Postpartum Infections

Pelvic infection is the most common serious complication of the puerperium. Any persistent fever over 38.0°C (100.4°F) should be considered to be caused by genital tract infection until proven otherwise. Extragenital causes of fever include respiratory tract infection (more common after cesarean section), pyelonephritis, mastitis, and thrombophlebitis.

The route of delivery is the single most significant risk factor for uterine infection, with the vast majority of endometritis occurring secondary to cesarean section. Other risk factors include lower socioeconomic level, multiple gestations, younger maternal age, longer duration of labor and membrane rupture, and internal fetal monitoring. Women with all of these risk factors who were not given antibiotics prophylactically have been found to have a 90 percent rate of pelvic infection. Digital examination after 37 weeks' gestation is thought to predispose to infection.

The most common pathogens are those that normally reside in the bowel and also colonize the perineum, vagina, and cervix. Both gram-positive and gram-negative aerobes, anerobes, Mycoplasma hominis, and Chlamydia trachomatis are seen. Gardnerella vaginalis is isolated more often in younger women. Many infections are polymicrobial.

Signs and symptoms of postpartum endometritis are foul-smelling, profuse, and bloody discharge and abdominal pain. Only scant discharge may be present, especially in patients with group A b-hemolytic streptococci. Shaking chills suggest bacteremia. Uterine and adnexal tenderness is found upon bimanual examination.

Infection may be localized to the decidua and adjacent myometrium and, if this is the case, responds readily to antibiotic therapy. Complications include parametrial phlegmons; surgical, incisional, and pelvic abscesses; infected hematomas; septic pelvic thrombophlebitis; necrotizing fasciitis; and peritonitis. Necrotizing fasciitis is a feared complication with high mortality and morbidity rates. Risk factors for this complication are obesity, diabetes mellitus, and hypertension.

The mainstay of treatment is antibiotic therapy, drainage of any collections of purulent material, and debridement of necrotic tissue. Routine vaginal cultures are of little clinical utility because of contamination with local flora. Blood culture results are positive in the minority of patients.

Oral antibiotics can be used on an outpatient basis for mild illness when disease is confined to the decidua and myometrium. Any patient who appears toxic or moderately ill, has had a cesarean section, or has underlying comorbid conditions should be hospitalized for parenteral therapy. There are many regimens of therapy. The combination of ampicillin and gentamicin is sufficient for 90 percent of patients. The b-lactam antimicrobials have the advantages of being safe and requiring administration of only one drug, thus being cost-effective. Cephalosporins that can be used include cefoxitin, cefotetan, and cefotaxime. Other regimens include clindamycin and gentamicin or metronidazole plus ampicillin and an aminoglycoside.

AMNIOTIC FLUID EMBOLUS Mortality rates between 60 and 80 percent have been reported for amniotic fluid embolism. Neurologic morbidity rates are even higher, and few patients are without sequelae.19 In a national registry of patients with amniotic fluid embolus, if the amniotic fluid had meconium staining, no mother survived without neurologic deficit. If the infant is still in utero at the time of the embolus, both mortality and neurologic morbidity rates are high. The factors that cause this catastrophe are not known. The only significant relationship found thus far is fetal male sex.

Onset is sudden, with the mother displaying cardiovascular collapse. Seizure or seizure-like activity at the time of collapse is common. Patients display profound cardiovascular instability, severe hypoxemia, and, if survival is long enough, disseminated intravascular coagulation. Death is rapid, with many patients dying within 1 h of onset of symptoms. It has been suggested that the syndrome resembles that seen with anaphylactic or septic shock. Histologic findings at autopsy usually show material of fetal origin, such as squamous cells, hair, fat droplets, trophoblasts, and other nonspecific cellular debris as well as proteinaceous material, in the maternal circulation. The cause is unknown.

Care is supportive, with use of high concentrations of oxygen and treatment of disseminated intravascular coagulation if the patient survives long enough. Delivery of the infant should be immediate, but infant mortality and morbidity rates remain high even with immediate delivery. 20

PERIPARTUM CARDIOMYOPATHY PPC is the development of heart failure during or shortly after labor with no apparent cause. Most women have an underlying cause found during workup for PPC.20 Causes include chronic hypertension, mitral stenosis, obesity, viral myocarditis, and preeclampsia. Terbutaline for tocolysis has been found in many patients who have congestive heart failure but no underlying heart disease. Still, there is a small group of women for whom no cause can be found. PPC appears to be similar to the idiopathic cardiomyopathy seen in young, nonpregnant women. Biopsy shows evidence of myocarditis in up to 30 percent.

Patients present with signs and symptoms of congestive heart failure. Dyspnea, orthopnea, cough, palpitations, and chest and abdominal pain are common complaints. Massive cardiomegaly is seen on chest radiograph and echocardiograph. Treatment is with diuretics and fluid restriction. Digitalis should be used with caution, since 60 percent of patients have complex ventricular arrhythmias. Afterload reduction has been used, but ACE inhibitors should be avoided if the patient is undelivered. Because of the high association of pulmonary embolus with PPC, anticoagulation with heparin is often recommended. If no underlying cause can be found, the prognosis is very poor, with mortality of almost 50 percent at 1 year. Many survivors demonstrate diminished contractile reserve when studied with dobutamine challenge in periods remote from pregnancy.21

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