Postpartum Pyrexia(PP) is defined as a temperature above 38 °C for 24-hour period or recurring between end of 1st first and 10th day after childbirth. United States Joint Commission on Maternal Welfare further specifies it as a temperature surpassing 38.0 °C on any 2 of 1st 10 days postpartum, excluding 1st 24 hours. ¹Temporary fever within 1^st24 hours postpartum is disregarded due to its spontaneous resolution, due to lack of clear postpartum cause .²

Postpartum pyrexia affects around 5–7% of births globally ³rates differ across regions, with significant impact on maternal health, especially in Sub-Saharan Africa where about 66% of maternal deaths occur. Estimates of PP prevalence in Africa showed disparity, ranging from 64% in one Nigerian study to 2.9% in a Ugandan study in 2018 ^4,5But prevalence data currently exist for India. Some studies indicated puerperal sepsis as main cause of postpartum pyrexia, accounting for around 4.2% and 14.3% of all maternal deaths, respectively.

Infection, or puerperal sepsis, is the main  cause of postpartum fever, as recognized by the World Health Organization ⁶Increasing rates of puerperal sepsis are attributed to nosocomial infections and increasing antibiotic resistance, posing significant challenges to healthcare systems globally . Previous research proved preventable nature of puerperal sepsis, which is a major contributor to maternal morbidity and mortality in both low and high-income countries . ICausative microorganisms like poly microbial strains with group A b-hemolytic streptococcus, underscore severity of few cases of puerperal sepsis, as seen in an Australian study ⁷

Factors contributing to PP include urinary tract infections (UTIs), surgical wound infections, septic thrombophlebitis, malaria, and mastitis ⁸Physiological changes during pregnancy, along with birth-related trauma or cesarean procedures, also enhance the susceptibility to postpartum infections [3]. Anemia, prolonged labor, and prolonged premature rupture of membranes (PPROM) and routine unsterilized vaginal examinations during labor, increase risk of sepsis and pyrexia in the postpartum period ^9,10

In spite of its significance in maternal health, no studies in India directly assessed the burden of PP on maternal morbidity and mortality. Hence, this study was aimed to know risk factors, and etiologies of postpartum pyrexia in our tertiary care setting, facilitating informed actions for its prevention and management.

INCLUSION CRITERIA: All postnatal women with puerperal pyrexia who got delivered or referred from outside to this tertiary care center were selected irrespective of their parity, mode of delivery, and with live or dead fetus.

EXCLUSION CRITERIA:

The patients were diagnosed with pre-existing infections in the antenatal period.

Patients on steroids

Patients who are not willing to enroll in the study.

Patients who used antibiotics in last 3 days.

Exclusion criteria were assessed mainly through oral history, medical records, and physical and obstetric examination to rule out the conditions mentioned above.

The data of all 164 women was complete. All patients provided consent for the study.

Methodology:

Testing for UTI:

All the women were advised to wash hands and to collect urine samplepato. This sample was sent to the laboratory within two hours. The sample was divided into two parts. One part of urine sample was tested for the presence of nitrite, albumin, sugar and pus cells along with colony count. Another part was tested for culture and sensitivity. Treatment was given to all patients having bacteriuria with oral amoxiclav 625mg bd for 7days. Urine culture was repeated 7 days after the completion of treatment. Patients with persistent bacteriuria were treated with Inj. Gentamicin 80mg bd X 5days.

All patients were followed up till one month after delivery and discharge.

Parameters assessed:

1. Demographic data: Age
2. Parity
3. Condition of membranes
4. Mode of delivery
5. Place of delivery
6. Aetiology
7. Duration of labour
8. Onset of labour
9. Presence of anemia
10. Presence of gestational diabetes
11. Presence of pregnancy induced hypertension
12. Presence of hydramnios
13. Presence of immunocompromised status
14. Complications

STATISTICAL ANALYSIS: The data collected was processed in MS Excel 365 and analysis was done using statistical software called EPI INFO free version.  7.2.6.0.P value <0.05, was considered as statistically significant.  Frequencies, percentages were also used.  Mean and SD were used. Chi square test was used to assess categorical parameters. Quantitative measures were compared using T test.

Ethical considerations: Permission from the Institutional ethical committee attached to BV(DU)MC&H, Sangli, was taken before conducting the study.  

Informed consent was taken from all patients.

RESULTS

AGE:

50% of the patients were aged 20 to 29 years, 19.51% were aged 30 to 35 years.

PARITY:

46.95% of the patients were multiparous women.

CONDITION OF MEMBRANES:

56.10% of the patients had intact membranes. PPROM was seen in 21.34% of women.

MODE OF DELIVERY:

57.93% of the patients underwent LSCS, 9.15% underwent instrumental vaginal delivery.

PLACE OF DELIVERY:

98.78% of the patients underwent delivery at hospital.

AETIOLOGY:

25.61% of the patients had MASTITIS,12.80% of the patients had UTI, 12.8% of patients had septic thrombophlebitis. The following causes are the foci of infection.

DURATION OF LABOUR:

29.27% had 8 to 16hrsof labour, 3.05% underwent labour for more than 18 hrs.

ONSET OF LABOUR:

31.10% of the patients had spontaneous onset of labour.

ANEMIA:

56% of women had anemia.

GDM:

21.34% of women had GDM.

PIH:

39.63% of women had PIH.

 HYDRAMNIOS:

29.88% of women had hydramnios.

IMMUNOCOMPROMISED STATUS:

18.90% of women were immunocompromised (HIV, TB, Malignancies etc)

COMPLICATIONS:

87.20% of women had no complications,3.66% of the patients had sepsis.

Death was seen among 1.22% of cases. No complications were seen in 87.2% of patients.

AGE & COMPLICATIONS:

There is significant association between complications & age.

Most of the complications were seen in patients aged above 35 years and below 19 years.

Single Table Analysis

MEMBRANES AND COMPLICATIONS:

There is significant association between complications &condition of membranes.

Most of the complications were seen in patients with PROM and PPROM.

Single Table Analysis

MODE OF DELIVERY & COMPLICATIONS:

There is significant association between complications &mode of delivery.

Most of the complications were seen in patients who underwent LSCS.

Single Table Analysis

PLACE OF DELIVERY & COMPLICATIONS:

There is significant association between complications &place of delivery.

2 patients who had home delivery expired.

Single Table Analysis

ANEMIA & COMPLICATIONS:

There is no significant association between complications &presence of anemia.

Single Table Analysis

GDM & COMPLICATIONS:

There is no significant association between complications & presence of GDM.

Single Table Analysis

PIH& COMPLICATIONS:

There is no significant association between complications &presence of PIH.

Single Table Analysis

HYDRAMNIOS & COMPLICATIONS:

There is no significant associationbetween complications &presence of hydramnios.

Single Table Analysis

COMPLICATIONS & IMMUNOCOMPROMISED:

There is significant association in complications & immunocompromised status. More complications were seen in patients who are immunocompromised.

Single Table Analysis

PARITY & DURATION OF LABOUR:

There is a significant association between parity & duration of labor.

Single Table Analysis

REFERENCES

1. Bianco A, Roccia S, Nobile CG, et al. Postdischarge surveillance following delivery: the incidence of infections and associated factors. Am J Infect Control 2013; 41: 549–553. [PubMed] [Google Scholar]
2. Ely JW, Dawson JD, Townsend AS, Rijhsinghani A, Bowdler NC. Benign fever following vaginal delivery. J Fam Pract. 1996;43(2):146–151. [PubMed] [Google Scholar]
3. Anbazhagan A, Harper A. Postpartum pyrexia. Obstet, Gynaecol Reproduct Med. 2015;25(9):249–54.
4. Uhunmwangho EJ, Ojieh GC, Anyanwu RA, Idehen IC, Isibor JO, Turay AA, et al. The incidence and pattern of puerperal pyrexia amongst post-natal women in Benin city, Nigeria. African Journals OnLine. 2012; Available from: https://www.ajol.info/index.php/ijcr/article/download/108348/98170. [Accessed 3 Dec 2019].
5. Ngonzi J, Bebell LM, Fajardo Y, Boatin AA, Siedner MJ, Bassett IV, et al. Incidence of postpartum infection, outcomes and associated risk factors at Mbarara regional referral hospital in Uganda. BMC Pregnancy Childbirth. 2018;18 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6022296. [Accessed 28 Apr 2019]. [PMC free article] [PubMed]
6. World Health Organization. Trends in maternal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division.
7. Zakour NLB, Venturini C, Beatson SA, Walker MJ. Analysis of a Streptococcus pyogenes puerperal Sepsis cluster by use of whole-genome sequencing. J Clin Microbiol. 2012;50(7):2224–2228. doi: 10.1128/JCM.00675-12. [PMC free article] [PubMed] [CrossRef] [Google Scholar]
8. Hamadeh G, Dedmon C, Mozley PD. Postpartum fever. Am Fam Physician. 1995;52(2):531–8. [PubMed]
9. Dare FO, Bako AU, Ezechi OC. Puerperal Sepsis: a preventable post-partum complication. Tropical Doctor. 1996;28(121):96. [PubMed] [Google Scholar]
10. Ross C, Arulkumaran S. Postpartum pyrexia. Obstet Gynaecol Reprod Med. 2018;28(6):177–182. doi: 10.1016/j.ogrm.2018.04.001. [CrossRef] [Google Scholar]