Hemorrhagic fever with renal syndrome

1. Disease Description (Causes and Symptoms)

• Definition: Refers to a body temperature of 38.0℃ or higher for two days when oral temperature is measured four times a day within 10 days after childbirth, excluding the first 24 hours after delivery (clinical diagnostic criteria).
• Pathophysiology: Bacteria multiply due to mucosal injury to the endometrium, vagina, and perineum during delivery, or localized infection develops at the perineal sutures or cesarean-section wound, spreading to conditions such as endometritis, wound infection, cystitis, and mastitis; sometimes the bacteria spread through the bloodstream and progress to sepsis.
• Major causative organisms: Group A Streptococcus (e.g., Streptococcus pyogenes), Staphylococcus aureus, Escherichia coli, various anaerobic bacteria, and others (distribution varies by region and hospital).
• Main symptoms:
  • Fever (38℃ or higher), chills
  • Lower abdominal pain, uterine tenderness, foul-smelling discharge (vaginal discharge)
  • Perineal wound pain, redness, and exudate (suture-site infection)
  • Dysuria and urinary frequency (when accompanied by a urinary tract infection)
  • Breast pain, redness, and swelling (when accompanied by mastitis)
• Findings raising diagnostic suspicion: Meeting the postpartum fever criteria and having related symptoms (uterine tenderness, foul-smelling discharge, wound redness, etc.). When necessary, the cause and complications are evaluated through tests (blood tests, cultures, and imaging).

2. Treatment Methods (Standard Treatment · Medications · Procedures/Surgery · Lifestyle Management · Precautions and Risk of Complications)

• Initial measures
  • Clinical evaluation (vital signs and examination of the uterus, perineum, breasts, and urinary tract) and assessment of severity (whether signs of sepsis are present).
  • When hospitalization is necessary: Persistent high fever, suspected sepsis (hypotension, tachycardia, altered mental status), need for IV antibiotics, inability of the mother to care for the newborn, and so on.
• Antibiotic treatment (empirical treatment → adjustment according to culture results)
  • Standard empirical regimen for postpartum endometritis (moderate or more severe): Intravenous combination of clindamycin (CLD) + gentamicin (GEN), or IV ampicillin–sulbactam.
  • Other options: A third-generation cephalosporin combined with metronidazole, or a broad-spectrum beta-lactam/beta-lactamase inhibitor (e.g., piperacillin–tazobactam)—for severe or complicated infections.
  • Mastitis (mild): Oral antibiotics (e.g., dicloxacillin or cephalexin). If MRSA is suspected, options include clindamycin and TMP-SMX.
  • Urinary tract infection: Selection of antibiotics according to urine culture results.
  • Treatment duration: It is generally switched to oral treatment after clinical improvement (becoming afebrile and improvement of symptoms), for a total of 7–10 days. Complicated infections (such as abscesses) may require longer treatment.
• Procedural/surgical treatment
  • If retained products in the uterus or infected exudate or an abscess is suspected, ultrasound examination and drainage (uterine curettage or percutaneous/surgical drainage) may be necessary.
  • An abscess in a wound (cesarean-section or perineal wound) requires drainage and appropriate wound care (if necessary, surgical debridement/cauterization and resuturing).
  • In rare cases of septic or necrotizing infection, extensive resection (rarely, hysterectomy) may be considered.
• Conservative treatment and lifestyle management
  • Antipyretics (acetaminophen), adequate fluid intake, rest, and early ambulation (for thrombosis prevention).
  • Breastfeeding: Breastfeeding can usually continue during antibiotic treatment (depending on the antibiotic used). When mastitis is present, active breastfeeding or pumping is recommended.
  • Disinfect and keep the wound clean, and maintain thorough hand hygiene.
• Precautions and risk of complications
  • Delayed treatment increases the risk of sepsis, pelvic abscess, and hysterectomy, as well as possible infertility (in cases of severe endometrial damage).
  • Monitoring for antibiotic adverse effects (allergic reactions, gastrointestinal symptoms, superinfection, etc.) is necessary.
  • Depending on the infectious pathogen, evaluation and management of the newborn may be necessary (e.g., Group A Streptococcus).

3. Checkpoints Before an Outpatient Visit (Items to Bring · Test Records · Symptom Records and Example Questions)

• Items to bring to the visit
  • A list indicating current medications and allergies
  • Recent temperature records (by time, based on oral measurements, for at least several days), with the symptom onset date indicated
  • Photographs of the discharge and wound condition, if available
  • Delivery-related records (whether a cesarean section was performed, the suture site, hospitalization and surgery dates) and recent test results (blood tests, urine tests, etc.)
  • Information about breastfeeding and the newborn’s condition
• Examples of records to show the doctor during the outpatient visit
  • Temperature log (date, time, and reading)
  • Location, intensity, and changes in pain (lower abdomen, perineum, breasts, etc.)
  • Changes in the color, odor, and amount of vaginal discharge
  • Urinary symptoms (frequency and dysuria), breast engorgement, and breast symptoms
• Tests that may be performed during the outpatient visit
  • Blood tests (CBC, CRP), blood cultures, vaginal/wound cultures, urinalysis and urine culture, and pelvic ultrasound (to check for retained products or an abscess)

4. Examples of General Questions to Ask the Doctor

• What side effects are expected with this medication, and what symptoms should be monitored?
• Do I need inpatient treatment at the hospital, or can I receive outpatient treatment with oral medication?
• Until when do I need to continue breastfeeding (or stop breastfeeding)? Is the medication safe during breastfeeding?
• What are the risks and prognosis of complications (endometritis → infertility, pelvic abscess, etc.)?
• When can I resume normal activities (exercise, sexual intercourse, and going out)?

5. Examples of Disease-Specific Questions

• Regarding the newborn:
  • Does the newborn need evaluation or preventive treatment (testing or antibiotics) because of the mother’s infection?
• Regarding imaging and procedures:
  • Is a pelvic ultrasound necessary? If retained products in the uterus or an abscess is suspected, what procedures (curettage or drainage) may be necessary?

Summary of Additional Precautions

• If fever persists or signs of sepsis such as hypotension, tachycardia, difficulty breathing, or altered mental status occur, visit the emergency room immediately.
• After a cesarean section, antibiotic prophylaxis before surgery (according to medical recommendations) reduces the risk of developing endometritis.