Puerperal Pyrexia: Definition and Clinical Overview
Puerperal pyrexia is defined as fever ≥38°C occurring in a woman within 6 weeks of giving birth, representing a leading cause of preventable maternal morbidity and mortality worldwide. 1, 2, 3
Clinical Definition and Timing
- Temperature threshold: Fever of ≥38°C (100.4°F) occurring within 6 weeks postpartum 3
- Peak incidence: Most postpartum infections occur within the first 3 days after delivery, with 85% of cases presenting during this early period 4
- Prevalence: Affects approximately 5-9% of all deliveries, with reported rates of 8.82% in tertiary centers 1, 4
Primary Etiologies
The causes of puerperal pyrexia vary by timing and clinical context:
Most Common Causes (in order of frequency):
- Malaria (46.7% in endemic regions, particularly within first 3 days postpartum) 4
- Urinary tract infections (18.7%, with E. coli as the predominant organism in 49.3% of positive cultures) 4
- Puerperal sepsis/Endometritis (17.9%, also termed endomyometritis or endomyoparametritis) 1, 2, 4
- Pneumonia (8.7%) 4
- Wound infections (cesarean section or episiotomy sites) 1, 2
- Mastitis 1, 2
- Septic thrombophlebitis 1, 2
Critical Risk Factors
The following factors significantly increase risk of puerperal pyrexia and should trigger heightened surveillance:
Intrapartum Risk Factors:
- Five or more vaginal examinations during labor (OR 59.151,95% CI: 21.463-163.019) - the single strongest predictor 4
- Perineal tears (OR 45.157,95% CI: 2.266-899.722) 4
- Prolonged labor >18 hours (OR 26.760,95% CI: 7.100-100.862) 4
- Prolonged rupture of membranes 1, 2
- Cesarean section 1, 2
- Retained products of conception 1, 2
- Postpartum hemorrhage 1, 2
Maternal Risk Factors:
- Home birth in unhygienic conditions 1, 2
- Low socioeconomic status and poor nutrition 1, 2
- Primiparity 1, 2
- Anemia 1, 2
Transmission Patterns and Microbiology
Infections are categorized by source:
- Nosocomial infections: Acquired in hospitals from the environment or patient's own flora 1, 2
- Exogenous infections: External contamination, especially with unhygienic delivery conditions 1, 2
- Endogenous infections: Mixed flora from the woman's own genital tract 1, 2
Serious Maternal Complications
Puerperal pyrexia can rapidly progress to life-threatening conditions:
- Septicemia and endotoxic shock 1, 2
- Peritonitis or abscess formation requiring surgical intervention 1, 2
- Compromised future fertility 1, 2
- Multi-organ failure and death (particularly with conditions like acute fatty liver of pregnancy masquerading as puerperal sepsis) 3
Critical Clinical Pitfall
Most postpartum infections occur after hospital discharge (typically within 24 hours of delivery), and in the absence of postnatal follow-up—common in developing countries—many cases go undiagnosed and unreported, contributing to preventable maternal mortality 1, 2