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
Emergency Department 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. [13]
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.
A review of trials for antibiotic regimens for the treatment of endometritis by French and Smaill concluded that gentamicin in combination with clindamycin is appropriate for endometritis. [14] In an update of these findings, on the basis of a Cochrane review of 42 trials comprising more than 4200 patients, investigators confirmed combination therapy with gentamicin and clindamycin remains appropriate for treatment of endometritis. [15] The researchers also noted that the use of additional oral therapy has not been proven to be beneficial.
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
The Academy of Breastfeeding Medicine recommends frequent and effective milk removal in managing mastitis (most important step) or fluid mobilization. [16] Supportive measures include rest, adequate fluids, and nutrition. [16] Also use local measures, such as ice packs, analgesics, and breast support. [13]
Administer a penicillinase-resistant antibiotic such as cephalexin, dicloxacillin or cloxacillin, or clindamycin in penicillin-allergic patients. [13]
The mother should be told to continue to breastfeed the baby. [16] 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. [13]
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. [17, 18, 19]
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. [17, 18]
Although the AAP considers fluoroquinolones to be safe for breastfeeding mothers, they also recommend that the safest drug should be prescribed. [17] 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. [20, 21] For this reason, fluoroquinolones should not be first-line therapy and temporary discontinuation of breastfeeding should be considered. [20, 22]
Trimethoprim-sulfamethoxazole and nitrofurantoin are to be avoided in mothers with breastfeeding infants with G-6-PD deficiency. [17, 18]
When possible, the medication should be taken just after the patient has breastfed the infant to minimize drug exposure. [17]
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. [17]
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. [12, 13]
Anticoagulation may be used, and it should be noted that there exists 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. [5] The aPTT is monitored for 2-3 times the normal value. [12, 13]
Alternatively, low-molecular weight heparin may be used with a dose of 1 mg/kg. [12, 13]
Hospitalization
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.
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.
Outpatient follow-up
All patients with a postpartum infection should undergo follow-up with an obstetrician.
For patient education resources, see Pregnancy Center as well as Postpartum Perineal Care.
Prevention
A Cochrane review found that for the prevention of post-caesarean endometritis, there was no clear difference between irrigation and intravenous antibiotic prophylaxis, however further research is necessary. [23] Another Cochrane review reported that post uncomplicated vaginal birth, routine administration of antibiotics may reduce the risk of endometritis, however, further studies are also needed. [24]
