Rosen & Barkin's 5-Minute Emergency Medicine Consult (569 page)

• Abdominal and/or uterine tenderness
  
• Foul-smelling lochia
  
• Unilateral tender, engorged, erythematous breast in cases of mastitis
  
• Examine episiotomy infections
  
• Suprapubic or costovertebral angle tenderness in cases of UTI/pyelonephritis
  

• Abdominal and pelvic exam
  
• Cervical cultures for
  Chlamydia
  
• Transcervical endometrial cultures
  

• CBC
  
• Urinalysis and culture
  
• Blood cultures
  

• CT or MRI for ovarian vein thrombosis
  
• US is sensitive for abscess or retained products of conception
  
• Plain x-rays may show retained foreign bodies or free air in septic abortion.
  

• Fever from other sources
  
• <6 hr:
  
  • Early streptococcal infection
    
  • Transfusion reaction
    
  • Thyroid crisis
    
• <48 hr:
  
  • Atelectasis
    
• <72 hr:
  
  • UTI
    
  • Pneumonia
    
• 3–5 days:
  
  • Mastitis
    
  • Breast engorgement
    
  • Necrotizing fasciitis
    
• 3–7 days:
  
  • Mastitis
    
  • Septic thrombophlebitis
    
• 7–14 days:
  
  • Abscess
    
• >2 wk:
  
  • Mastitis
    
  • Pulmonary embolism
    

TREATMENT

• ABCs
  
• IV and IV fluids if signs of shock or impending shock
  

Manage airway and resuscitate as indicated:

• Prompt evaluation of respiratory and hemodynamic status
  
• Supplemental oxygen, cardiac monitor, and pulse oximetry, as needed
  
• Venous access; support circulatory status with crystalloid and pressors, if needed
  

• IV antibiotics and close observation
  
• Septic abortion is usually treated with dilatation and curettage and removal of any inciting agents
  
• Monitor for signs of impending shock, circulatory failure, ARDS, and/or sepsis.
  
• Heparin if suspicion or evidence of thrombophlebitis
  
• Infected wound or abscess should be opened to establish drainage
  
• Necrotizing fasciitis requires wide surgical débridement, parenteral antibiotics, and adjunctive hyperbaric oxygen therapy
  
• Peritonitis requires imaging to evaluate cause
  

Per underlying infection. See corresponding chapters for complete list (consider safety in breast-feeding)

• Cefoxitin: 2 g IV q6h
  or
  
• Cefotetan: 2 g IV q12h
  or
  
• Piperacillin/tazobactam: 3.375 g IV q6–8h
  or
  
• Ampicillin/sulbactam: 1.5–3 g IV q6h
  or
  
• Clindamycin: 600–900 mg IV q8h +
  
• Gentamicin: 2 mg/kg load, then 1–1.5 mg/kg IV q8h
  

• Triple antibiotics
  
• Gram-positive coverage:
  
  • Ampicillin/sulbactam: 1.5–3 g IV q6h
    or
    
  • Cefoxitin: 2 g IV q6h
    or
    
  • Cefotetan: 2 g IV q12h
    
• Gram-negative coverage:
  
  • Gentamicin: 2 mg/kg load, then 1–1.5 mg/kg IV q8h
    
• Anaerobic coverage:
  
  • Clindamycin: 600–900 mg IV q8h
    or
    
  • Metronidazole: 500 mg IV q8h
    

• Dicloxacillin: 250 mg q6h PO for 10 days
  
• Mupirocin 2% ointment TID
  
• Cephalexin: 500 mg q6h PO for 10 days
  
• Clindamycin: 300 mg q6h PO for 10 days
  
• Erythromycin: 500 mg q6h PO for 10 days
  
• If MRSA positive: Vancomycin 1 g IV q12h
  

• Ciprofloxacin: 400 mg IV q12h
  or
  
• Ceftriaxone: 1–2 g IV q24h
  or
  
• Piperacillin/tazobactam: 3.375 g IV q6–8h
  

FOLLOW-UP

• Patients with endometritis or suspicion for septic pelvic thrombophlebitis should be admitted
  
• Septic abortion
  

Nontoxic, mildly symptomatic patient may be considered for outpatient management in consultation and close follow-up with obstetrics

Close follow-up with obstetrician and/or primary care physician to evaluate treatment

• Mastitis and UTI account for 80% of postpartum infections
  
• C-section increases risk for PPE
  
• Entertain broad differential with regard to source of infection
  
• Early broad-spectrum antibiotics are often indicated
  

• Faro S. Postpartum endometritis.
  Clin Prenatal
  . 2005;32:803–814.
  
• French LM, Smaill FM. Antibiotic regimens for endometritis after delivery.
  Cochrane Database Syst Rev
  . 2004;(4):CD001067.
  
• Gorgas DL. Infections related to pregnancy.
  Emerg Med Clin North Am
  . 2008;26:345–366.
  
• Gupta, K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women: A 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases.
  Clin Infect Dis
  . 2010;52:103–120.
  
• Levine BJ.
  EMRA Antibiotic Guide.
  15th ed. EMRA; 2013.
  
• Wong AW, Rosh AJ. Pregnancy, postpartum infections.
  http://emedicine.medscape.com/article/796892-overview
  

See Also (Topic, Algorithm, Electronic Media Element)

• Mastitis
  
• Urinary Tract Infection
  
• Pyelonephritis
  

CODES

• 670.00 Major puerperal infection, unspecified as to episode of care or not applicable
  
• 670.10 Puerperal endometritis, unspecified as to episode of care or not applicable
  
• 670.20 Puerperal sepsis, unspecified as to episode of care or not applicable
  

BASICS

• Hypertension in pregnancy:
  
  • 1% of all pregnancies
    
  • 16% of maternal deaths
    
• Gestational hypertension (GH)
  
  • Hypertension associated with pregnancy
    
  • Resolves with delivery
    
  • 6–7% of all pregnancies
    
• Preeclampsia
  
  • GH PLUS proteinuria
    
  • 2.2–6.3% of all pregnancies
    
• Eclampsia
  
  • Preeclampsia with seizure
    
• Postpartum preeclampsia
  
  • Occurs within 6 wk of delivery
    
  • Usually no history of hypertension
    
  • Occurs in 5% patients
    
  • Most women are African American
    
• HELLP syndrome
  
  • May occur in women with preeclampsia or eclampsia
    
  • Hemolysis
    
  • Elevated liver function tests
    
  • Low platelets
    
• Superimposed preeclampsia
  
  • Preeclampsia in the setting of chronic hypertension
    
  • Complicates pregnancy in up to 25% of women with chronic hypertension
    
  • Risk factors:
    
    • African American
      
    • Antihypertensive medication use
      
• Chronic hypertension
  
  • Systolic BP (SBP) >140 or diastolic BP (DBP) >90
    
  • Measured twice prior to 20 wk gestation or lasting >12 wk after delivery