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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