Postpartum Endometritis

Aka: Postpartum Endometritis, Postpartum Endomyometritis

1. See Also
   1. Endometritis
2. Definition
   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)
3. Epidemiology
   1. Onset postpartum (days 5 to 21 after delivery)
4. Pathophysiology
   1. Polymicrobial material into amniotic fluid seeded from vaginal flora
   2. Contiguous infection spread to myometrium and Pelvis
5. Risk Factors
   1. Cesarean Section
   2. Intrauterine instrumentation (e.g. manual placental removal)
   3. Prolonged Rupture of Membranes
   4. Vaginal infections and colonization (e.g. Bacterial Vaginosis, Group B Streptococcus)
6. 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
7. Symptoms
   1. Fever
   2. Lower midline Abdominal Pain
   3. Purulent Vaginal Discharge
8. Signs
   1. Maternal Fever
      1. Temperature > 38.0 C (100.4 F)
         1. Two separate recorded values
         2. Occurs >24 hours Postpartum and within first 10 post-partum days
      2. Temperature > 38.7 C (101.5 F)
   2. General physical examination
      1. See Postpartum Fever
      2. Sinus Tachycardia
   3. Pelvic examination
      1. Vaginal hematoma
      2. Lochia blockage
      3. Foul lochia
9. Differential Diagnosis
   1. See Maternal Fever
10. Labs
    1. Complete Blood Count
    2. Urinalysis
    3. Urine Culture
    4. Blood Culture
11. Imaging
    1. Chest XRay
    2. Pelvic Ultrasound when indicated
    3. CT Abdomen and Pelvis
       1. Changes management in up to 40% of cases
12. 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
13. Complications
    1. See Pelvic Vein Thrombophlebitis
14. References
    1. Swadron, Schmitz, Bridwell, Carius in Herbert (2019) EM:Rap 19(3): 12-4
    2. Dalton (2014) Obstet Med 7(3): 98–102 +PMID:27512432 [PubMed]
       1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934978/