AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Endometritis is an infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis is divided into obstetric and nonobstetric endometritis. It is the most common cause of fever during the postpartum period. Pelvic inflammatory disease (PID) is a common predecessor in the nonobstetric population.

Pathophysiology

Endometritis is infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis usually results from an ascending infection from the lower genital tract. From a pathologic perspective, endometritis can be classified as acute versus chronic. Acute endometritis is characterized by the presence of neutrophils within the endometrial glands. Chronic endometritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stroma.

In the nonobstetric population, PID and invasive gynecologic procedures are the most common precursors to acute endometritis. In the obstetric population, postpartum infection is the most common predecessor. Chronic endometritis in the obstetric population is usually associated with retained products of conception after delivery or elective abortion. In the nonobstetric population, chronic endometritis has been seen with infections, such as chlamydia, tuberculosis, and bacterial vaginosis, and the presence of an intrauterine device.

Frequency

United States

Incidence varies depending on the route of delivery and the patient population. After a vaginal delivery, incidence is 1-3%. Following cesarean delivery, incidence ranges from 13-90%, depending on the risk factors present and whether perioperative antibiotic prophylaxis had been given.

Mortality/Morbidity

• Infection of the genital tract is the most common cause of puerperal morbidity. Puerperal morbidity is defined as a temperature of 100.4°F (38°C) or higher occurring in any 2 of the first 10 days postpartum, exclusive of the first 24 hours. In the past, infection accounted for up to 16% of maternal mortality.
• In the nonobstetric population, concomitant endometritis may occur in up to 70-90% of documented cases of salpingitis.

Age

This disorder affects females of reproductive age.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Diagnosis usually is based on clinical findings.

• Fever
• Lower abdominal pain
• Foul-smelling lochia in the obstetric population
• Abnormal vaginal bleeding
• Abnormal vaginal discharge
• Dyspareunia (may be present in patients with PID)
• Dysuria (may be present in patients with PID)
• Malaise

Physical

• Fever, usually occurring within 36 hours of delivery, in the obstetric population
• Lower abdominal pain
• Uterine tenderness
• Adnexal tenderness if there is an associated salpingitis
• Foul-smelling lochia
• Tachycardia

Causes

• Endometritis is a polymicrobial disease involving, on average, 2-3 organisms.
• In the majority of cases, it arises from an ascending infection from organisms found in the normal indigenous vaginal flora.
• Commonly isolated organisms include Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, and group B Streptococcus.
• Chlamydia has been associated with late-onset postpartum endometritis.
• Enterococcus is identified in up to 25% of women who have received cephalosporin prophylaxis.
• Route of delivery is the most important factor in the development of postpartum endometritis.
• Major risk factors include cesarean delivery, prolonged rupture of membranes, long labor with multiple vaginal examinations, extremes of patient age, and low socioeconomic status.
• Minor contributing factors include maternal anemia, prolonged internal fetal monitoring, prolonged surgery, and general anesthesia.
• Bacterial vaginosis has been associated with endometritis after cesarean delivery and with PID after first trimester elective abortion.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Pyelonephritis
Viral syndrome
Pelvic thrombophlebitis

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• On complete blood count the finding of leukocytosis may be difficult to interpret, secondary to the physiologic leukocytosis of pregnancy.
• Blood culture is positive in 10-30% of cases.
• Urine culture should be ordered.
• Endocervical cultures (or DNA probe) are obtained for gonorrhea and chlamydia.
• Culture of the endometrial cavity usually results in contamination from normal resident cervicovaginal flora.

Imaging Studies

• Perform imaging studies on patients who do not respond to adequate antimicrobial therapy in 48-72 hours.
• CT scanning of the abdomen and pelvis may be helpful for excluding broad ligament masses, septic pelvic thrombophlebitis, ovarian vein thrombosis, and phlegmon.
• Sonographic findings of the abdomen and pelvis may be normal in patients with a clinical diagnosis of endometritis. Abnormal findings overlap with those of retained products of conception and intrauterine hematoma.

Procedures

Endometrial biopsy can be obtained to assess chronic endometritis in the nonobstetric population.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Most cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate.

• Combination intravenous clindamycin and gentamicin administered every 8 hours has been considered the criterion standard treatment. Recent studies have revealed adequate efficacy with daily dosing as well.
• Second- or third-generation cephalosporin in combination with metronidazole is another popular choice.
• Improvement is usually noted within 48-72 hours in nearly 90% of women. Parenteral therapy is continued until the patient has been afebrile for longer than 24 hours. Thereafter, oral antibiotics are not usually necessary.

Surgical Care

Surgical management is not usually necessary in acute endometritis in the obstetric population. Dilatation and curettage may be advised for retained products of conception, however.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

After making the diagnosis of endometritis and excluding other sources of infection, broad-spectrum antibiotics should be promptly initiated. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen. For mild cases following vaginal delivery, an oral agent may be adequate.

Drug Category: Antibiotics

A combination therapy with clindamycin and an aminoglycoside is considered the criterion standard by which most antibiotic clinical trials are judged.

A combination regimen of ampicillin, gentamicin, and metronidazole provides coverage against most of the organisms that are encountered in serious pelvic infections.

Doxycycline should be used if Chlamydia is the cause of the endometritis.

Ampicillin sulbactam can be used as monotherapy. Single-agent therapies have been found to be efficacious in 80-90% of patients.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

In/Out Patient Meds

• Patient may be discharged without antibiotic therapy after being afebrile for at least 24 hours and with a benign physical examination.
• Further outpatient therapy has proved to be unnecessary.

Complications

• Wound infection
• Peritonitis
• Adnexal infection
• Parametrial phlegmon
• Pelvic abscess
• Pelvic hematoma
• Septic pelvic thrombophlebitis

Prognosis

• Nearly 90% of women treated with an approved regimen note improvement in 48-72 hours.

Patient Education

• For excellent patient education resources, see eMedicine's Women's Health Center and Pregnancy and Reproduction Center and Sexually Transmitted Diseases Center and the patient education articles Pelvic Inflammatory Disease, Sexually Transmitted Diseases, Cesarean Childbirth, and Dilation and Curettage (D&C).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Prophylactic antibiotics reduce the incidence of postpartum febrile morbidity in patients undergoing cesarean delivery.
• Single-agent cephalosporin therapy of the first- or second-generation type is considered the best choice.

Special Concerns

Current research is evaluating the timing of administration of cephalosporin prior to skin incision versus at cord clamp for prevention of postcesarean infectious morbidity.

Another topic of research is the preoperative use of povidone-iodine vaginal preparation prior to cesarean delivery.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Cunningham FG. Infection and disorders of the puerperium. In: Cunningham GF, MacDonald PC, Leven KJ, et al, eds. Williams Obstetrics. 20^th ed. Stamford, Conn: Appleton & Lange; 1997:548-55.
• French L. Prevention and treatment of postpartum endometritis. Curr Womens Health Rep. Aug 2003;3(4):274-9. [Medline].
• French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004;CD001067. [Medline].
• Ledger WJ. Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. Dec 2003;29(6):364-73. [Medline].
• Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. Jun 2007;62(6):393-9. [Medline].
• Gudas JM, Fridovich-Keil JL, Datta MW, Bryan J, Pardee AB. Characterization of the murine thymidine kinase-encoding gene and analysis of transcription start point heterogeneity. Gene. Sep 10 1992;118(2):205-16. [Medline].
• Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. May 2007;196(5):455.e1-5. [Medline].

Article Last Updated: Aug 15, 2007