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Puerperal Infection

Puerperal infection - a common cause of child­birth-related death - is an inflammation of the birth canal after birth or abortion. It can occur as localized lesions of the perineum, vulva, and vagina, or it may spread, causing endometritis, parametritis, pelvic and femoral thrombophlebitis, peritonitis, and life-threatening endomyoparametritis. In the United States, puerperal infection develops in about 6% of maternity patients. The prognosis is good with treatment.


Microbes that commonly cause puerperal infection include streptococci, coagulase-negative staphylococci, Clostridium pelfringens, Bacteroidesfragilis, and Escherichia coli. Most of these microbes are considered normal vaginal flora. But they may cause puerperal infection in the presence of certain predisposing factors, such as prolonged and premature rupture of the membranes, prolonged (more than 24 hours) or traumatic labor, cesarean section, frequent or unsanitary vaginal examinations or unsanitary delivery, retained products of conception, hemorrhage, and maternal couditions, such as anemia or dehilitation from malnutrition.

Signs and Symptoms

Typically, the history reveals a temperature of at least 100.4° F (38° C) developing 2 to 3 days postpartum, or on any 2 consecutive days up to the 11th day, exclusive of the first 24 hours. (Fever during the first 24 hours postpartum may be from dehydration.) The fever can increase to as high as 105° F (40.6° C). The patient may also report chills, headache, malaise, restlessness, and anxiety.

With local lesions of the perineum, vulva, and vagina, the patient may complain of pain and dysuria. Inspection may disclose inflammation and edema of the affected area and profuse purulent discharge.

A patient with endometritis may present with a backache and severe uterine contractions that persist after childbirth. Inspection finds heavy, sometimes foul-smelling lochia. Palpation reveals a tender, enlarged uterus.

With parametritis (pelvic cellulitis), the history may include vaginal tenderness and abdominal pain and tenderness (pain may become more intense as infection spreads). In pelvic thrombophlebitis, the history may reveal severe, repeated chills and dramatic swings in body temperature. The patient may complain of lower abdominal or flank pain. Palpation may reveal a tender mass over the affected area, which usually develops near the second postpartum week.

A patient with femoral thrombophlebitis may report pain, stiffness, or swelling in a leg or the groin. Malaise, fever, and chills usually begin 10 to 20 days postpartum. Inspection reveals inflammation or a shiny, white appearance of the affected leg. Palpation detects Rielander's sign (palpable veins inside the calf and thigh). Examination also may provoke Payr's sign (pain in the calf when pressure is applied to the inside of the foot) and Homans' sign (pain on dorsiflexion of the foot with the knee extended). These signs may precede pulmonary embolism.

In peritonitis, fever accompanies tachycardia (over 140 beats/minute) and a weak pulse. The patient may complain of hiccups, nausea, vomiting, and diarrhea, as well as constant, possibly excruciating, abdominal pain.

Diagnostic tests

Development of the typical clinical features, especially fever within 48 hours after delivery, suggests a puerperal infection. Extrapelvic causes of fever (breast engorgement, mastitis, pneumonia, pyelonephritis, and wound infection) should be ruled out in the initial evaluation.

Culture of lochia, blood, incisional exudate (from cesarean incision or episiotomy), uterine tissue, or material collected from the vaginal cuff, revealing the causative organism, is used to confirm the diagnosis.

White blood cell count 36 to 48 hours postpartum usually reveals leukocytosis (15,000 to 30,000/µl) and an increased erythrocyte sedimentation rate.

Pelvic examination shows induration without purulent discharge in parametritis.

Culdoscopy shows pelvic adnexal induration and thickening. Red, swollen abscesses on the broad ligaments are even more serious, because rupture leads to peritonitis.

Venography and Doppler ultrasonography help to confirm pelvic or femoral thrombophlebitis.

Differential diagnosis excludes cystitis, pyelonephritis, appendicitis, pelvic thrombophlebitis (septic), paralytic ileus, viral syndrome and mastitis.


Therapy usually begins with I.V. infusion of a broadspectrum antibiotic to control the infection while awaiting culture results. After identification of the infecting organism, a more specific antibiotic should be administered. (An oral antibiotic may be prescribed after discharge.)

Ancillary measures include analgesics for pair anticoagulants, such as I.V. heparin, for thrombophlebitis and endometritis (after clotting time and partial thromboplastin time determine dosage); antiseptics for local lesions; and emetics for nausea and vomiting from peritonitis. Isolation or transfer from the maternity unit also may be indicated.

Supportive care includes bed rest, adequate fluid intake, I.V. fluids when necessary, and measures to reduce fever. Sitz baths and heat lamps may relieve discomfort from local lesions. Surgery may be needed to remove any remaining products of conception or to drain local lesions, such as an abscess in parametritis.

Management of femoral thrombophlebitis requires warm soaks, elevation of the affected leg to promote venous return, and observation for signs of pulmonary embolism.


Careful attention to antiseptic procedures during childbirth is the basic underpinning of preventing infection. With some procedures, such as cesarean section, a doctor may administer prophylactic antibiotics as a preemptive strike against infectious bacteria.

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