What is the standard of care for a postpartum patient experiencing rigors, headache, abdominal pain, tachycardia, shortness of breath, back pain, chills, and weakness 2 days after delivery?

Postpartum Sepsis: Standard of Care for a Patient 2 Days Post-Delivery with Systemic Symptoms

This clinical presentation—rigors, fever, tachycardia, abdominal pain, back pain, shortness of breath, and weakness at 2 days postpartum—represents sepsis or septic shock until proven otherwise and requires immediate emergency management with aggressive resuscitation, broad-spectrum antibiotics within 1 hour, and urgent identification of the infection source. 1, 2

Immediate Recognition and Emergency Response

Sepsis in the postpartum period is a medical emergency requiring treatment and resuscitation to begin immediately. 2

• Consider sepsis in any pregnant or postpartum patient with otherwise unexplained end-organ damage in the presence of a suspected or confirmed infectious process, regardless of the presence of fever 2
• The combination of rigors, tachycardia, and systemic symptoms indicates possible septic shock, which has a mortality risk requiring immediate intervention 1, 2
• Activate emergency protocols simultaneously, including calling for intensive care consultation, laboratory studies, and preparing for potential surgical intervention 1, 2

Initial Diagnostic Workup (Do Not Delay Treatment)

Obtain diagnostic tests immediately but do not delay antibiotic administration—treatment should begin within 1 hour of recognition. 2

Essential Laboratory Studies

• Serum lactate level (elevated lactate indicates tissue hypoperfusion and septic shock) 2
• Blood cultures before starting antimicrobial therapy, as long as there are no substantial delays in timely administration of antibiotics 2
• Complete blood count (hemoglobin, platelets), coagulation panel (PT, PTT, fibrinogen) to assess for disseminated intravascular coagulation 1
• Comprehensive metabolic panel (creatinine, liver enzymes) to evaluate end-organ damage 2
• Urinalysis and urine culture 3, 4

Imaging Considerations

• MRI of the spine is the preferred imaging modality if epidural abscess or hematoma is suspected, particularly if the patient had neuraxial anesthesia and presents with back pain 5
• CT abdomen and pelvis with IV contrast if intra-abdominal source is suspected (retained products of conception, uterine rupture, abscess) 5
• Pelvic ultrasound to evaluate for retained placental tissue or endometritis 3, 6

Immediate Resuscitation Protocol

Fluid Resuscitation

Administer 1-2 liters of balanced crystalloid solution intravenously within the first 3 hours for sepsis complicated by hypotension or suspected organ hypoperfusion. 1, 2

• Use balanced crystalloid solutions (lactated Ringer's or Plasma-Lyte) as first-line fluid for resuscitation 2
• Do NOT use starches or gelatin for resuscitation 2
• Establish large-bore IV access immediately 1
• Monitor response to fluid resuscitation using dynamic measures of preload (pulse pressure variation, stroke volume variation) rather than static measures 2

Vasopressor Support

• Use norepinephrine as the first-line vasopressor if hypotension persists despite adequate fluid resuscitation 2
• Consider intravenous corticosteroids if the patient continues to require vasopressor therapy despite fluids 2

Blood Product Transfusion

If postpartum hemorrhage is also present, activate massive transfusion protocol and transfuse blood products in a 1:1:1 ratio (packed red blood cells:fresh frozen plasma:platelets). 1

• Keep the patient warm (temperature >36°C) as hypothermia impairs clotting factor function 1
• Avoid crystalloid alone for resuscitation to prevent dilutional coagulopathy 1

Antibiotic Therapy

Administer empiric broad-spectrum antimicrobial therapy ideally within 1 hour of recognition in patients with septic shock or high likelihood of sepsis. 2

Empiric Antibiotic Regimen

• The combination of clindamycin and gentamicin is preferred for postpartum endometritis as it can be administered once-daily and covers the polymicrobial flora (aerobic and anaerobic organisms) typically involved 6
• Alternative regimens include extended-spectrum cephalosporins (cefotetan, ceftizoxime) or beta-lactamase inhibitor combinations 7, 6
• Ensure coverage for genital mycoplasmas, which are commonly isolated and usually resistant to penicillins and cephalosporins 7

Antibiotic Adjustment

• Modify antibiotic therapy based on culture results and clinical response 6
• Continue antibiotics until the patient is afebrile for 24-48 hours and clinically improving 3, 6

Source Control and Surgical Intervention

Rapidly identify or exclude an anatomic source of infection and perform emergency source control when indicated. 2

Uterine Source

If a uterine source for sepsis is suspected or confirmed, perform prompt delivery or evacuation of uterine contents to achieve source control, regardless of gestational age. 2

• Retained products of conception are the second most common cause of postpartum hemorrhage after uterine atony and a common source of postpartum infection 5, 7
• Do not delay intervention waiting for the cervix to dilate—retained placenta with septic shock requires urgent removal regardless of cervical status 1
• Proceed urgently to manual removal of placenta or surgical evacuation once the patient is hemodynamically stabilized 1

Other Potential Sources

• Evaluate for wound infection (cesarean incision or perineal lacerations), which is a common cause of antimicrobial failure in post-cesarean patients 7, 3
• Consider urinary tract infection, which is a frequent cause of postpartum fever 3, 4
• Assess for septic pelvic thrombophlebitis if fever persists despite appropriate antibiotics and source control 3, 6
• Rule out epidural abscess or hematoma if the patient had neuraxial anesthesia and presents with back pain, fever, or neurological symptoms 5

Surgical Exploration

• Have a low threshold for hysterectomy if bleeding is uncontrollable or if there is evidence of necrotizing endometritis 1
• Perform surgical exploration if the patient fails to respond to antibiotic therapy within 48-72 hours 3

Critical Differential Diagnoses to Consider

Epidural Abscess or Hematoma

If the patient received neuraxial anesthesia (epidural or spinal), epidural abscess or hematoma must be considered, particularly with the combination of back pain, fever, and systemic symptoms. 5

• Fever is present in only about one-third of patients with epidural abscess 5
• Localized back pain is present in most patients and is often the first symptom 5
• Radiculopathy may cause radiating or lancinating pain, including chest or abdominal pain 5
• Spinal cord syndromes (paraparesis progressing to paraplegia) may be a relatively late presentation—do not delay investigations if other features suggest abscess or hematoma 5

Postpartum Preeclampsia

Postpartum preeclampsia should be suspected in any patient with high blood pressure combined with symptoms of persistent headache, severe abdominal pain, shortness of breath, or vision changes. 5

• Check blood pressure immediately—severe hypertension (BP ≥160/110 mmHg) requires urgent treatment 5, 8
• However, the presence of rigors, chills, and fever makes infection more likely than preeclampsia alone 5

Intensive Care Monitoring

Transfer to ICU for intensive hemodynamic monitoring for at least 24 hours. 1

• Monitor for ongoing coagulopathy, disseminated intravascular coagulation (which occurs in >80% of severe hemorrhage cases), renal failure, liver failure, and unrecognized organ injury 1
• Continue monitoring blood pressure every 4-6 hours and repeat laboratory studies (hemoglobin, platelets, creatinine, liver enzymes, coagulation panel) until stable 8
• Have a low threshold for re-exploration if bleeding continues despite initial intervention 1

Venous Thromboembolism Prophylaxis

Use pharmacologic venous thromboembolism prophylaxis in postpartum patients with septic shock due to increased risk. 2

Glucose Management

• Initiate insulin therapy at a glucose level >180 mg/dL in critically ill pregnant patients with sepsis 2

Common Pitfalls to Avoid

• Do not wait for laboratory results or imaging before starting antibiotics—treat based on clinical presentation of hypotension and fever 1, 2
• Do not delay surgical intervention for source control—retained placenta or products of conception with septic shock require urgent removal 1, 2
• Do not use methylergonovine for uterine atony due to its vasoconstrictive effects, which could worsen hypotension in septic shock 1
• Do not dismiss back pain as musculoskeletal—in the context of neuraxial anesthesia and systemic symptoms, epidural abscess or hematoma must be ruled out 5
• Do not assume a normal initial presentation means the patient is stable—sepsis can progress rapidly, and early aggressive intervention is critical 2, 4

Long-Term Follow-Up

Because of an increased risk of physical, cognitive, and emotional problems in survivors of sepsis and septic shock, provide ongoing comprehensive support for postpartum sepsis survivors and their families. 2

• Schedule follow-up within 1 week of discharge 8
• Comprehensive review at 3 months postpartum to ensure complete recovery 8
• Screen for postpartum depression, anxiety, and post-traumatic stress disorder 5