Intrapartum and Postpartum Fever
6/1/2014 - C. Morosky, MD
Mentor: Roger Smith, MD
Editor: Pamela Berens, MD
Initial Approval: 11/1/15; Reaffirmed: 5/1/16
Maternal fever is defined as an oral temperature ≥ 38.0oC (100.4oF). More than 90% of intrapartum and postpartum fever is caused by organisms from the genital tract. Other less common causes of maternal fever include pulmonary infection, kidney-ureter-bladder infection, wound infection, breast engorgement or infection, thrombophlebitis, thromboembolism, and drug reaction.
Intrapartum chorioamnionitis complicates in 1 – 10% of deliveries. Risk factors include prolonged labor, prolonged ruptured membranes, multiple cervical examinations, intrauterine monitoring, low socioeconomic status, young maternal age, and nulliparity. These infections are polymicrobial and include Gram-positive and Gram-negative aerobes, anaerobes and atypical organisms. Maternal complications of chorioamnionitis include postpartum infectious morbidity, labor dystocia, bacteremia, acute respiratory distress syndrome, disseminated intravascular coagulopathy, septic shock, and on rare occasions death. Neonatal complications include respiratory distress syndrome, bronchopulmonary dysplasia, cystic periventricular leukomalacia, intraventricular hemorrhage, cerebral palsy, sepsis, and death.
The diagnosis of chorioamnionitis is made clinically and in addition to maternal fever must include one of the following: uterine tenderness, maternal tachycardia, fetal tachycardia, or foul smelling amniotic fluid. Intravenous antibiotics effective against Gram-negative aerobes and anaerobes can reduce the risk of maternal and neonatal complications. The most studied antibiotic regimen is ampicillin and gentamicin, which provides excellent coverage for organisms causing fetal infection and rapidly attains therapeutic levels in the fetus and amniotic fluid. Other regimens include extended-spectrum penicillin’s combined with beta-lactamase inhibitors, as well as cephalosporins. While chorioamnionitis alone is not an indication for cesarean delivery, resolution of the infection will not occur until after delivery of the fetus, placenta, umbilical cord, and membranes. If a cesarean delivery is necessary, coverage should be broadened to include anaerobes by adding metronidazole or clindamycin. Patients are often continued on parenteral antibiotics for 24 – 48 hours after the fever has resolved. Small studies suggest that one additional dose of antibiotics postpartum is sufficient to prevent persistent maternal fever.
Approximately 1-3% of vaginal deliveries are complicated by postpartum endomyometritis. Endomyometritis occurs much more frequently after a cesarean delivery, from 5 – 40%. Risk factors for endomyometritis include cesarean delivery, intrapartum chorioamnionitis, failure to treat chorioamnionitis and failure to administer antibiotic prophylaxis prior to a cesarean delivery. The organisms responsible for endomyometritis are similar to those for chorioamnionitis, with a higher prevalence of anaerobes.
The diagnosis of endomyometritis is made clinically and includes maternal fever that is associated with chills, abdominal pain, uterine tenderness and foul-smelling lochia. A combination of clindamycin and gentamicin has been shown to be effective in 95% of cases of endomyometritis when administered until the patient has been afebrile for 24 – 48 hours. Ampicillin is often added initially to include coverage for Enterococcus species. Combinations of extended-spectrum penicillin’s, beta-lactamase inhibitors, cephalosporins, metronidazole, and imipenem have been shown to be equivalent to “triple” antibiotics. These alternate combinations can be helpful in patients with allergies. Oral antibiotics are not necessary following intravenous therapy, as they have not been shown to decrease the risk of complications or hospital readmission. Complications of endomyometritis include wound infection, peritonitis, parametrial phlegmon, pelvic abscess, and septic pelvic thrombophlebitis.
Date of Last Review: November 2014Back to Search Results