Postpartum (puerperal) pyrexia

What it is

Postpartum pyrexia is T above 38 C for 24 hrs, or recurring, from the end of the 1st day to the end of the 10th day post delivery or abortion.

Causes and risk

The causes divide into those related to pregnancy and those unrelated to it, and the first group divides again into genital tract and non-genital tract. All three groups are gone through in turn, and the note ends the list with the rule: think about it from head to toe.

Related to pregnancy, genital tract: endometritis; infection of the myometrium or parametrium; pelvic abscess; CS wound infection; infection of an episiotomy or of a vaginal or cervical tear.

Related to pregnancy, non-genital tract: UTI; breast infection, that is mastitis and abscess; lung infection; VTE; septic thrombophlebitis; cannula site infection.

Unrelated to pregnancy: appendicitis; cholecystitis; pancreatitis; RTI; cerebral abscess; rheumatic endocarditis; myocarditis; lymphoma; ID, that is malaria, TB and HIV/AIDS; parasitic infection; DVT; drug fever; meningitis.

How it is diagnosed

History: the full history, plus the delivery details, which are the part that is easy to leave out. Type of delivery, CS or vaginal; when the membranes ruptured; the length of labour; instrumentation; sutures; whether the placenta was complete; and whether there was a PPH.

Examination, in order: vitals, that is T and BP; palpate the uterus for size and tenderness; assess the perineal wounds and the lochia; examine the breast; chest examination; abdomen; legs.

Other signs of systemic infection, each with what it points to: rigors or persistent spiking fever suggest abscess; vomiting or diarrhea may mean exotoxin production, that is early toxic shock; breast engorgement, redness or rash; abdominal or pelvic pain and tenderness; wound infection with spreading cellulitis or discharge; offensive vaginal discharge, where smelly suggests anaerobes and serosanguinous suggests streptococcus; productive cough; urinary symptoms; delay in uterine involution with heavy lochia; and lethargy with reduced appetite.

Investigations: high vaginal swab, to rule out the commonest cause, endometritis; urine culture and microscopy; wound or throat swab if necessary; FBC and CRP; blood culture; US, to see retained products of conception; sputum culture; serum lactate if shock is suspected; RFT and LFT; D-Dimer.