puerperal pyrexia/ puerperal fever/ postpartum fever / सूतिका ज्वर/ प्रसूति बुखार क्या होता है

Puerperal pyrexia is defined as the presence of a fever, which is greater than or equal to 38°C, in a woman within six weeks of her having given birth Aetiology Specific causes of puerperal pyrexia may include: Urinary tract infection: Frequency, dysuria, haematuria. Rigors from pyelonephritis. 95% caused by Escherichia coli, Proteus spp. and Klebsiella spp. Genital tract infection: Tender bulky uterus. Prolonged bleeding/pink or discoloured lochia. Painful inflamed perineum. May be caused by E. coli, other anaerobes, Group A streptococcus (GAS) (also known as Streptococcus pyogenes), Staphylococcus spp. and Clostridium welchii (rare, but serious). Mastitis: Flu-like symptoms. Painful, hard, red breast with possible abscess. Nipple trauma and cellulitis. Usually caused by Staphylococcus spp. Postoperative infection following caesarean section: lower segment caesarean section (LSCS) is the most important risk factor for puerperal pyrexia; there is a significantly increased risk of postpartum sepsis, wound problems, urinary tract infections and fever following LSCS. In the UK there is an 8% risk of infection following LSCS - appropriate antibiotic prophylaxis (not co-amoxiclav) before skin incision should be offered routinely[5]. Prophylaxis reduces endometritis by 66-75% and also reduces rate of wound infection[6]. Presenting features may include: Painful, red suture line. Deep tenderness on palpation. Lochia pink/coloured. Deep venous thrombosis A low-grade pyrexia can be caused by venous thromboembolism. Caused by venous stasis and hypercoagulability. Painful, swollen calf. Ovarian vein thrombophlebitis is a rare cause of persistent puerperal pyrexia Other infections: Pyrexia in a recently delivered mother may also be due to causes common to all, such as viral infection or chest infection. Glandular fever may be a common cause of fever in the postpartum period History A full history should be taken, to include a full history of the delivery - establish: When the membranes ruptured. The length of labour. The instrumentation used. Sutures required. Whether the placenta was complete. Whether there was any bleeding during or after delivery. Management General measures Ice packs may be helpful for pain from perineal wounds or mastitis. Rest and adequate fluid intake are required, particularly for mothers who are breastfeeding. The following signs and symptoms should prompt urgent referral for hospital assessment and, if the woman appears seriously unwell, by emergency ambulance[1]: Pyrexia (greater than or equal to 38°C). Sustained tachycardia (≥90 beats/minute). Breathlessness (respiratory rate ≥20 breaths/minute). Abdominal or chest pain. Diarrhoea and/or vomiting - may be due to endotoxins. Uterine or renal angle pain and tenderness. The woman is generally unwell or seems unduly anxious or distressed. Prophylaxis should be considered for close family members if either Group A streptococcal (GAS) or meningococcus (Neisseria meningitidis) infection is suspected. antibiotics within one hour of suspicion of severe sepsis, with or without septic shock, is recommended[1]: Analgesia may be required. NB: non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided for pain relief in cases of sepsis, as they impede the ability of polymorphs to fight GAS infection. Antibiotics should be commenced after taking specimens and should not be delayed until the results are available. A combination of either piperacillin/tazobactam or a carbapenem plus clindamycin provides one of the broadest ranges of treatment for severe sepsis. Meticillin-resistant Staphylococcus aureus (MRSA) may be resistant to clindamycin; hence, if the woman is, or is highly likely to be, MRSA-positive, vancomycin or teicoplanin may be added until sensitivity is known. Breastfeeding limits the use of some antimicrobials; hence, the advice of a consultant microbiologist should be sought at an early stage. Intravenous immunoglobulin (IVIg) is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed. It has an immunomodulatory effect and, in staphylococcal and streptococcal sepsis, it also neutralises the super-antigen effect of exotoxins. It also inhibits production of tumour necrosis factor and interleukins. If the fever is prolonged then treatment with heparin should also be considered. The possible complications of the infection will depend on the site, although several complications such as septicaemia, pulmonary embolus, disseminated intravascular coagulation and pneumonia are common to all. Sepsis with acute organ dysfunction has a mortality rate of 20-40%, rising to around 60% if septicaemic shock develops[10]. Genital tract infection may lead to abscess formation, adhesions, peritonitis, haemorrhage and subsequent infertility if not treated early and aggressively.