Puerperal Pyrexia

Puerperal pyrexia is a temperature of 38 degrees Celsius or more on any 2 of the first 10 days after birth, not counting the first 24 hours, measured by mouth at least 4 times daily. It is a sign and not a diagnosis, and the cause may be endometritis, urinary infection, wound infection, mastitis, thrombosis, malaria or breast engorgement. It matters because untreated infection can progress to sepsis, so the source must be found and treated.

• Risk factors: caesarean section, prolonged labour, rupture of membranes for 18 hours or more, instrumental delivery, perineal tears, retained products, catheterisation, anaemia, HIV.
• Low grade fever of 24 to 72 hours with engorged breasts usually settles without antibiotics.
• Fever beyond 48 hours of treatment needs a new search for abscess or thrombophlebitis.

Women have a raised temperature with or without chills, and the other features point to the source: lower abdominal pain and foul lochia (uterus), dysuria and loin pain (urinary tract), a hot red wound or perineum, a painful wedge-shaped red area of the breast, a swollen tender calf, or cough and chest pain.

• Pulse and respiratory rate rise with temperature.
• Examination of the uterus, wound, perineum, breasts, calves, chest and urine is needed every time.
• Differential diagnosis: endometritis, urinary tract infection, wound or perineal infection, mastitis, breast engorgement, deep vein thrombosis, pneumonia or atelectasis, malaria, septic pelvic thrombophlebitis, drug fever.
• Complications: sepsis, abscess, secondary haemorrhage, venous thrombosis, delayed breastfeeding, prolonged hospital stay, readmission.

The approach is a full examination and targeted tests.

• Temperature, pulse, blood pressure, respiratory rate, abdomen and uterine tenderness, lochia smell, wound, perineum, breasts, calves, chest.
• Urine dipstick and culture, high vaginal swab, wound swab, full blood count, C-reactive protein, malaria test, blood culture if temperature is 38.5 degrees Celsius or more.
• Pelvic ultrasound for retained products or collection; compression ultrasound of the legs if calf swelling; chest X-ray if cough or low saturation.
• Repeat the full examination 24-hourly if fever persists.

The principle is to find the source and treat it, and to avoid antibiotics when no bacterial cause is found.

• Supportive: oral fluids 2 to 3 litres daily; rest; mobilise; chest physiotherapy; continue breastfeeding with frequent emptying of the breasts; stop tampons and intercourse.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); endometritis: clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily until afebrile for 24 to 48 hours; urinary infection: cefalexin 500 mg oral 6-hourly for 5 to 7 days; wound infection: flucloxacillin 500 mg oral 6-hourly for 7 days; mastitis: flucloxacillin 500 mg oral 6-hourly for 10 days; malaria: artemether-lumefantrine 4 tablets (each 20 mg and 120 mg) oral at 0, 8, 24, 36, 48 and 60 hours; deep vein thrombosis: enoxaparin 1 mg/kg subcutaneous 12-hourly.
• Procedures: evacuation of retained products; drainage of abscess; opening of an infected wound.
• Red flags: temperature above 39 degrees Celsius, rigors, systolic blood pressure below 90 mmHg, pulse above 120 per minute, severe pain, rigid abdomen, breathlessness, fever persisting beyond 48 hours of treatment.
• Follow-up: temperature 4-hourly until afebrile for 24 hours; review at 1 week and 6 weeks; ultrasound if fever returns.