Fever During and After Childbirth Advances in Maternal and Neonatal Health

Fever During and After Childbirth

Advances in Maternal and Neonatal Health

2 Fever 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


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


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 after delivery 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.


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.


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.


Providing Therapeutic Antibiotics

For general treatment of obstetrical infection or until diagnosis is 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

except metritis)


Principles of Treatment with Antibiotics

Adequate dosing

Adequate duration

Continued re-evaluation of the patient


Fever During Pregnancy and Labor: Differential Diagnosis

Cystitis

Acute pyelonephritis

Septic abortion

Amnionitis

Pneumonia

Malaria

Typhoid

Hepatitis


Acute Pyelonephritis

Treat, because of risks of:

Preterm labor Sepsis

Easy to treat

Inexpensive


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


Acute Pyelonephritis: Subsequent Prophylaxis

Recurrence of acute pyelonephritis in the same gestation is reported to be 10–18%

Suppressive therapy: 2.7% will get another urinary tract infection

No suppressive therapy: 20–30% 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.


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


Management of Septic Abortion

Begin antibiotics as soon as possible before evacuation:

Ampicillin every 6 hours PLUS gentamicin daily PLUS metronidazole every 8 hours

Continue until fever-free for 48 hours

Manual vacuum aspiration


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.


Amnionitis: Antibiotics (continued)

Ampicillin and gentamicin

Broad coverage for wide variety of organisms Crosses placenta and achieves adequate concentrations in

the 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.


Management of Amnionitis

Give combination of antibiotics until delivery:

Ampicillin every 6 hours 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

ACOG 1998.


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


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 1980–1996

Gleaned exposure data from antenatal care records, medical documents, questionnaire to mother

Czeizel et al 2000.


Aminoglycosides During Pregnancy: Results

No detectable teratogenesis from parenteral gentamicin, streptomycin, tobramycin or oral neomycin

Czeizel et al 2000.


Fever after Childbirth: Differential Diagnosis

Metritis

Pelvic abscess

Peritonitis

Breast engorgement

Mastitis

Breast abscess

Wound abscess, wound seroma or wound hematoma

Wound cellulitis

Cystitis

Acute pyelonephritis

Deep vein thrombosis

Pneumonia

Atelectasis

Uncomplicated malaria

Severe/complicated malaria

Typhoid

Hepatitis


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.


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.


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


Management of Metritis

Start antibiotics:

Ampicillin every 6 hours Gentamicin every 24

hours 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 of abscess


Antibiotics for Metritis

IV antibiotics:

Ampicillin every 6 hours

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


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.


Managing Metritis: Results

More treatment failure with regimens other than clindamycin and an aminoglycoside RR 1.37 (1.10–1.70)

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 (0.30–1.20)

No difference in nephrotoxicity, lower cost

French and Smaill 2000.


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 (2–3 liters to start)

Look for abscess, peritonitis or other condition requiring surgery

IV antibiotics may be necessary for longer if bacteremia


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


Summary

Many causes of fever during and after childbirth

Therapeutic antibiotics ONLY if disease is diagnosed

Duration or treatment dependent on disease, whether or not cesarean section has occurred or presence of bacteremia


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: 309–313.

Duff P. 1996. Maternal and Perinatal Infections, in Obstetrics: Normal and Problem Pregnancy, 3rd ed. Gabbe SG, JR Niebyl and OL Simpson (eds). Churchill Livingstone: Edinburgh, Scotland.

French LM and FM Smaill. 2000. Antibiotic regimens for endometritis after delivery (Cochrane Review), in The Cochrane Library. Issue 4. Update Software: Oxford.

Gibbs RS et al. 1988. A randomized trial of intrapartum versus immediate postpartum treatment of women with intra-amniotic infection. Obstet Gynecol 72(6): 823–828.


References (continued)

Gyssens IC. 1999. Preventing postoperative infections: Current treatment recommendations. Drugs 57(2): 175–185.

Hauth JC et al. 1985. Term maternal and neonatal complications of acute chorioamnionitis. Obstet Gynecol 66(1): 59–62.

Hopkins L and F Smaill. 2000. Antibiotic prophylaxis regimens and drugs for cesarean section (Cochrane Review), in The Cochrane Library. Update Software: Oxford.

Kwast B. 1991. Puerperal sepsis: Its contribution to maternal mortality. Midwifery 7(3): 102–106.

Polk Jr. HC and AB Christmas. 2000. Prophylactic antibiotics in surgery and surgical wound infections. Am Surg 66: 105–111.

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

Documents

Fever During and After Childbirth Advances in Maternal and Neonatal Health