Postpartum Endometritis

Aka: Postpartum Endometritis, Postpartum Endomyometritis

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II. Definitions

  1. Postpartum Endometritis
    1. Postpartum uterine infection of the endometrial cavity
  2. Endomyometritis
    1. Uterine infection of the endometrial cavity and the uterine wall (typically after Cesarean Section)

III. Epidemiology

  1. Incidence after Vaginal Delivery: up to 1 to 3%
  2. Onset postpartum (days 5 to 21 after delivery)

IV. Pathophysiology

  1. Polymicrobial material into amniotic fluid seeded from vaginal flora
  2. Contiguous infection spread to myometrium and Pelvis

V. Risk Factors

  1. Cesarean Section (most significant risk factor)
    1. Relative Risk 5 to 20 over Vaginal Delivery
  2. Operative Vaginal Delivery (forceps or Vacuum Assisted Delivery)
  3. Intrauterine instrumentation
    1. Intrauterine Monitor
    2. Internal Fetal Monitor (scalp electrode)
  4. Manual placental removal
  5. Prolonged Rupture of Membranes
  6. Vaginal infections and colonization (e.g. Bacterial Vaginosis, Group B Streptococcus)

VI. Causes

  1. Group B Streptococcus
    1. Most common organism in the first 24 hours postpartum
  2. Mixed anaerobic and aerobic Bacteria
    1. Most common organisms at 3-7 days postpartum
    2. Gram Negative Bacteria (e.g. Escherichia coli)
    3. Anaerobic Bacteria (e.g. Bacteroides, Clostridium, Peptostreptococci)
    4. Staphylococcus Aureus is uncommon in Postpartum Endometritis
  3. Chlamydia
    1. Most common organism after 2-3 weeks postpartum
  4. HIV Positive related causes
    1. Herpes Simplex Virus
    2. Cytomegalovirus

VII. Symptoms

  1. Fever
  2. Lower midline Abdominal Pain
  3. Purulent, malodorous Vaginal Discharge

VIII. Signs

  1. Maternal Fever (Temperature > 38.0 C or 100.4 F)
    1. Two separate recorded values
    2. Occurs >24 hours Postpartum and within first 10 post-partum days
  2. General physical examination
    1. See Postpartum Fever
    2. Evaluate for Sepsis
      1. Sinus Tachycardia
      2. Hypotension
  3. Pelvic examination
    1. Vaginal Hematoma
    2. Lochia blockage
    3. Foul lochia

IX. Differential Diagnosis

  1. See Maternal Fever
  2. Pelvic Pain
    1. Tuboovarian Abscess
    2. Uterine Rupture
    3. Ovarian Torsion
  3. Infection or Inflammation
    1. Cystitis or Acute Pyelonephritis
    2. Appendicitis
    3. Acute Cholecystitis
    4. Pancreatitis

X. Labs

  1. Complete Blood Count
  2. Comprehensive metabolic panel
  3. Urinalysis
  4. Urine Culture
  5. Blood Cultures

XI. Imaging

  1. Chest XRay
  2. Pelvic Ultrasound (when indicated)
    1. Retained products of conception
    2. Tuboovarian Abscess
    3. Ovarian Torsion
  3. CT Abdomen and Pelvis
    1. Changes management in up to 40% of cases

XII. Management

  1. Antibiotics
    1. See Endometritis Antibiotic Management
    2. Continue Antibiotics until 1-2 days after afebrile
  2. Persistent fever >48 to 72 hours despite Antibiotics
    1. Evaluate for pelvic abscess or phlegmon (requires surgical drainage)
    2. Evaluate for Septic Pelvic Thrombophlebitis
    3. Consider Drug Fever
    4. Consider infected retained products of conception

XIII. Complications

  1. See Pelvic Vein Thrombophlebitis

XIV. References

  1. Lively and Clare (2022) Crit Dec Emerg Med 36(5): 4-10
  2. Swadron, Schmitz, Bridwell, Carius in Herbert (2019) EM:Rap 19(3): 12-4
  3. Dalton (2014) Obstet Med 7(3): 98–102 +PMID:27512432 [PubMed]
    1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934978/

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Related Studies

Ontology: Endomyometritis (C0269050)

Definition (MSH) Inflammation of both the ENDOMETRIUM and the MYOMETRIUM, usually caused by infections after a CESAREAN SECTION.
Concepts Disease or Syndrome (T047)
MSH D004716
SnomedCT 198193005, 88027004
English Endomyometritis unspecified, Endomyometritis, endomyometritis, endomyometritis (diagnosis), Endomyometritis unspecified (disorder), Endomyometritis (disorder), Endomyometritis, NOS
Dutch endomyometritis
Spanish Endrometritis, Endomiometritis, endomiometritis, no especificada (trastorno), endomiometritis, no especificada, endomiometritis (trastorno), endomiometritis
Japanese 子宮内膜筋層炎, ｼｷｭｳﾅｲﾏｸｷﾝｿｳｴﾝ
Czech endomyometritida, Endomyometritida
Portuguese Endomiometrite
French Endomyométrite
German Endomyometritis
Hungarian Endomyometritis
Norwegian Endomyometritt
Italian Endomiometrite
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Endometritis postpartum (C0678198)

Definition (NCI) Infection of the endometrium, decidua and/or myometrium occurring at any time between birth and 42 days postpartum.(NICHD)
Concepts Disease or Syndrome (T047)
Dutch endometritis postpartum
French Endométrite du post-partum
German Endometritis, postpartal
Italian Endometrite postpartum
Portuguese Endometrite pós-parto
Spanish Endometritis postparto
Japanese 分娩後子宮内膜炎, ﾌﾞﾝﾍﾞﾝｺﾞｼｷｭｳﾅｲﾏｸｴﾝ
Czech Poporodní endometritida
English Endometritis postpartum, endometritis postpartum, postpartum endometritis, Puerperal Endometritis, Postpartum Endometritis
Hungarian Endometritis postpartum
Derived from the NIH UMLS (Unified Medical Language System)

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