BASICS
DESCRIPTION
- Endometritis (infection of the endometrium) is the most common postpartum infection.
- Bacterial infection of genital tract, usually within the 1st week after delivery, can occur as late as 1 to 6 weeks postpartum.
- Less common are postpartum infections of the myometrium and parametrial tissues. Vaginal and cervical infections, perineal cellulitis, pelvic cellulitis, septic pelvic vein thrombophlebitis, and parametrial phlegmon are other less-common postpartum infections of the pelvic region.
- System(s) affected: reproductive
- Synonym(s): postpartum infection; endometritis; endoparametritis; endomyometritis; myometritis; endomyoparametritis; metritis; metritis with pelvic cellulitis
EPIDEMIOLOGY
Incidence
Predominant age and gender: women of childbearing years á
Prevalence
- Occurs after 1-3% of all births
- Infection is 10 times more likely after cesarean section
- 2-15% of infections occur prior to labor
- 30-35% occur after labor in absence of appropriate antibiotic prophylaxis; 2-15% occur after labor with appropriate prophylaxis
- Fifth leading cause of maternal mortality, accounting for 11% of maternal deaths
ETIOLOGY AND PATHOPHYSIOLOGY
- Endometritis is more common in labors complicated by chorioamnionitis.
- Other infections follow trauma to the perineum, vagina, cervix, and uterus.
- Postpartum infections are typically polymicrobial, involving organisms ascending from the lower genital tract:
- Aerobic isolates (70%): Streptococcus faecalis, Streptococcus agalactiae, Streptococcus viridans, Staphylococcus aureus, Escherichia coli
- Anaerobic isolates (80%): Peptococcus sp., Peptostreptococcus sp., Clostridium sp., Bacteroides bivius, Bacteroides fragilis, Fusobacterium sp.
- Other genital mycoplasmata
- Consider herpes simplex virus and cytomegalovirus, particularly in immunocompromised patients failing to improve on appropriate antibiotics.
- Thrombosis of any pelvic vein, including vena cava
- Phlegmon on leaves of the broad ligament
RISK FACTORS
- Cesarean delivery is the primary risk factor.
- Chorioamnionitis
- Bacterial vaginosis
- Group B streptococcal colonization of genital tract
- HIV infection
- Prolonged labor
- Prolonged rupture of membranes
- Multiple vaginal examinations
- Internal fetal monitoring during labor
- Operative vaginal delivery
- Manual extraction of the placenta
- Low socioeconomic status
- Obesity
- Anemia
- Care in a teaching hospital
GENERAL PREVENTION
- Vaginal delivery
- Avoid unnecessary vaginal examinations.
- Treat chorioamnionitis during labor.
- Avoid manual placental extraction and retained placental products.
- Consider antibiotic prophylaxis for third- and fourth-degree laceration (1)[B].
- Use aseptic technique for operative vaginal delivery.
- Antibiotic prophylaxis for operative vaginal delivery is not necessary (2)[A].
- Cesarean delivery
- Preoperative preparation using a paint and scrub technique with a 10% povidone iodine scrub and topical solution decreases puerperal infection by up to 38% (3)[B].
- Prophylactic antibiotics before both emergency and scheduled cesarean deliveries prior to skin incision reduces the prevalence of postpartum infection (4)[A],(5,6)[B].
- Antibiotics should be administered within 1 hour of the surgery start time (6)[B].
- Appropriate administration of antibiotics results in a 40% reduction in postpartum maternal infections without any increase in neonatal infectious outcomes (6)[B].
- Extending the spectrum of coverage to include both a cephalosporin and a macrolide may further decrease infection risk (7)[A],(8)[B].
- Vaginal preparation with povidone iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis (9)[A].
- Weight-based antibiotic dosage helps ensure appropriate tissue concentrations prior to skin incision (10).
COMMONLY ASSOCIATED CONDITIONS
- Chorioamnionitis
- Wound infection
DIAGNOSIS
HISTORY
- History of cesarean delivery or chorioamnionitis
- Fever and chills
- Malaise
- Headache
- Anorexia
- Abdominal pain
- Heavy vaginal bleeding or foul smelling lochia
PHYSICAL EXAM
- Oral temperature >38 ░C (100.4 ░F)
- Tachycardia
- Uterine tenderness on exam
- Other localized abdominopelvic tenderness on exam
- Purulent or malodorous lochia
- Heavy vaginal bleeding
- Ileus
- Group A or B streptococcal bacteremia may have no localizing signs.
DIFFERENTIAL DIAGNOSIS
- "5 Ws"Ł: Wind (pneumonia); Water (UTI); Wound infection; Wow (mastitis); Wonder drug (medication-related fever)
- Viral syndrome; dehydration
- Thrombophlebitis
- Thyroid storm
- Appendicitis
DIAGNOSTIC TESTS & INTERPRETATION
Initial Tests (lab, imaging)
- CBC: Interpret with care (Physiologic leukocytosis may be as high as 20,000 WBCs.).
- Two sets of blood cultures (especially with suspected sepsis)
- Note: Diagnosis often made on clinical grounds. Potential testing includes:
- Genital tract cultures and rapid test for group B streptococci (may be done during labor)
- Amniotic fluid Gram stain: usually polymicrobial
- Uterine tissue cultures: Prep the cervix with Betadine and use a shielded specimen collector or Pipelle; difficult to obtain without contamination
- If patient is not responsive to antibiotics in 24 to 48 hours:
- Ultrasound for retained products of conception, pelvic abscess, or mass
- CT or MRI looking for pelvic vein thrombophlebitis, abscess, or deep-seated wound infection
Diagnostic Procedures/Other
Paracentesis/culdocentesis with culture rarely necessary á
Test Interpretation
- Superficial layer of infected necrotic tissue in microscopic sections of uterine lining
- >5 NEUTROPHILS per high-power field in superficial endometrium; ≥1 plasma cell in endometrial stroma
TREATMENT
MEDICATION
First Line
- Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h (11)[A]
- Potential side effects include nephrotoxicity, ototoxicity, pseudomembranous colitis, or diarrhea (in up to 6%).
Second Line
- Ampicillin-sulbactam 3 g IV q6h
- Metronidazole 500 mg q8-12h + penicillin 5,000,000 U q6h, or
- Ampicillin 2 g q6h + gentamicin 5 mg/kg q24h (11)[A]
- Cefoxitin 2 g IV q6h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours
- Cefotetan 2 g IV q12h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours (11)[A]
- Note: Base therapy on cultures, sensitivities, and clinical response.
- Contraindications
- Drug allergy
- Renal failure (aminoglycosides)
- Avoid sulfa, tetracyclines, and fluoroquinolones before delivery and if breastfeeding. Metronidazole is relatively contraindicated if breastfeeding.
- Precautions:
- Clindamycin and other antibiotics occasionally cause pseudomembranous colitis.
- Antibiotic-associated diarrhea (Clostridium difficile)
- Note: Consider adding a macrolide antibiotic (for chlamydia coverage) for infections occurring after 48 hours.
- Note: Heparin typically indicated for septic pelvic vein thrombophlebitis; requires 10 days of full anticoagulation
SURGERY/OTHER PROCEDURES
- Curettage for retained products of conception
- Surgery to drain abscess
- Surgery to decompress the bowel
- Surgical drainage of a phlegmon is not advised unless it is suppurative. Surgical removal of other inflamed tissue is usually not required.
INPATIENT CONSIDERATIONS
Admission Criteria/Initial Stabilization
- Inpatient care is recommended for postpartum infections.
- Many infections occur after hospital discharge.
- IV antibiotics and close observation for severe infections
- Open and drain infected wounds.
- Optimize fluid status.
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
- Individualize according to severity
- IV antibiotics can be stopped when the patient is afebrile for 24 to 48 hours.
- Oral antibiotics on discharge are not necessary, unless patient was bacteremic; then continue oral antibiotics to complete a 7-day course.
DIET
As tolerated, although may be limited by ileus á
PATIENT EDUCATION
- Advise patient to contact physician with fever >38 ░C (100.4 ░F) postpartum, heavy vaginal bleeding, foul-smelling lochia, or other symptoms of infection.
- Information available at http://www.healthline.com/health/pregnancy/complications-postpartum-endometritis
PROGNOSIS
With supportive therapy and appropriate antibiotics, most patients improve quickly and recover without complication. á
COMPLICATIONS
- Resistant organisms; peritonitis; pelvic abscess
- Septic pelvic thrombophlebitis
- Ovarian vein thrombosis
- Sepsis; death
REFERENCES
11 Duggal áN, Mercado áC, Daniels áK, et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol. 2008;111(6):1268-1273.22 Liabsuetrakul áT, Choobun áT, Peeyananjarassri áK, et al. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2014;(10):CD004455.33 Weed áS, Bastek áJA, Sammel áMD, et al. Comparing postcesarean infectious complication rates using two different skin preparations. Obstet Gynecol. 2011;117(5):1123-1129.44 Smaill áFM, Grivell áGM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Sys Rev. 2014;(10):CD007482.55 Dinsmoor áMJ, Gilbert áS, Landon áMB, et al. Perioperative antibiotic prophylaxis for nonlaboring cesarean delivery. Obstet Gynecol. 2009;114(4):752-756.66 American College of Obstetricians and Gynecologist. ACOG practice bulletin No. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472-1483.77 Costantine áMM, Rahman áM, Ghulmiyah áL, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol. 2008;199(3):301.e1-301.e6.88 Tita áAT, Owen áJ, Stamm áAM, et al. Impact of extended-spectrum antibiotic prophylaxis on incidence of postcesarean surgical wound infection. Am J Obstet Gynecol. 2008;199(3):303.e1-303.e3.99 Haas áDM, Morgan áS, Contreras áK. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;(12):CD007892.1010 Pevzner áL, Swank áM, Krepel áC, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol. 2011;117(4):877-882.1111 French áLM, Smaill áFM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2015;(2):CD001067.
ADDITIONAL READING
- Baaqeel áH, Baaqeel áR. Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis. BJOG. 2013;120(6):661-669.
- Bianco áA, Roccia áS, Nobile áCG, et al. Postdischarge surveillance following delivery: the incidence of infections and associated factors. Am J Infect Control. 2013;41(6):549-553.
- Maharaj áD. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62(6):393-399.
- Maharaj áD. Puerperal pyrexia: a review. Part II. Obstet Gynecol Surv. 2007;62(6):400-406.
- Srinivas áSK, Fager áC, Lorch áSA. Variations in postdelivery infection and thrombosis by hospital teaching status. Am J Obstet Gynecol. 2013;209(6):567.e1-567.e7.
- Sun áJ, Ding áM, Liu áJ, et al. Prophylactic administration of cefazolin prior to skin incision versus antibiotics at cord clamping in preventing postcesarean infectious morbidity: a systematic review and meta-analysis of randomized controlled trials. Gynecol Obstet Invest. 2013;75(3):175-178.
SEE ALSO
Algorithm: Pelvic Pain á
CODES
ICD10
- O86.12 Endometritis following delivery
- O86.4 Pyrexia of unknown origin following delivery
- O86.13 Vaginitis following delivery
- O85 Puerperal sepsis
- O86.19 Other infection of genital tract following delivery
- O86.11 Cervicitis following delivery
ICD9
- 670.14 Puerperal endometritis, postpartum condition or complication
- 646.64 Infections of genitourinary tract in pregnancy, postpartum condition or complication
- 670.04 Major puerperal infection, postpartum condition or complication
- 670.24 Puerperal sepsis, postpartum condition or complication
- 670.84 Other major puerperal infection, postpartum condition or complication
SNOMED
- 22399000 Puerperal endometritis (disorder)
- 178280004 postnatal infection (disorder)
- 40125005 Major puerperal infection
- 2858002 Puerperal septicemia (disorder)
- 419760006 Bacterial vaginosis (disorder)
- 428252001 Vaginitis in pregnancy
CLINICAL PEARLS
- Postpartum endometritis follows 1-3% of all births.
- Infections are typically polymicrobial and involve organisms ascending from the lower genital tract.
- Evidence supports antibiotic prophylaxis prior to skin incision for all cesarean deliveries but not for operative vaginal deliveries.
- clindamycin 900 mg IV q8h and gentamicin 5 mg/kg q24h are recommended as first-line therapy for endometritis. Treat until the patient is afebrile for 24 to 48 hours, at which point antibiotics can be stopped completely (except in cases of documented bacteremia, which require a 7-day course of therapy).
- If no improvement occurs on antibiotics, consider retained placental products, abscess, wound infection, hematoma, cellulitis, phlegmon, or septic pelvic vein thrombosis.