8 years: 2-5 mg/kg/d PO/IV qd or divided bid

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can permanently discolor teeth; Fanconi-like syndrome may occur with outdated tetracyclines

Gentamicin (Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Commonly used with an agent against gram-positive organisms in treatment of endometritis. Consider if penicillins or other less toxic drugs are contraindicated, when clinically indicated, and in mixed infections caused by susceptible staphylococci and gram-negative organisms. Dosing regimens are numerous and adjusted on the basis of CrCl and changes in volume of distribution. Gentamicin may be given IV/IM.

Dosing

Adult

1 mg/kg IV q12h

Pediatric

<5 years: Not established
>5 years: 1.5-2.5 mg/kg/dose IV/IM q8h or 6-7.5 mg/kg/d IV/IM divided q8h; not to exceed 300 mg/d

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents thus prolong respiratory depression; coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non–dialysis-dependent renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (patients not undergoing dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment

Clindamycin

Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at the bacterial ribosome where it binds preferentially to the 50S ribosomal subunit, causing bacterial growth inhibition. Must be used with other drugs in the treatment of endometritis. Second drug of choice, after dicloxacillin, in postpartum mastitis.

Dosing

Adult

450-900 mg IV/IM q8h or 300 mg PO q6h

Pediatric

20-40 mg/kg/d IV/IM divided tid/qid or 8-20 mg/kg/d PO as hydrochloride, with 8-25 mg/kg/d as palmitate divided tid/qid

Interactions

Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Dicloxacillin

Bactericidal antibiotic that inhibits cell wall synthesis. Used in treatment of infections caused by penicillinase-producing staphylococci. Primary drug of choice used for postpartum mastitis to cover S aureus.

Dosing

Adult

500 mg PO q6h

Pediatric

<40 kg: 12.5 mg/kg/d PO q6h
>40 kg: 125 mg PO q6h

Interactions

Decreases efficacy of oral contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels; concurrent tetracyclines may decrease effectiveness

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor PT in patients taking anticoagulant medications; toxicity may increase in renal impairment

Metronidazole

Used with heparin and third-generation parenteral cephalosporin in the treatment of septic pelvic vein thrombophlebitis to cover streptococci and Bacteroides and Enterobacteriaceae species.

Dosing

Adult

500 mg PO/IV q6h

Pediatric

15-30 mg/kg/d PO/IV divided bid/tid for 7 d

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy

Cephalexin

First-generation cephalosporin used to cover S aureus in mastitis. Encourage the mother to continue breastfeeding to shorten duration of symptoms. Another DOC for postpartum mastitis.

Dosing

Adult

500 mg PO qid for 10-14 d

Pediatric

Not established

Interactions

Coadministration with aminoglycosides increase nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment

Follow-up

Further Inpatient Care

• Patients with early postpartum endometritis (especially after cesarean delivery) should be admitted, as should any patient with suspected septic pelvic vein thrombosis. Postsurgical wound infections may also require inpatient management, particularly if there is extensive involvement of surrounding soft tissues, intractable pain, and fever.

Further Outpatient Care

• All patients with a postpartum infection should undergo follow-up with an obstetrician.

Complications

• Scarring
• Infertility
• Sepsis
• Septic shock
• Death

Prognosis

• The prognosis for postpartum infections is good with prompt and appropriate therapy.

Patient Education

• For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center. Also, see eMedicine's patient education article Postpartum Perineal Care.

Miscellaneous

Medicolegal Pitfalls

• Failure to diagnose
• Inappropriate antibiotics

References

1. Cunningham G, Levano KJ, Gilstrap LC, et al. Williams Obstetrics. 22^nd ed. McGraw-Hill; 2005.

2. Yokoe DS, Christiansen CL, Johnson R, Sandu KE, et al. Epidemiology of and Surveillance for Postpartum Infectious. Emerg Infect Dis. Sep-Oct 2001;7(5):837-41. [Medline].

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4. Chang J, Elam-Evans LD, Berg CJ, Herndon J, Flowers L, Seed KA, et al. Pregnancy-related mortality surveillance--United States, 1991--1999. MMWR Surveill Summ. Feb 21 2003;52(2):1-8. [Medline].

5. Schwartz MA, Wang CC, Eckert LO, Critchlow CW. Risk factors for urinary tract infection in the postpartum period. Am J Obstet Gynecol. Sep 1999;181(3):547-53. [Medline].

6. Monif GR, Baker DA. Infectious Diseases in Obstetrics and Gynecology. 6^th ed. Informa HealthCare; 2008.

7. Atterbury JL, Groome LJ, Baker SL, Ross EL, Hoff C. Hospital readmission for postpartum endometritis. J Matern Fetal Med. Sep-Oct 1998;7(5):250-4. [Medline].

8. Newton ER, Prihoda TJ, Gibbs RS. A clinical and microbiologic analysis of risk factors for puerperal endometritis. Obstet Gynecol. Mar 1990;75(3 Pt 1):402-6. [Medline].

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

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11. Chaim W, Burstein E. Postpartum infection treatments: a review. Expert Opin Pharmacother. Aug 2003;4(8):1297-313. [Medline].

12. [Guideline] American Academy of Pediatrics Committee on Drugs. Transfer of drugs and other chemicals into human milk. Pediatrics. Sep 2001;108(3):776-89. [Medline].

13. Kaiser J, McPherson V, Kaufman L, Huber T. Clinical inquiries. Which UTI therapies are safe and effective during breastfeeding?. J Fam Pract. Mar 2007;56(3):225-8. [Medline].

14. Wagenlehner FM, Weidner W, Naber KG. An update on uncomplicated urinary tract infections in women. Curr Opin Urol. Jul 2009;19(4):368-74. [Medline].

15. Cipro package insert. West Have, Conn. Bayer Pharmaceuticals Corporation. April 2009.

16. Grady R. Safety profile of quinolone antibiotics in the pediatric population. Pediatr Infect Dis J. Dec 2003;22(12):1128-32. [Medline].

17. Bar-Oz B, Bulkowstein M, Benyamini L, Greenberg R, Soriano I, Zimmerman D. Use of antibiotic and analgesic drugs during lactation. Drug Saf. 2003;26(13):925-35. [Medline].

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19. Del Priore G, Jackson-Stone M, Shim EK, Garfinkel J, Eichmann MA, Frederiksen MC. A comparison of once-daily and 8-hour gentamicin dosing in the treatment of postpartum endometritis. Obstet Gynecol. Jun 1996;87(6):994-1000. [Medline].

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Keywords

postpartum infection, endometritis, puerperal infection, postsurgical wound infections, perineal cellulitis, mastitis, retained products of conception, urinary tract infections, UTI, septic pelvic phlebitis, pyelonephritis, genital tract infections, thrombosis, perineal cellulitis, episiotomy, respiratory complications from anesthesia

Contributor Information and Disclosures

Author

Andy W Wong, MD, Resident Physician, Department of Emergency Medicine, Wayne State University, Detroit Receiving Hospital
Andy W Wong, MD is a member of the following medical societies: American College of Emergency Physicians and Emergency Medicine Residents Association
Disclosure: Nothing to disclose.

Coauthor(s)

Adam J Rosh, MD, MS, Assistant Professor, Department of Emergency Medicine, Wayne State University/Detroit Receiving Hospital
Adam J Rosh, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Assaad J Sayah, MD, Chief, Department of Emergency Medicine, Cambridge Health Alliance
Assaad J Sayah, MD is a member of the following medical societies: National Association of EMS Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Mark Zwanger, MD, MBA, Assistant Professor, Department of Emergency Medicine, Thomas Jefferson University
Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association
Disclosure: Medicines Company Consulting fee Consulting; Pfizer Salary Employment

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Elicia S Kennedy, MD to the development and writing of this article.

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