Fever During and After Childbirth

1. Fever During and After Childbirth Advances in Maternal and Neonatal Health

2. 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 Fever During and After Childbirth

3. 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 Fever During and After Childbirth

4. 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. Fever During and After Childbirth

5. 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. Fever During and After Childbirth

6. 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. Fever During and After Childbirth

7. 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) Fever During and After Childbirth

8. Principles of Treatment with Antibiotics • Adequate dosing • Adequate duration • Continued re-evaluation of the patient Fever During and After Childbirth

9. Fever During Pregnancy and Labor: Differential Diagnosis • Cystitis • Acute pyelonephritis • Septic abortion • Amnionitis • Pneumonia • Malaria • Typhoid • Hepatitis Fever During and After Childbirth

10. Acute Pyelonephritis • Treat, because of risks of: • Preterm labor • Sepsis • Easy to treat • Inexpensive Fever During and After Childbirth

11. 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 Fever During and After Childbirth

12. 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. Fever During and After Childbirth

13. 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 Fever During and After Childbirth

14. 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 Fever During and After Childbirth

15. 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 Fever During and After Childbirth Gibbs RS et al 1988.

16. 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) Fever During and After Childbirth Hauth et al 1985.

17. 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 Fever During and After Childbirth ACOG1998.

18. 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 Fever During and After Childbirth

19. 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 Fever During and After Childbirth Czeizel et al 2000.

20. Aminoglycosides During Pregnancy: Results No detectable teratogenesis from parenteral gentamicin, streptomycin, tobramycin or oral neomycin Fever During and After Childbirth Czeizel et al 2000.

21. 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 Fever after Childbirth: Differential Diagnosis Fever During and After Childbirth

22. 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 Fever During and After Childbirth Kwast 1991.

23. 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 Fever During and After Childbirth Kwast 1991.

24. 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 Fever During and After Childbirth

25. 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 Management of Metritis Fever During and After Childbirth

26. 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 Fever During and After Childbirth

27. 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 Fever During and After Childbirth French and Smaill 2000.

28. 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 Fever During and After Childbirth French and Smaill 2000.

29. 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 Fever During and After Childbirth

30. 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 Prevention Strategies Fever During and After Childbirth

31. 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 Fever During and After Childbirth

32. 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. Fever During and After Childbirth

33. 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. Fever During and After Childbirth