eMedicine Specialties > Emergency Medicine > Obstetrics & Gynecology
Pregnancy, Postpartum Infections: Treatment & Medication
Updated: Aug 10, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
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.
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
Probenecid may increase effects; concurrent use with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)
Documented hypersensitivity
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.
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
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
Documented hypersensitivity; severe hepatic dysfunction
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.
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
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)
Documented hypersensitivity; non–dialysis-dependent renal insufficiency
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.
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
Increases duration of neuromuscular blockade, induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption
Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis
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.
Adult
500 mg PO q6h
Pediatric
<40 kg: 12.5 mg/kg/d PO q6h
>40 kg: 125 mg PO q6h
Decreases efficacy of oral contraceptives; increases effects of anticoagulants; probenecid and disulfiram may increase penicillin levels; concurrent tetracyclines may decrease effectiveness
Documented hypersensitivity
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.
Adult
500 mg PO/IV q6h
Pediatric
15-30 mg/kg/d PO/IV divided bid/tid for 7 d
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
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.
Adult
500 mg PO qid for 10-14 d
Pediatric
Not established
Coadministration with aminoglycosides increase nephrotoxic potential
Documented hypersensitivity
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
More on Pregnancy, Postpartum Infections |
| Overview: Pregnancy, Postpartum Infections |
| Differential Diagnoses & Workup: Pregnancy, Postpartum Infections |
 Treatment & Medication: Pregnancy, Postpartum Infections |
| Follow-up: Pregnancy, Postpartum Infections |
| References |
| « Previous Page | Next Page » |
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Further Reading
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
