Clinical Approach

A woman who has febrile morbidity after cesarean delivery most likely has endomyometritis. The mechanism of infection is ascension of bacteria, a mixture of organisms from the normal vaginal flora. In other words, postcesarean delivery infection almost always is "polymicrobial," with a mix of both aerobic and anaerobic bacteria. The uterine incision site, being devitalized and containing foreign material (i.e., suture), is commonly the site of infection. Typically, the fever occurs on postoperative day 2. When inlra-amniotic infection occurs during labor, the fever usually continues postpartum. The patient may complain of abdominal tenderness or foul-smelling lochia. Uterine tenderness is common. Broad-spectrum antimicrobial therapy, especially with anaerobic coverage, is important. Intravenous gentamicin and clindamycin is a well-studied regimen and effective in 90% of cases. Other choices include extended penicillins or cephalosporins. In contrast to postcesarean infection, endometritis after vaginal delivery does not necessarily require anaerobic antimicrobial coverage, and ampicillin and gentamicin usually are sufficient. The fever usually improves significantly after 48 hr of antimicrobial therapy. Enterococcal infection may be one reason for nonresponse; ampicillin is the treatment for this organism and often is added if fever persists after 48 hr of therapy.

Another cause of fever after cesarean delivery is wound infection. Prophylactic antibiotics given during surgery decrease the incidence. When a patient fails to respond to antibiotic therapy, wound infection is the most likely etiology. The fever usually occurs on postoperative day 4. Erythema or drainage may be present in the wound site. The organisms often are the same as those involved with endomyometritis. The treatment includes surgical opening of the wound (and dressing changes) and antimicrobial agents. The fascia must be inspected for integrity.

SPT is a rare bacterial infection affecting thrombosed pelvic veins, usually the ovarian vessels. The bacterial infection at the placental implantation site spreads to the ovarian venous plexuses or to the common iliac veins, sometimes extending to the inferior vena cava. Women with SPT may have a hectic fever

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