Postpartum Infection

What is Postpartum Infection?

Problems relating to the health and survival of mothers during and after pregnancy is a significant issue worldwide. One key problem is postpartum infections, which are those that occur after childbirth. These infections contribute largely to this worldwide health problem and can often be prevented. Typically, we consider the ‘postpartum period’ to be the six weeks following birth. During this time, infections are fairly common, affecting roughly 5 to 7% of women.

One condition called puerperal sepsis is particularly worrying as it’s among the top five reasons for maternal deaths globally. It’s responsible for 10-15% of deaths during those six weeks after a birth. Infections are also the leading cause of death after natural or medically-induced miscarriages. To make matters worse, the bacteria that cause these infections are becoming significantly resistant to the antibiotics usually used to treat them.

Beyond the medical problems, postpartum infections also have social implications. They can increase a mother’s worry and risk of postpartum depression. They can also interfere with the bonding process between a mother and her baby, and negatively affect breastfeeding. This discussion covers infections occurring after the successful birth of a child, after stillbirth, and after spontaneous or medically-induced miscarriages. However, we’re not considering mastitis – a breast infection – because it doesn’t occur directly as a result of pregnancy or delivery.

What Causes Postpartum Infection?

Most infections after childbirth are due to natural and treatment-related injuries to the abdomen and reproductive, sexual, and urinary areas during childbirth or abortion. Such injuries allow bacteria to enter these areas which are usually germ-free.

Risk Factors and Frequency for Postpartum Infection

Maternal death rates in the United States have alarmingly increased by 140% between 1987 and 2013, despite worldwide improvements. This makes the U.S. one of the countries with the highest mortality rates related to pregnancy among economically developed countries. Sadly, this increase can’t be entirely blamed on just improvements in record-keeping. Also, these stats do not include deaths linked with miscarriages, medically induced abortions, or following stillbirths – situations that pose even greater risks to maternal health than live births.

Understanding the impact of post-pregnancy infections is tough. Most infections happen after the mother has left the hospital, and shorter hospital stays after childbirth make detecting these complications even harder. However, available data tells us that post-pregnancy infections are responsible for 19% of maternal deaths following a stillbirth and 34% of deaths after a miscarriage or abortion.

According to the latest data from the Centers for Disease Control, infections are the leading cause of deaths related to pregnancy in Hispanic women in the United States. They disproportionately affect ethnic minorities and are more prevalent in women who have had a cesarean section, especially if labor occurred prior.

• Increased risk of post-pregnancy infection is seen in women at extreme ages, those with high body mass index, diabetes, high blood pressure, weakened immune system, bacterial vaginosis (an imbalance of bacteria in the vagina), positivity for group-B streptococcus, and sexually transmitted infections.
• Certain birth-related factors can also increase infection risk: labor that is too early or too late, prolonged rupture of the water bag or labor, multiple internal exams, significant staining with baby’s first feces (meconium), internal fetal or uterine monitoring, operative vaginal delivery, manual removal of the placenta, retained remnants of pregnancy, use of a bladder catheter, and heavy bleeding after childbirth (postpartum hemorrhage).

Signs and Symptoms of Postpartum Infection

When taking a patient’s medical history, doctors work to collect information about a variety of issues. These include the time of delivery or abortion, whether the delivery was surgical or vaginal, any previous surgeries or illnesses, gestational age at the time of delivery or abortion, and any complications during pregnancy or delivery. They also take note of the patient’s GBS status and look for symptoms such as foul-smelling lochia or excessive vaginal bleeding.

• Time of delivery or abortion
• Surgical or vaginal delivery
• Prior surgical and medical history
• Gestational age at the time of the delivery or abortion
• Complications of pregnancy and delivery
• GBS status
• Presence of foul-smelling lochia or excessive vaginal bleeding

As part of the physical examination, the doctor evaluates any surgical incision the patient may have and conducts several other examinations. They look at the skin for any unusual features, feel the stomach and the uterine fundus, and perform a sterile speculum and bimanual examination.

• Evaluation of the surgical incision (if present)
• Examination of the skin for any changes
• Palpation of the abdomen and the uterine fundus
• Sterile speculum and bimanual examination

For endometritis, fever is usually the first symptom. Other possible symptoms include uterine tenderness, bleeding, and foul-smelling lochia. Infection with GAS should be suspected in cases with signs of severe systemic illness, shock, or disproportionate abdominal pain. Septic abortion can cause a symptoms like fever and mild abdominal pain which can progress into generalized peritonitis in severe infections. Post-surgery infections commonly present with redness, warmth, and pain, and puss at the surgical site. Deep incisional infections display minimal physical symptoms, but could be identified by fevers and potential serious conditions like necrotizing fasciitis. Patients with persistent pain, a high count of white blood cells, and fever who don’t respond well to antibiotics might be suffering from Septic pelvic thrombophlebitis (SPT). Similarly, deep organ infections could be a possible explanation if patients do not respond to appropriate antibiotics.

Testing for Postpartum Infection

If the doctor suspects an infection, a blood sample or a sample from the infected wound may be taken to decide which type of antibiotics will work best. Common signs of an infection seen in the lab results include an increase in white blood cells (leukocytosis), particularly a type called neutrophils, and elevated lactic acid levels in the blood. However, it’s important to note that infections after giving birth can’t be ruled out based only on lab results. Even if lab results come back normal, an infection may still be present, so doctors shouldn’t make decisions based solely on the lab results.

Endometritis is an infection in the uterus, typically diagnosed based on clinical symptoms. Signs could include fever, sensitivity in the abdomen, and foul-smelling vaginal discharge after giving birth (lochia).

If a woman has symptoms of a septic abortion (an abortion followed by an infection), the doctor may use ultrasound to check for any remaining pregnancy tissue in the uterus.

If the uterus infection has progressed, gas may be seen in the uterine muscle (myometrium) during a normal X-ray or CT scan. Surgical site infections are typically diagnosed based on the patient’s symptoms and a physical examination. If a deep organ infection is suspected following surgery, a CT scan may help confirm this.

Workup for pelvic vein inflammation related to blood clots (pelvic thrombophlebitis) should be started if the fever does not subside after receiving a wide variety of antibiotics for 3-5 days. Pelvic vein blood clots are typically detected using CT scan or MRI.

Treatment Options for Postpartum Infection

When treating different types of infections that occur after childbirth, the specific types of bacteria causing the infection, their resistance to antibiotics, and how severe the patient’s illness is all play a big role in what antibiotics the doctor chooses to use. Initially, doctors often select an antibiotic that can fight a wide variety of bacteria, especially if the patient is very sick. Later, the doctor may change the antibiotic based on the results from the lab tests or tissue samples. Pharmacists can provide guidance with this process.

The doctor will also factor in if the patient is breastfeeding— the goal is to use antibiotics that will not harm the baby and will allow the patient to continue breastfeeding safely.

The main approach to managing most infections after childbirth is generally the same. For patients with unstable blood flow, fluids are given to stabilize them. If their blood pressure remains low even after fluid treatment, a medication to raise blood pressure may be started. Broad-spectrum antibiotics, which combat a broad range of bacteria, should be given as soon as possible. Blood cultures, which are lab tests to check for bacteria in the blood, should be taken before the antibiotics are given (if possible, without delaying the antibiotics).

If the infection requires surgical intervention, immediate consultation of a surgical team is highly crucial.

The treatment for endometritis, an infection of the lining of the uterus, can vary based on its severity. Patients with a mild case may be able to receive treatment outside of the hospital. It’s important that the patient and healthcare provider have a discussion before deciding to treat on an outpatient basis. Safe antibiotics for breastfeeding patients are used and have shown an above 85% success rate in treating mild cases of endometritis. For more severe cases requiring stay in the hospital, a combination of antibiotics can be effectively used.

The go-to treatment for septic abortion, a potentially life-threatening infection following a miscarriage or an abortion, is removing the infected tissue. Antibiotics should be started within an hour of diagnosis. Depending on the patient’s condition, specific antibiotic regimens are recommended for the best care.

For mild surgical site infections without signs of spreading or pus, a course of oral antibiotics is typically sufficient.

Necrotizing fasciitis, a rapid, severe infection of the deeper layers of skin and tissues beneath the skin, is a surgical emergency and needs immediate intervention. In the meantime, before surgery, broad-spectrum antibiotics can be given to fight the infection.

When there is infection of the veins in the pelvis (known as septic pelvic thrombophlebitis), a certain combination of antibiotics is recommended for treatment. The use of blood-thinning medications remains a topic of discussion, as there are no studies so far that suggest a clear clinical benefit.

What else can Postpartum Infection be?

The term “postpartum fever” refers to a situation where a person’s oral temperature exceeds 38.0°C (100.4°F) on any two of the ten days following childbirth, excluding the first day. Doctors don’t count the first day because new mothers often experience temporary fevers that don’t indicate serious health issues and don’t last long.

Postpartum fever can be a result of an infection, over-heating (hyperthermia), deep vein thrombosis (a type of blood clot), or breast engorgement (when the breasts become overly full of milk). Despite the fact that breast engorgement can cause a person’s temperature to rise slightly, there’s no specific temperature that’s considered too high for it to be just because of engorgement. For example, fever combined with muscle aches and redness of the breast might indicate mastitis (breast tissue infection) rather than just engorgement.

While most postpartum infections are related to childbirth, some infections aren’t. Therefore, checking for common issues like urinary tract infections and pneumonia is still important. Evaluation is typically done through discussions about symptoms and physical exams.

There are several other causes of hyperthermia during the postpartum period.

• Serotonin syndrome: A potentially life-threatening condition which can cause overactive reflexes and muscle spasms. This can be a side effect of some medications used to treat postpartum depression or psychosis.
• Neuroleptic malignant syndrome: A severe reaction to antipsychotic drugs characterized by notable muscle stiffness.
• Aspirin toxicity: Overdosing on aspirin can cause altered mental state, fast breathing, and abdominal discomfort.
• Sympathomimetic agents overdose: Symptoms include a rapid heart rate, high blood pressure, excessive sweating, and restlessness.
• Withdrawal from benzodiazepines or ethanol: Causes tremors, increased heart rate, high blood pressure, and overheating. In severe cases, it can lead to seizures.
• Anticholinergic toxicity: This condition, caused by certain medications, can cause alterations in mental state, overheating, dilated pupils, flushed skin, and difficulty urinating.
• Thyroid storm: A rare life-threatening condition, where the thyroid gland suddenly releases large amounts of thyroid hormone. It may cause nausea, vomiting, and abdominal pain alongside increased temperature and reflexes.

With all of these conditions, the patient’s medical history and a physical examination are key to making a diagnosis. It’s important to review any medications that the patient may be taking, especially new ones, to determine whether they could be causing any symptoms.

What to expect with Postpartum Infection

Infections after childbirth affect 5 to 10% of pregnant patients. The outlook of these infections, also known as puerperal infections, depends on how severe the infection is. Patients who develop a serious condition known as sepsis have an estimated 20% chance of not surviving. For those who progress to a more critical condition known as septic shock, the mortality rate is about 40%.

Possible Complications When Diagnosed with Postpartum Infection

If not treated properly, all types of infections that occur after giving birth can quickly turn into severe conditions, such as blood infections, sepsis, shock, and even cause death. Necrotizing fasciitis, a type of flesh-eating disease, is specifically known for how quickly it can lead to severe infection and death.

One of the complications of endometritis, an infection of the womb, and other serious infections of the pelvic region is a condition called septic pelvic thrombophlebitis (SPT). When endometritis gets worse, it can move beyond the womb, leading to abscesses, inflammation of the inner lining of the abdomen, and SPT.

SPT is a result of damage to the inner lining of the pelvic veins, due to an infection in the womb, a bacteria-induced blood infection, or trauma experienced during vaginal or surgical childbirth. This infection can also spread to the ovarian veins and the large vein carrying deoxygenated blood to the heart from the lower body, known as the inferior vena cava. The factors increasing the risk of these serious infections include giving birth via C-section and chorioamnionitis, an infection of the membranes and the amniotic fluid in the womb during pregnancy.

Main Risks:

• Infections turning into sepsis or shock
• Necrotizing Fasciitis
• Endometritis leading to abscesses or inflammation in the abdomen
• Septic pelvic thrombophlebitis (SPT)
• Infections spreading to the heart from the lower body
• Increased risk with C-section and chorioamnionitis
• Potential Death

Preventing Postpartum Infection

Lack of access to healthcare can increase the risk of infections after giving birth. It can also cause delays in getting treatment, which may lead to serious health problems and, in some cases, even death. Some new moms might avoid seeking medical care because they worry about being separated from their baby in the hospital. Women who got an infection after an abortion might also avoid getting medical help because they fear people will judge them.

Additionally, mental health conditions after giving birth or increased incidents of domestic violence during the same period might keep some women from seeking help. Healthcare professionals should strive to create an understanding and non-judgmental environment, to make these patients feel more comfortable discussing their concerns. The doctors should also share decisions about any need for hospital stays and the choice of antibiotics. By doing this, patients will feel more included and comfortable with the healthcare process.