A 42-year-old woman, gravida 6 para 6, is evaluated in the postpartum unit on postoperative day 2 after a cesarean delivery. The patient has had increasing vaginal bleeding, abdominal pain, and fever. She is breastfeeding exclusively with a good latch. The patient was initially admitted to the hospital for prelabor rupture of membranes at 40 weeks gestation. A primary cesarean delivery was performed for arrest of descent of a 5-kg (11-lb) infant after 3 hours of pushing. The pregnancy was complicated by recurrent vaginal candidiasis. Prior pregnancies were uncomplicated; the patient's last delivery was 12 years ago. Temperature is 38.7 C (101.7 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 18/min. On physical examination, the patient appears pale and tired. The lungs are clear to auscultation bilaterally; the breasts are full but without erythema. The uterine fundus is tender to palpation. Speculum examination shows heavy lochia but no active bleeding. The transverse incision across the lower abdomen is intact and without erythema or drainage.
Which of the following is this patient's most important risk factor for her current postpartum infection?

Question

A 42-year-old woman, gravida 6 para 6, is evaluated in the postpartum unit on postoperative day 2 after a cesarean delivery.  The patient has had increasing vaginal bleeding, abdominal pain, and fever.  She is breastfeeding exclusively with a good latch.  The patient was initially admitted to the hospital for prelabor rupture of membranes at 40 weeks gestation.  A primary cesarean delivery was performed for arrest of descent of a 5-kg (11-lb) infant after 3 hours of pushing.  The pregnancy was complicated by recurrent vaginal candidiasis.  Prior pregnancies were uncomplicated; the patient's last delivery was 12 years ago.  Temperature is 38.7 C (101.7 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 18/min.  On physical examination, the patient appears pale and tired.  The lungs are clear to auscultation bilaterally; the breasts are full but without erythema.  The uterine fundus is tender to palpation.  Speculum examination shows heavy lochia but no active bleeding.  The transverse incision across the lower abdomen is intact and without erythema or drainage.
Which of the following is this patient's most important risk factor for her current postpartum infection?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c034_aab7_8f63_5f792035d8ce_MD0005_00 Postpartum endometritis is caused by inoculation and infection of the endometrial cavity by vaginal flora during labor or delivery. Risk factors (eg, history of bacterial vaginosis, group B Streptococcus colonization, prolonged rupture of membranes, protracted labor, operative vaginal delivery, cesarean delivery) either are associated with an increased vaginal bacterial load or facilitate bacterial ascent into the uterus. Cesarean delivery is the most significant risk factor for postpartum endometritis, particularly when performed after labor commences or membranes rupture. The postoperative course after cesarean delivery is associated with necrosis of the myometrium along the hysterotomy repair, the presence of foreign bodies (eg, sutures), and the potential for incisional hematomas/seromas, all of which amplify infection risk. (Choice A) Advanced maternal age is associated with increased risk for chromosomal abnormalities, medical complications of pregnancy (eg, gestational diabetes mellitus, hypertension), and cesarean delivery. It is not an independent risk factor for postpartum endometritis. (Choice B) Increased fetal weight (ie, fetal macrosomia) is associated with shoulder dystocia and postpartum hemorrhage. Although fetal macrosomia increases the likelihood of protracted labor and cesarean delivery, fetal weight is not an independent risk factor for postpartum endometritis. (Choice C) Preterm (<37 weeks) and postterm (≥42 weeks) gestations are risk factors for postpartum endometritis. This patient delivered at 40 weeks gestation (term). (Choice D) A history of bacterial vaginosis (caused by overgrowth of anaerobes such as Gardnerella vaginalis or Mycoplasma hominis) during pregnancy increases the risk of postpartum endometritis, but recurrent vaginal candidiasis does not. Educational objective: The most significant risk factor for postpartum endometritis is cesarean delivery, particularly when performed after the onset of labor. Other risk factors include group B Streptococcus colonization, prolonged rupture of membranes, protracted labor, and operative vaginal delivery. References: Post partum infections: a review for the non-OBGYN. (http://www.ncbi.nlm.nih.gov/pubmed/27512432)

A 42-Year-Old Woman, Gravida 6 Para 6, Is Evaluated in the Postpartum