Postpartum Pain/Fever

Anne Kennedy, MD

DIFFERENTIAL DIAGNOSIS

Common

Less Common

ESSENTIAL INFORMATION

Key Differential Diagnosis Issues

Puerperal fever is defined as fever ≥ 38° C within 14 days of giving birth
Aim to differentiate pregnancy-related from other sources of fever
- Check for vaginal bleeding, discharge
- History of vaginal vs. cesarean delivery
- History of prior C-section
Post-operative population at risk for pneumonia, venous thromboembolic disease, urinary tract infection

Helpful Clues for Common Diagnoses

Endometritis
- Mixed echogenicity debris in endometrial cavity
- Punctate bright echoes with distal shadowing suggest gas in cavity
- Increased risk with retained products of conception, C-section
Bladder Flap Hematoma
- Occurs after C-section
- Typical location between lower uterine segment and bladder wall

Helpful Clues for Less Common Diagnoses

Adnexal Torsion
- Increased risk in puerperium as ovaries descend back into pelvis
- Ovary enlarged, edematous with peripheral follicles
- Use Doppler to evaluate flow; venous flow obliterated before arterial
Ovarian Vein Thrombosis
- Difficult diagnosis on ultrasound but contrast-enhanced CT shows typical findings
  - Distended ovarian vein with surrounding inflammation
  - Typical course extending from pelvis to inferior vena cava (IVC) on right, pelvis to renal vein on left
  - Inflammation can extend to surrounding bowel; do not confuse with appendicitis or other bowel pathology
Uterine Rupture
- More common in labor but may occur as delayed event
- History of prior C-section or uterine surgery
- Anterior uterine segment hematoma at site of dehiscence ± intraperitoneal fluid