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IV./4.1.: Epidemiology
According to the traditional interpretation, the puerperal fever is a fever developed after child birth or miscarriage, caused by the bacterial infection of the genitals. Until the middle of the 19th century puerperal fever was a very common, nearly every day obstetric care complication with high maternal mortality rate (2-15%) due to the overcrowding and poor sanitation of obstetric institutions.
Ignác Semmelweis (1818-1865), a Hungarian obstetrician was the first to identify the spreading mechanism of puerperal fever before the discovery of bacteria. He made chlorine- water hand disinfection mandatory and introduced other hygiene regulations. After that the puerperal fever caused maternal mortality decreased from above 10% to less than 1%.
Despite of the fact that postpartum fever is mostly of genital origin, it can be caused by many extragenital factors as well. Therefore according to the currently adopted definition of puerperal fever, a fever (>38 0C) occurring within ten days of obstetric events (except for the first day), lasting for more than 24 hours or recurring is considered to be puerperal fever, regardless of the underlying cause. The most common disorders are endometriosis (endometritis/endomyometritis) ; wound infection (episiotomy, cesarean section); mastitis (mastitis puerperalis); urinary tract infections; pulmonary infections (pneumonia/atelectasia); deep vein thrombosis and/or pulmonary embolism, and drug-induced febrile conditions.
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Today, puerperal fever with genital origin after vaginal birth is 1-3%; after elective cesarean section 5-10%, after unplanned surgery 15-20%. For those patients who did not receive antibiotic prophylaxis before cesarean section, the frequency of the infection may be 50-60% higher. The maternal mortality rate of puerperal sepsis (1-5/100 000 in developed countries) is greatly influenced by the social, economic and cultural situation of the region, country or continent. In the United States puerperal infection is the 4th most common reason for postpartum maternal death and is responsible for 7% of all maternal loss. In the United Kingdom besides the decreasing rate of direct maternal death there is an increase of mortality caused by puerperal infection, attributed mainly to the group A streptococcus (GAS) infection.
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The most common risk factors are maternal diabetes and severe anemia, low socio-economic status, surgical birth, preterm birth, prolonged and exhausting labor, premature rupture of membranes, unduly large number of pelvic exams, manual separation of the placenta, non compliance with hygiene regulations and prelabor lower genital tract infections (group B streptococcus, GBS.
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