Infections are among the most prominent puerperal complications. An improved understanding of the natural history of female genital infections and the availability of powerful antibiotics may have produced a complacent attitude toward puerperal infections that is unrealistic. Postpartum infections still are costly to both patients and society, and they are associated with an admittedly small but not negligible threat of serious disability and death.
Puerperal morbidity due to infection has occurred if the patient's temperature is higher than 38°C (100.4°F) on 2 separate occasions at least 24 hours apart following the first 24 hours after delivery. Overt infections can and do occur in the absence of these criteria, but fever of some degree remains the hallmark of puerperal infection, and the patient with fever can be assumed to have a genital infection until proved otherwise.
Puerperal infectious morbidity affects 2–8% of pregnant women and is more common in those of low socioeconomic status, who have undergone operative delivery, with premature rupture of the membranes, with long labors, or who have multiple pelvic examinations.
Postpartum infections are responsible for much of the morbidity associated with childbirth, and they either are directly responsible for or contribute to the death of approximately 7% of all pregnant women who die each year in the United States. The costs are considerable, not only in additional days of hospitalization and medications but also in time lost from work.
Sterility may result from the sequelae of postpartum infections, such as periadnexal adhesions. Hysterectomy occasionally is required in patients with serious postpartum or postoperative infection.
The flora of the birth canal of pregnant women is essentially the same as that of nonpregnant women, although variations in culture techniques and in the study populations have produced markedly different results. The vaginal flora typically includes aerobic and anaerobic organisms that are commonly considered pathogenic (Table 21–1). Several mechanisms appear to prevent overt infection in the genital tract, such as the acidity of the normal vagina; thick, tenacious cervical mucus; and maternal antibodies to most vaginal flora.
Table 21–1. Percentage of Organisms Isolated from the Vagina or Cervix in Normal Pregnant and Nonpregnant Women. ||Download (.pdf)
Table 21–1. Percentage of Organisms Isolated from the Vagina or Cervix in Normal Pregnant and Nonpregnant Women.
|Group D streptococci||4–44|
During labor and particularly after rupture of the membranes, some of the protective mechanisms are no longer present. Examinations and invasive monitoring apparatus probably facilitate the introduction of vaginal bacteria into the uterine cavity. Bacteria can be cultured from the amniotic fluid of most women undergoing intrauterine pressure monitoring, but overt postpartum infection is seen in fewer than 10% of these cases. Contractions during labor may spread bacteria present in the amniotic cavity to the adjacent uterine lymphatics and even into the bloodstream.
The postpartum uterus initially is devoid of mechanisms that keep it sterile, and bacteria may be recovered from the uterus in nearly all women in the postpartum period. Whether or not disease is clinically expressed depends on the presence of predisposing factors, the duration of uterine contamination, and the type and amount of microorganisms involved. The necrosis of decidua and other intrauterine contents (lochia) promotes an increase in the number of anaerobic bacteria, heretofore limited by lack of suitable nutrients and other factors necessary for growth.
Sterility of the endometrial cavity returns by the third or fourth postpartum week. Granulocytes that penetrate the endometrial cavity and the open drainage of lochia are effective in preventing infection in most patients.
Almost all postpartum infections are caused by bacteria normally present in the genitalia of pregnant women. The lochia is an excellent culture medium for organisms ascending from the vagina. In women who have undergone caesarean section, more devitalized tissue and foreign bodies (sutures) are present, providing additional fertile ground for possible contamination and subsequent infection. Approximately 70% of puerperal soft tissue infections are mixed infections consisting of both aerobic and anaerobic organisms; infections occurring in women undergoing caesarean section are more likely to be serious.
The source of infection should be identified, the likely cause determined, and the severity assessed. Most women with fever in the postpartum period have endometritis. Urinary tract infection is the next most common infection. Neglected or virulent endomyometritis may progress to more serious infection. Generalized sepsis, septic pelvic thrombophlebitis, or pelvic abscess may be the end result of an initial infection of the endometrial cavity.
- Infection of the endometrium
- Fever and a soft, tender uterus on physical examination
All of the following circumstances have led to higher than normal postpartum infection rates: prolonged rupture of the membranes (>24 hours), chorioamnionitis, an excessive number of digital vaginal examinations, prolonged labor (>12 hours), toxemia, intrauterine pressure catheters (>8 hours), fetal scalp electrode monitoring, preexisting vaginitis or cervicitis, operative vaginal deliveries, caesarean section, intrapartum and postpartum anemia, poor nutrition, obesity, low socioeconomic status, and coitus near term.
Caesarean section and low socioeconomic class are consistently associated with higher rates of postpartum infection, and caesarean section is easily the most common identifiable risk factor for development of puerperal infection. Some series report an infection rate of 40–80% following caesarean section delivery. Postpartum infection is more likely to be serious after caesarean section than after vaginal delivery. A history of bacterial vaginosis is associated with a higher risk of postcaesarean endometritis.
Fever and a soft, tender uterus are the most prominent signs of endometritis. The lochia may or may not have a foul odor. Leukocytosis is seen. In more severe disease, high fever, malaise, abdominal tenderness, ileus, hypotension, and generalized sepsis may be seen. Movement of the uterus causes increased pain.
Although the puerperium is a period of high metabolic activity, this factor should not raise the temperature above 37.2°C (99°F) and then only briefly in the first 24 hours postpartum. Modest temperature elevations may occur with dehydration. Any woman with a fever over 38°C (100.4°F) at any time in the puerperium should be evaluated.
Endometritis results in temperatures ranging from 38°C to over 40°C (100.4°F to >104°F), depending on the patient, the causative microorganism, and the extent of infection. The lower range of temperatures is more common. Endometritis usually develops on the second or third postpartum day. Early fever (within hours of delivery) and hypotension are almost pathognomonic for infection with β-hemolytic streptococci.
The uterus is soft and exquisitely tender. Motion of the cervix and uterus may cause increased pain.
Abdominal tenderness is generally limited to the lower abdomen and does not lateralize. A carefully performed baseline examination should include an adnexal evaluation. Adnexal masses palpable on abdominal or pelvic examination are not seen in uncomplicated endometritis, but tubo-ovarian abscess may be a later complication of an infection originally confined to the uterus. Bowel sounds may be decreased and the abdomen distended and tympanitic.
Pelvic examination confirms the findings disclosed by abdominal examination.
Leukocytosis is a normal finding during labor and the immediate puerperal period. White blood cell counts may be as high as 20,000/μL in the absence of infection, so higher counts can be anticipated in infection. Bacteremia is present in 5–10% of women with uncomplicated endometritis. Mycoplasma is frequently recovered from the blood of patients with postpartum fever. Infections with Bacteroides as the predominant organism are frequently associated with positive blood cultures.
Urinalysis should be routinely performed in patients thought to have endometritis because urinary tract infections are often associated with a clinical picture similar to that of mild endometritis. If pyuria and bacteria are noted in a properly collected specimen, appropriate antibiotic therapy for urinary tract infections should be started and a portion of the specimen sent for culture.
Bacteria colonizing the cervical canal and ectocervix almost always can be recovered from lochia cultures, but they may not be the same organisms causing endometritis. Accurate cultures can be achieved only if specimens obtained transcervically are free from vaginal contamination. Material should be obtained using a speculum to allow direct visualization of the cervix and a gloved culture device (a swab that is covered while it is passed through a contaminated area, then uncovered to obtain a culture from the desired area). Transabdominal aspiration of uterine contents does secure an uncontaminated specimen, but routine use of this technique probably is not justified, and confirmation of placement within the uterine cavity may be difficult. Unless special means are taken to prevent cervical contamination and to ensure the recovery of anaerobic species, results of lochia cultures must be interpreted with great care.
Although the organisms responsible for puerperal infections vary considerably among hospitals, most puerperal infections are due to anaerobic streptococci, gram-negative coliforms, Bacteroides spp., and aerobic streptococci. Chlamydia and Mycoplasma are also implicated in many postpartum infections, but clinical isolates are rare because of the difficulty in culturing these organisms. Gonococci are recovered in varying degrees. The percentage of representative microorganisms recovered from women with endometritis is given in Table 21–2.
Table 21–2. Percentage of Organisms Recovered from Women with Postpartum Endomyometritis. ||Download (.pdf)
Table 21–2. Percentage of Organisms Recovered from Women with Postpartum Endomyometritis.
|Group A streptococci||2–6|
|Group B streptococci||6–21|
|Group D streptococci||3–14|
Patterns of bacterial isolates in puerperal infections in the patient's hospital are more important in guiding selection of appropriate antibiotics than are studies from the literature.
Group A streptococci are no longer a major cause of postpartum infection, but infection with these organisms still occurs occasionally, often associated with rapid progression of toxic shock syndrome. If more than an isolated instance of infection due to these streptococci occurs, immediate measures should be taken to halt a potential epidemic. Penicillin is highly effective.
In as many as 30% of women with clinically recognized endometritis, group B streptococci are partly or wholly responsible for the infection. Classic presenting signs are high fever and hypotension shortly after delivery. However, group B streptococci are commonly recovered from the vaginas of pregnant women whether or not they have endometritis. Why some women with positive cultures develop serious illness whereas others do not undoubtedly depends on the presence of predisposing factors as well as other, as yet unknown, elements. It is interesting that positive cultures in women do not correlate well with the incidence of streptococcal infection in their newborns. Penicillin is the treatment of choice for patients with endometritis.
Group D streptococci, which include Streptococcus faecalis, are common isolates in endometritis. Ampicillin in high doses is the treatment of choice. Aminoglycosides are also effective against this group.
Staphylococcus aureus is not commonly seen in cultures from women with postpartum infections of the uterus. Staphylococcus epidermidis is frequently recovered from women with postpartum infections. These organisms are typically not seen in pure culture. When established staphylococcal infections require treatment, nafcillin, cloxacillin, or cephalosporins should be used.
Among the gram-negative aerobic organisms likely to be recovered in postpartum uterine infections, Escherichia coli is the most common. In postpartum uterine infections, E coli is more likely to be isolated from seriously ill patients, whereas in urinary tract infections, it is the most commonly isolated organism but is not necessarily found in the sickest patients. Hospital-acquired E coli is most susceptible to aminoglycosides and cephalosporins.
The incidence of Neisseria gonorrhoeae is 2–8% in pregnant women antepartum. Unless repeat screening examinations and treatment of patients with positive cultures are undertaken in women near term, the incidence of asymptomatic endocervical gonorrhea at delivery probably is only slightly less, and it is reasonable to believe that some cases of puerperal endometritis are gonococcal in origin.
Gardnerella vaginalis, a cause of vaginitis, is seen in isolates from women with postpartum infections, usually in those with a polymicrobial cause, although pure isolates have been reported.
Other gram-negative bacilli that are commonly encountered on medical and surgical wards (eg, Klebsiella pneumoniae, Enterobacter, Proteus, and Pseudomonas spp.) are uncommon causes of endometritis.
Anaerobic bacteria are involved in puerperal infections of the uterus in at least 50% and perhaps as many as 95% of cases. They are much less commonly seen in urinary tract infections. Anaerobic peptostreptococci and peptococci are commonly recovered in specimens from women with postpartum infection, particularly with other anaerobic species. Clindamycin, chloramphenicol, and the newer cephalosporins are active against these organisms.
Bacteroides spp., particularly Bacteroides fragilis, are commonly found in mixed puerperal infections. These are likely to be the more serious infections (eg, puerperal pelvic abscess, caesarean section wound infections, and septic pelvic thrombophlebitis). When infection with this organism is suspected or confirmed, clindamycin, chloramphenicol, or third-generation cephalosporins should be used.
Gram-positive anaerobic organisms are represented only by Clostridium perfringens, which is not infrequently isolated from an infected uterus but which is a rare cause of puerperal infection.
Mycoplasma and Ureaplasma spp. are common genital pathogens that have been isolated from the genital tract and blood of postpartum women both with and without overt infection. These pathogens are frequently found in the presence of other bacteria. The role of these organisms in puerperal infections is unknown.
Chlamydia trachomatis is now thought to be the leading cause of pelvic inflammatory disease in some populations. Because the population most at risk for pelvic inflammatory disease is the same as that most likely to become pregnant, it is not surprising that Chlamydia is in some way involved in puerperal infections, but it is infrequently isolated as a cause of early postpartum endometritis. Chlamydia is more frequently associated with mild late-onset endometritis, so cultures for this organism should be obtained from patients with endometritis diagnosed several days after delivery. Chlamydia is difficult to culture, and it is possible that as more effective culture techniques become available, the place of this organism in the morbidity associated with postpartum infections will be clarified.
In the immediate postpartum period, involuntary chills are common and are not necessarily an indication of overt infection. Lower abdominal pain is common as the uterus undergoes involution with continuing contractions.
Extragenital infections are much less common than endometritis and urinary tract infections. Most of these infections can be effectively ruled out by history and examination alone. Patients should be asked, at a minimum, about coughing, chest pain, pain at the insertion site of IV catheters, breast tenderness, and leg pain. Examination of the breasts, chest, IV catheter insertion site, and leg veins should determine whether these areas might be the source of the postpartum fever. Chest x-ray films are rarely of benefit unless signs and symptoms point to a possible pulmonary cause of the fever.
The choice of antibiotics for treatment of endometritis depends on the suspected causative organisms and the severity of the disease. If the illness is serious enough to require antibiotics, initial therapy should consist of IV antibiotics in high doses. Factors reinforcing the need for this approach include the large volume of the uterus, the expanded maternal blood volume, the brisk diuresis associated with the puerperium, and the difficulty in achieving adequate tissue concentrations of the antibiotic distal to the thrombosed myometrial blood vessels. Clindamycin plus an aminoglycoside is a standard first-line regimen. Good evidence now indicates that once-a-day dosing of gentamicin is as effective as the traditional thrice-daily regimen. Single-agent therapy with second- or third-generation cephalosporins is an acceptable alternative.
The response to therapy should be carefully monitored for 24–48 hours. Deterioration or failure to respond determined both clinically and by laboratory test results requires a complete reevaluation. Ampicillin is added when the patient has a less than adequate response to the usual regimen, particularly if Enterococcus spp. are suspected.
IV antibiotics are continued until the patient has been afebrile for 24–48 hours. Randomized and prospective trials have shown that additional treatment with oral antibiotics after IV therapy is unnecessary. Patients with documented concurrent bacteremia can be treated similarly, unless they have persistently positive blood cultures or a staphylococcal species cultured. If the patient remains febrile despite the standard antibiotic regimens, further evaluation should be initiated to look for abscess formation, hematomas, wound infection, and septic pelvic thrombophlebitis.
For patients known to be infected or at extremely high risk for infection at the time of delivery, initial therapy with 2- or 3-drug regimens in which 1 of the agents is clindamycin is prudent. Single-agent IV infusion of broad-spectrum agents such as piperacillin or cefoxitin appears to be equally effective.
Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: A meta-analysis. Am J Obstet Gynecol
Thurman AR. Post-cesarean delivery infectious morbidity: Focus on preoperative antibiotics and methicillin-resistant Staphylococcus aureus. Am J Infect Control
- Urine culture demonstrating the presence of bacteria in the urine in a patient symptomatic for urinary tract infection
- Pyelonephritis typically presents with symptoms of flank pain and/or systemic signs of fever, chills, and nausea/vomiting
Approximately 2–4% of women develop a urinary tract infection postpartum. After delivery, the bladder and lower urinary tract remain somewhat hypotonic, and residual urine and reflux result. This altered physiologic state, in conjunction with catheterization, birth trauma, conduction anesthesia, frequent pelvic examinations, and nearly continuous contamination of the perineum, is sufficient to explain the high incidence of lower urinary tract infections postpartum. In many women, preexisting asymptomatic bacteria, chronic urinary tract infections, and anatomic disorders of the bladder, urethra, and kidneys contribute to urinary tract infection postpartum.
Urinary tract infection usually presents with dysuria, frequency, urgency, and low-grade fever; however, an elevated temperature is occasionally the only symptom. White blood cells and bacteria are seen in a centrifuged sample of catheterized urine. A urine culture should be obtained. The history should be reviewed for evidence of chronic antepartum infections. If a woman had an antepartum urinary tract infection, then her postpartum infection likely is caused by the same organism. Repeated urinary tract infections call for careful postpartum evaluation. Urethral diverticulum, kidney stones, and upper urinary tract anomalies should be ruled out.
Urinary retention postpartum in the absence of regional anesthesia or well after its effects have worn off almost always indicates urinary tract infection.
Pyelonephritis may be accompanied by fever, chills, malaise, and nausea and vomiting. Characteristic signs of kidney involvement associated with pyelonephritis include costovertebral angle tenderness, dysuria, pyuria, and, in the case of hemorrhagic cystitis, hematuria.
E coli is easily the most common organism isolated from infected urine in postpartum women (approximately 75% of cases). Other gram-negative bacilli are much less likely to be recovered. E coli is less likely to be the causative organism in women who had repeated urinary tract infections in the recent past.
Antibiotics with specific activity against the causative organism are the cornerstone of therapy in uncomplicated cystitis. These drugs include sulfonamides, nitrofurantoin, trimethoprim-sulfamethoxazole, oral cephalosporins (cephalexin, cephradine), and ampicillin. Some hospitals report a high incidence of microbial resistance to ampicillin. The oral combination of amoxicillin-clavulanic acid provides a better spectrum of bacterial sensitivity. Sulfa antibiotics can be used safely in women who are breastfeeding if the infants are term without hyperbilirubinemia or suspected glucose-6-phosphate dehydrogenase deficiency. High fluid intake should be encouraged.
Pyelonephritis requires initial therapy with high doses of IV antibiotics, such as ampicillin 8–12 g/d or first-generation cephalosporins (cefazolin 3–6 g/d, cephalothin 4–8 g/d). An aminoglycoside can be added when resistant organisms are suspected or when the patient has clinical signs of sepsis. A long-acting third-generation cephalosporin, such as ceftriaxone 1–2 g every 12 hours, also can be used. The response to therapy may be rapid, but some women respond with gradual defervescence over 48 hours or longer. Urine cultures should be obtained to guide any necessary modifications in drug therapy if the patient's response is not prompt. Even with prompt resolution of fever, antibiotic therapy should be continued IV or orally for a total of 10 days. Urine for culture should be obtained at a postpartum visit after therapy has been completed.
- Pneumonia typically presents with fever, chills, and productive cough.
- Women with obstructive lung disease, smokers, and those undergoing general anesthesia have an increased risk for developing pneumonia postpartum.
Symptoms and signs are the same as those of pneumonia in nonpregnant patients: productive cough, chest pain, fever, chills, rales, and infiltrates on chest x-ray film. In some cases, careful differentiation from pulmonary embolus is required.
X-Ray & Laboratory Findings
Chest x-ray film confirms the diagnosis of pneumonia. Gram-stained smears of sputum and material for culture should be obtained.
Streptococcus pneumoniae and Mycoplasma pneumoniae are the 2 most likely causative organisms. S pneumoniae can easily be identified on gram-stained smears. Infection with M pneumoniae can be suspected on clinical grounds.
Appropriate antibiotics, oxygen (if the patient is hypoxic), IV hydration, and pulmonary toilet are the mainstays of therapy.
Caesarean Section Wound Infection
- Wound erythema and tenderness +/– drainage from the wound
- The patient may also demonstrate systemic signs of infection such as fever or malaise
Wound infection occurs in 4–12% of patients after caesarean section. The following risk factors predispose to subsequent wound infection in women undergoing caesarean section: obesity, diabetes, prolonged hospitalization before caesarean section, prolonged rupture of the membranes, chorioamnionitis, endomyometritis, prolonged labor, emergency rather than elective indications for caesarean section, and anemia.
The high rate of infection (averaging 35–40%) after caesarean section is sufficient reason to consider prophylactic perioperative antibiotic administration. A major difference in practice in terms of prophylactic antibiotic administration prior to caesarean delivery has recently been advocated. While historically antimicrobial prophylaxis has been given after umbilical cord clamping, due to concerns regarding the masking of a neonatal infection, reductions in postcaesarean wound infection as great as 50% can be attributed to a single dose of cefazolin (1 g) given IV prior to skin incision.
Fever with no apparent cause that persists to the fourth or fifth postoperative day strongly suggests a wound infection. Wound erythema and tenderness may not be evident until several days after surgery. Occasionally, wound infections are manifested by spontaneous drainage, often accompanied by resolution of fever and relief of local tenderness. Rarely, a deep-seated wound infection becomes apparent when the skin overtly separates, usually after some strenuous activity by the patient.
Gram-stained smears and culture of material from the wound may be helpful in guiding selection of the initial antibiotic. Blood cultures may be positive in the patient with systemic sepsis due to wound infection. The organisms responsible for most wound infections originate on the patient's skin. S aureus is the organism most commonly isolated. Streptococcus species, E coli, and other gram-negative organisms that may originally have colonized the amniotic cavity are also seen. Occasionally, Bacteroides, which comes only from the genital tract, is isolated from material taken from serious wound infections. In addition, methicillin-resistant S aureus (MRSA) is an emerging isolate from caesarean delivery wound infections. At this point, prophylactic antibiotic regimens have not addressed this particular organism.
Rarely, necrotizing fasciitis and the closely related synergistic bacterial gangrene can involve caesarean section incisions. They are recognized by their intense tissue destruction, lack of sensation in the involved tissues, and rapid extension. Radical debridement of necrotic and infected tissue is the cornerstone of treatment.
The incision should be opened along its entire length and the deeper portion of the wound gently explored to determine whether fascial separation has occurred. If the fascia is not intact, the wound is dissected to the fascial level, debrided, and repaired. Wound dehiscence has a high mortality rate and should be treated aggressively. Dehiscence is uncommon in healthy patients and with Pfannenstiel incisions. The skin can be left open to undergo delayed closure or to heal by primary intention.
If the fascia is intact, the wound infection can be treated by local measures.
Mechanical cleansing of the wound is the mainstay of therapy for caesarean wound infection. Opening the wound encourages drainage of infected material. The wound can be packed with saline-soaked gauze 2–3 times per day, which will remove necrotic debris each time the wound is unpacked. The wound can be left open to heal, or it can be closed secondarily when granulation tissue has begun to form.
Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: A meta-analysis. Am J Obstet Gynecol
Thurman AR. Post-cesarean delivery infectious morbidity: Focus on preoperative antibiotics and methicillin-resistant Staphylococcus aureus. Am J Infect Control
- Pain at the episiotomy site
- Physical examination demonstrates disruption of the episiotomy wound
It is surprising that infected episiotomies do not occur more often than they do, because contamination at the time of delivery is universal. Subsequent contamination during the healing phase also should be common, yet infection and disruption of the wound are infrequent (0.5–3%). The excellent local blood supply is suggested as an explanation for this phenomenon.
In general, the more extensive the laceration or episiotomy, the greater are the chances for infection and breakdown of the wound. More tissue is devitalized in a large episiotomy, thereby providing greater opportunity for contamination. Women with infections elsewhere in the genital area probably are at greater risk for infection of the episiotomy.
Pain at the episiotomy site is the most common symptom. Spontaneous drainage is frequent, so a mass rarely forms. Incontinence of flatus and stool may be the presenting symptom of an episiotomy that breaks down and heals spontaneously.
Inspection of the episiotomy site shows disruption of the wound and gaping of the incision. A necrotic membrane may cover the wound and should be debrided if possible. A careful rectovaginal examination should be performed to determine whether a rectovaginal fistula has formed. The integrity of the anal sphincter should be evaluated.
Infection with mixed aerobic and anaerobic organisms is common. Staphylococcus may be recovered from cultures of material from these infections. Culture results frequently are misleading because the area of the episiotomy typically is contaminated with a wide variety of pathogenic bacteria.
Initial treatment should be directed toward opening and cleaning the wound and promoting the formation of granulation tissue. Warm sitz baths or Hubbard tank treatments help the debridement process. Attempts to close an infected, disrupted episiotomy are likely to fail and may make ultimate closure more difficult. Surgical closure by perineorrhaphy should be undertaken only after granulation tissue has thoroughly covered the wound site. There is an increasing trend toward early repair of episiotomy wound dehiscence, in contrast to conventional wisdom, which suggests a 3- to 4-month delay. Several large case series show excellent results once initial infection is treated.
- One or both breasts are tender, erythematous, and engorged on physical examination.
- With infectious mastitis or breast abscess, the patient commonly demonstrates fever and malaise.
Congestive mastitis, or breast engorgement, is more common in primigravidas than in multiparas. Infectious mastitis and breast abscesses also are more common in women pregnant for the first time and are seen almost exclusively in nursing mothers.
Infectious mastitis and breast abscesses are uncommon complications of breastfeeding. They almost certainly occur as a result of trauma to the nipple and the subsequent introduction of organisms from the infant's nostrils to the mother's breast. S aureus contracted by the infant while in the hospital nursery is the usual causative agent.
Breast engorgement usually occurs on the second or third postpartum day. The breasts are swollen, tender, tense, and warm. The patient's temperature may be mildly elevated. Axillary adenopathy can be seen.
Mastitis presents 1 week or more after delivery. Usually only 1 breast is affected and often only 1 quadrant or lobule. It is tender, reddened, swollen, and hot. There may be purulent drainage, and aspiration may produce pus. The patient is febrile and appears ill.
The organism responsible for infectious mastitis and breast abscess almost always is S aureus. Streptococcus spp. and E coli are occasionally isolated. Leukocytosis is evident.
The form of treatment depends on whether or not the patient plans to breastfeed. If she does not, tight breast binding, ice packs, restriction of breast stimulation, and analgesics help to relieve pain and suppress lactation. Medical suppression of lactation probably does not hasten involution of congested breasts unless the drug is taken very early after delivery. Bromocriptine 2.5 mg twice daily orally for 10 days is an effective regimen, although concerns about its side effect profile have curtailed its use. For the woman who is breastfeeding, manually emptying the breasts following infant feeding is all that is necessary to relieve discomfort.
Infectious mastitis is treated in the same way as congestive mastitis. Local heat and support of the breasts help to reduce pain. Cloxacillin, dicloxacillin, nafcillin, or a cephalosporin—antibiotic with activity against the commonly encountered causative organisms—should be administered. Infants tolerate the small amount of antibiotics in breast milk without difficulty. It may be prudent to check the infant for possible colonization with the same bacteria present in the mother's breast.
If an abscess is present, incision and drainage are necessary. The cavity should be packed open with gauze, which is then advanced toward the surface in stages daily. Most authorities recommend cessation of breastfeeding when an abscess develops. Antistaphylococcal antibiotics should be prescribed. Inhibition of lactation is also recommended.