Puerperal infection (also referred to as postpartum infection in the literature) represents maternal infection within six weeks after delivery, a period also known as the puerperium. Several risk factors have been established - prolonged rupture of membranes, postpartum hemorrhage (PPH), preexisting chorioamnionitis, the need for a cesarean section, anemia, primiparity and giving birth in unhygienic conditions (for example, home birth) [1] [2] [3]. A majority of the risk factors are related to birth-related events with most of the infections developing within 24 hours after labor [1]. However, one of the main factors in the pathogenesis of puerperal infections is the lack of adequate postnatal follow-up, which leads to delayed recognition and increased risk for complications [1]. The presence of a high fever (> 38°) is one of the most important signs of a puerperal infection, while additional symptoms are related to the type of infection [3] [4] [5]:

• Endometritis - In the case of infection of the upper genital tract, fever is accompanied by bleeding, foul smelling lochia (uterine discharge after birth) and uterine tenderness [5]. Enterobacteriaceae such as Escherichia coli, Klebsiella pneumoniae, Proteus spp., staphylococci, enterococci, and streptococci, as well as Bacteroides and Prevotella spp. have been identified as causative agents [5]
• Surgical site infections - Cesarean delivery unequivocally predisposes women to a puerperal infection, which is why prophylactic antibiotic therapy is always necessary. Unfortunately, between 3-15% of women suffer from an infection at the site of the surgical incision, and localized pain is the main symptom [5]. Recognized risk factors are diabetes mellitus, obesity, previous use of corticosteroids and preexisting infections [3] [4]. Enterococci, anaerobic bacteria, and group B streptococcus are described as causes [5].
• Urinary tract infections (UTIs) - Important for their propensity to progress to disseminated infections and even sepsis, UTIs are important to recognize early on, although only a quarter of women with a UTI will complain of dysuria and UTI-specific symptoms [5].
• Mastitis - Depending on the severity of infection, puerperal mastitis can present as unilateral breast tenderness with swelling in milder cases, or diffuse bilateral discomfort, pain and the formation of abscesses in severe forms, causing fever and malaise [5]. Staphylococcus aureus and coagulase-negative staphylococci are documented causes [5].
• Sepsis - Responsible for about 15% of all maternal deaths and considered to be one of the most important causes of maternal death, puerperal sepsis is a life-threatening systemic infection predominantly caused by group A streptococcus [2] [4] [6] [7]. Fever, dyspareunia and chronic pelvic pain and a poor overall condition of the mother are main complaints [1].
• Septic pelvic thrombophlebitis (SPT) and episiotomy infections - SPT denotes the infection of the pelvic veins with a significant risk for systemic dissemination, and symptoms such as pain and fever in spite of antibiotic therapy [5]. Episiotomy infections are quite rare, but still important causes of infections in the puerperium, with symptoms of local swelling, purulent discharge, pain, and fever in most severe cases [5].
• Respiratory infections - Influenza virus, particularly in the developing countries, remains an important cause of maternal death, and the appearance of symptoms suggestive of a respiratory tract infection must be taken seriously [4] [5].

Because life-threatening sepsis and shock may develop from puerperal infections, an early diagnosis is pivotal in reducing maternal morbidity and mortality [1]. For this reason, the appearance of fever during the puerperium must raise suspicion about an infectious etiology. Firstly, a thorough patient history should be obtained, including information about the delivery (particularly if a cesarean section was performed), preexisting comorbidities and risk factors, as well as evaluation of additional symptoms, if present. A detailed physical exam could potentially determine the focus of the infection by observing localized pain, tenderness, swelling or other organ-specific symptoms [5], after which a complete laboratory workup is advised. A complete blood count (CBC), serum inflammatory markers (C-reactive protein and erythrocyte sedimentation rate, or CRP and ESR, respectively), a full coagulation panel, urinalysis, and kidney function tests must be included in the initial workup [8]. In addition, microbiological testing for blood, urine, or breast milk cultures, and wound and genital swabs, is recommended [5] [8]. Besides bacterial organisms, influenza and human immunodeficiency (HIV) viruses have been established as important causes of maternal mortality, suggesting that the clinical workup should also assess lung function, and appropriate serological or molecular testing should be performed in the presence of a suspicion of HIV or influenza infection [4].

The primary treatment for puerperal infection is antibiotics, which are chosen based on the suspected or confirmed type of bacteria. In severe cases, hospitalization may be necessary to administer intravenous antibiotics and provide supportive care. If there is retained placental tissue or an abscess, surgical intervention may be required to remove the infected material. Pain management and hydration are also important components of treatment to ensure the patient's comfort and recovery.

With prompt and appropriate treatment, the prognosis for puerperal infection is generally good. Most women recover fully without long-term complications. However, if the infection is not treated in a timely manner, it can lead to more serious conditions such as sepsis, which is a life-threatening response to infection. Early diagnosis and intervention are crucial to prevent these adverse outcomes.

Puerperal infections are typically caused by bacteria that are normally present in the vagina or on the skin. Common culprits include Streptococcus, Staphylococcus, and Escherichia coli. Risk factors for developing a puerperal infection include prolonged labor, cesarean delivery, premature rupture of membranes, and poor hygiene during delivery. These factors can facilitate the entry and growth of bacteria in the reproductive tract.

Puerperal infections are more common in developing countries due to limited access to healthcare and sanitation. However, they can occur anywhere and affect approximately 1-8% of women after childbirth. The incidence is higher in women who have undergone cesarean sections compared to those who have had vaginal deliveries. Efforts to improve maternal healthcare and hygiene practices have significantly reduced the incidence of these infections in many parts of the world.

The pathophysiology of puerperal infection involves the invasion and multiplication of bacteria in the reproductive tract following childbirth. The trauma of delivery, whether vaginal or surgical, creates an environment conducive to bacterial growth. The body's immune response to the infection can lead to inflammation and tissue damage, which manifest as the symptoms of puerperal infection. If the infection spreads beyond the reproductive tract, it can lead to systemic complications.

Preventing puerperal infection involves several strategies aimed at reducing the risk of bacterial contamination during and after childbirth. These include maintaining strict hygiene practices in the delivery room, using prophylactic antibiotics in high-risk cases, and ensuring proper wound care for surgical incisions. Educating healthcare providers and patients about the signs of infection and the importance of early treatment is also crucial in preventing complications.

Puerperal infection is a bacterial infection that occurs after childbirth, affecting the reproductive tract. It presents with symptoms such as fever, abdominal pain, and abnormal discharge. Diagnosis involves clinical evaluation and laboratory tests, while treatment primarily consists of antibiotics. With timely intervention, the prognosis is generally favorable. Understanding the risk factors and implementing preventive measures can significantly reduce the incidence of this condition.

If you have recently given birth and are experiencing symptoms such as fever, chills, or unusual vaginal discharge, it is important to seek medical attention. Puerperal infection is a treatable condition, and early diagnosis can prevent complications. Maintaining good hygiene and following your healthcare provider's advice during the postpartum period can help reduce your risk of infection. Remember, your health and well-being are important, and taking care of yourself is a crucial part of caring for your new baby.

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