Endometritis
Christina C. Reed and Susan Drummond
Definition
A.Endometritis is an infection of the endometrium (the interior lining of the uterus) that occurs postpartum. Endometritis is the most common cause of puerperal fever in obstetrics.
Incidence
A.The incidence of endometritis has been noted to be as high as 38.5% after cesarean section; the incidence is 1.2% after vaginal delivery.
Pathogenesis
A.During labor and delivery, indigenous cervicovaginal flora enter the uterine cavity. Onset is usually 3 to 5 days after delivery, unless it is caused by beta-hemolytic streptococcus, in which case the onset is earlier and more precipitous. Infection is usually polymicrobial in nature. Undiagnosed or unsuccessfully treated infection of the endomyometrium can progress to involve the entire uterus and may spread to accessory pelvic structures. The main pathway for spread of the infection is the broad ligament. Sources of bacteria may be any one or a combination of the following:
1.Indigenous vaginal bacteria, usually pathogenic only when tissue is damaged:
a.Beta-hemolytic streptococcus.
b.Streptococcus viridans.
c.Neisseria gonorrhoeae.
d.Gardnerella.
2.Contamination by normal bowel bacteria:
a.Clostridium perfringens.
b.Escherichia coli.
c.Proteus mirabilis.
d.Aerobacter aerogenes.
e.Enterococcus.
f.Pseudomonas aeruginosa.
g.Klebsiella pneumoniae.
3.Contamination from environment; staphylococcus is a common organism.
Predisposing Factors
A.Operative delivery: Cesarean section is the major predisposing factor for pelvic infection. The most important determinant of infection for patients undergoing cesarean delivery is the duration of labor.
B.Intrapartum: Prolonged rupture of membranes, numerous vaginal exams in labor, use of internal monitoring devices during labor, use of instruments in delivery, prolonged labor, and intrauterine manipulation such as internal rotation or manual removal of placenta can all lead to endometritis.
C.Postpartum: Retained placental fragments or membranes, improper perineal care, and host resistance also predispose a patient to infection.
D.Anemia: This probably represents a marker for poor nutrition.
E.Obesity.
Common Complaints
A.Feeling ill
with fever or chills.
B.Muscle aches.
C.Headache.
D.Uterine pain and tenderness.
E.Foul-smelling lochia.
Other Signs and Symptoms
A.Fever (100.4°F–104.0°F).
B.Subinvolution.
C.Uterus may be atonic.
D.Abnormalities of lochia:
1.May be scant and odorless if anaerobic infection.
2.May be moderately heavy, foul, bloody, or seropurulent if aerobic infection.
E.Tachycardia.
Subjective Data
A.Elicit onset, duration, and course of symptoms.
B.Review the color, odor, and amount of lochia.
C.Review the patient’s pain or discomfort and the relief measures used.
D.Review other body symptoms to rule out other infections such as urinary tract infection (UTI), breast engorgement, or mastitis.
E.Review labor and delivery events for complications (see section Predisposing Factors
).
Physical Examination
A.Check temperature, pulse, and blood pressure (BP): The patient may be tachycardic with heart rate 100 to 140 bpm.
B.Inspect: Observe color, amount, and odor of lochia. Check abdominal incision, if applicable. Check the perineum for lacerations, breakdown of incision, redness, and drainage.
C.Palpate:
1.Palpate the abdomen; check uterine tenderness.
2.Palpate the back; check costovertebral angle (CVA) tenderness.
D.Auscultate: Auscultate the heart and lungs.
E.Pelvic exam:
1.Speculum exam: Inspect the cervix for lacerations, drainage, or redness.
2.Bimanual exam: Check for cervical motion tenderness; palpate adnexa for masses and tenderness; note heat
of the pelvis.
Diagnostic Tests
A.Complete blood count (CBC) with differential.
B.Blood and urine cultures.
C.Cervical cultures, to rule out a sexually transmitted infection (STI), if indicated.
D.Wet mount, to rule out bacterial vaginosis and candidal vaginitis, if indicated.
Differential Diagnoses
A.Endometritis.
B.STIs, such as chlamydia, gonorrhea, or trichomoniasis.
C.Septic pelvic thrombophlebitis.
D.UTI/pyelonephritis.
E.Pneumonitis.
F.Extreme breast engorgement secondary to abrupt weaning causing maternal reabsorption of milk.
G.Wound infection.
Plan
A.General interventions:
1.Instruct on proper hygiene. Teach the patient proper techniques to prevent infection (perineal area, incision site, breast).
2.Acetaminophen (Tylenol) for fever as needed.
B. 
See Section III: Patient Teaching Guide Endometritis.
C.Pharmaceutical therapy:
1.Outpatient setting antibiotic therapy compatible with breastfeeding:
a.Clindamycin 600 mg orally every 6 hours for 14 days PLUS Gentamicin 4.5 mg/kg intramuscularly every 24 hours for 48 to 72 hours.
b.Clindamycin 600 mg orally every 6 hours for 14 days PLUS amoxicillin-clavulanic acid 875
mg orally every 12 hours.
c.Suspected clindamycin resistance per geographic region: Ampicillin-sulbactam 1.5 g every 6 hours for 14 days.
d.Group B strep (GBS) colonizer in pregnancy: Add ampicillin 500 mg orally every 6 hours for 14 days to the clindamycin PLUS gentamicin regimen OR use ampicillin-sulbactam 1.5 g every 6 hours for 14 days alone.
e.Penicillin allergy: Use vancomycin 500 mg orally every 6 hours for 14 days instead of ampicillin.
2.Inpatient setting antibiotic therapy:
a.If uterus is boggy and/or bleeding is excessive: Methylergonovine maleate (Methergine) 0.2 mg orally every 4 hours for six doses. (Do not give if the patient is hypertensive.)
b.IV clindamycin 900 mg every 8 hours PLUS gentamicin 1.5 mg/kg every 8 hours OR 5 mg/kg every 24 hours till patient clinical improvement and afebrile for at least 24 to 48 hours.
c.Suspected clindamycin resistance and/or GBS colonizer during pregnancy: IV ampicillin-sulbactam 1.5 g every 6 hours till patient clinical improvement and afebrile for at least 24 to 48 hours.
Follow-Up
A.Call the patient in 24 to 48 hours to evaluate her status.
Emergent Issues/Instructions
A.Instruct the patient to call immediately or go to the emergency room if symptoms do not resolve within 24 hours or if they worsen.
Consultation/Referral
A.Consult with physician if symptoms do not resolve, if they worsen within 24 hours, or if the patient’s temperature does not go below 100.0°F after 48 hours on antibiotics. If no significant improvement is seen within 2 to 3 days, the patient may need to be admitted to the hospital.