Management of STIs/RTIs
Chapter 9. STI/RTI complications related to pregnancy, miscarriage, induced abortion, and the postpartum period

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Infection following childbirth

Postpartum endometritis and puerperal sepsis

Postpartum endometritis (uterine infection) and puerperal sepsis are common causes of maternal morbidity and mortality respectively and are largely preventable with good antenatal care, delivery practices and postpartum care. When care is delayed or inadequate, however, infection can progress quickly to generalized sepsis, which can result in infertility, chronic disability and even death.

Postpartum endometritis is commonly caused by gonococci, chlamydia, anaerobic bacteria, Gram-negative facultative bacteria, and streptococci. In developed countries, most postpartum infections are related to caesarean section. Elsewhere, postpartum endometritis more often follows vaginal delivery. Early postpartum endometritis occurs within the first 48 hours, and late infection between 3 days and 6 weeks following delivery. Aggressive treatment should be given for all postpartum infections (for complete management, see Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003).

Women with signs of infection immediately postpartum should be stabilized, given a first dose of antibiotics intravenously (or intramuscularly) and referred urgently to hospital.

Flowchart 8 outlines the management of women presenting with fever between 24 hours and 6 weeks postpartum.

 

FLOWCHART 8. postpartum Infection

 

Activities to prevent postpartum infection include prevention and detection of STI/RTI during pregnancy (Chapter 2 and Chapter 3) and good delivery practice. See the WHO publications: Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, Geneva, World Health Organization, 2003 or Managing complications in pregnancy and childbirth: a guide for midwives and doctors, Geneva, World Health Organization, 2000 for guidelines on prevention and comprehensive management of postpartum complications.

 

Treatment table 11. Antibiotic regimens for treatment of infection following miscarriage, induced abortion or delivery (septic abortion, postpartum endometritis)

Option 1	Option 2	Option 3	Option 4
Commonly available, least expensive. Give all 3 drugs	Choose one drug from each box (= 3 drugs)	Give both drugs	Choose one drug from each box (= 3 drugs)
ampicillin 2 g intravenously or intramuscularly, then 1 g every 6 hours	ceftriaxone 250 mg by intramuscular injection, once a day	clindamycin 900 mg by intravenous injection, every 8 hours	ciprofloxacinb 500 mg orally, twice a day, or spectinomycin 1 g by intramuscular injection, 4 times a day
gentamicin 80 mg intramuscularly every 8 hours	doxycycline 100 mg orally or by intravenous injection, twice a day, or tetracycline 500 mg orally 4 times a day	gentamicin 1.5 mg/kg of body weight by intravenous injection every 8 hours	doxycycline 100 mg orally or by intravenous injection, twice a day, or tetracycline, 500 mg orally, 4 times a day
metronidazolea 500 mg orally or by intravenous infusion every 8 hours	metronidazolea 400�500 mg orally or by intravenous injection, twice a day, or chloramphenicol 500 mg orally or by intravenous injection, 4 times a day		metronidazolea 400�500 mg orally or by intravenous injection, twice a day, or chloramphenicol 500 mg orally or by intravenous injection, 4 times a day
For all regimens, therapy should be continued for 2 days after the patient is fever free.

^a. Patients taking metronidazole should be counselled to avoid alcohol.

^b. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

 

Treatment table 12. Antibiotic regimens for treatment of infectious complications with viable pregnancy (chorioamnionitis, rupture of membranes)

Option 1 � safest for fetus when there are no signs of maternal infection	Option 2 � best coverage when maternal signs of infection (fever, foul-smelling discharge) are present
Oral/intramuscular combination that is safe in pregnancy Choose one from each box (= 3 drugs)	Commonly available, least expensive. Give all 3 drugs until delivery. If woman delivers vaginally, discontinue all antibiotics after delivery. If delivery is by Caesarean section, continue antibiotics until she is fever free for 48 hours
cefixime 400 mg orally as a single dose, or ceftriaxone 125�250 mg by intramuscular injection	ampicillin 2 g intravenously or intramuscularly, then 1 g every 6 hours
erythromycina 500 mg orally 4 times a day for 7 days, or azithromycin 1 g orally as a single dose	gentamicin 80 mg intramuscularly every 8 hours
metronidazoleb 2 g orally as a single dose	metronidazoleb 500 mg orally or by intravenous infusion every 8 hours

^a. Erythromycin estolate is contraindicated in pregnancy because of drug-related hepatotoxicity; only erythromycin base or erythromycin ethylsuccinate should be used. Note that oral erythromycin alone has been shown to decrease preterm birth in women with preterm, prelabour rupture of membranes in Europe (where gonorrhoea is uncommon). Since gonorrhoea is resistant to erythromycin in many areas, addition of cefixime or ceftriaxone is recommended where gonorrhoea is common.

^b. Patients taking metronidazole should be counselled to avoid alcohol.