fever during and after childbirth

8/14/2019 Fever During and After Childbirth

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Fever During and After Childbirth

Advances in Maternal and Neonatal Health


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2Fever During and After Childbirth

Session Objectives

Discuss best practices for management of infection during and

after childbirth, especially:

Amnionitis Metritis

Describe strategies for prevention of infection

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


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Providing Prophylactic Antibiotics

(continued)

Should be given 30 minutes before procedure, to allow

adequate blood levels at time of procedure

Except at cesarean, give antibiotics when cord is clamped afterdelivery 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 1500 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.


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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 diagnosisis made, give broad spectrum antibiotics

Treat specific infection with specific antibiotics

If response is poor after 48 hours:

Ensure adequate doses 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 exceptmetritis)


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Principles of Treatment with Antibiotics

Adequate dosing

Adequate duration

Continued re-evaluation of the patient


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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 1996; 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:


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

delivery) 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 RS 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 inthe fetus

Excellent activity against group B streptococci and E. coli

major 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 delivery:


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

ACOG1998.


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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, woundseroma or woundhematoma

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 delivery

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:


Gentamicin every 24hours

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 ofabscess


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Antibiotics for Metritis

IV antibiotics:


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.


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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), and

Anaerobes (metronidazole)

Adequate doses of antibiotics are necessary

Aggressive fluid resuscitation (23 liters to start)

Look for abscess, peritonitis or other condition requiringsurgery

IV antibiotics may be necessary for longer if bacteremia


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Prevention Strategies

Infection prevention

practices for every delivery:

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 notcesarean section has occurred or presence of bacteremia


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References

American College of Obstetricians and Gynecologists (ACOG)Educational Bulletin: Antimicrobial Therapy for Obstetric Patients,March 1998. p. 292-300.

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 andOL Simpson (eds). Churchill Livingstone: Edinburgh, Scotland.

French LM and FM Smaill. 2000. Antibiotic regimens for

endometritis after delivery (Cochrane Review), in The CochraneLibrary. Issue 4. Update Software: Oxford.

Gibbs RS et al. 1988. A randomized trial of intrapartum versusimmediate postpartum treatment of women with intra-amnioticinfection. Obstet Gynecol72(6): 823828.


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References (continued)

Gyssens IC. 1999. Preventing postoperative infections: Currenttreatment 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 regimensand drugs for cesarean section (Cochrane Review), in TheCochrane Library. 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 insurgery and surgical wound infections. Am Surg 66: 105111.

Sweet RL and RS Gibbs. 1998. Infectious Diseases of the FemaleGenital Tract, 3rd ed. Williams & Wilkins: Baltimore, Maryland.

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