Postpartum endometritis refers to infection of the decidua also known as pregnancy endometrium. It occurs during labor and delivery in which the endogenous cervicovaginal flora enters the uterine cavity and causes the infection.

Microbiology:

It is polymicrobial infection most due to anaerobic streptococci, gram-negative coliforms, Bacteroides spp. and aerobic streptococci.

Risk Factors:

• C-section is the most important risk factor, especially when performed after the onset of labor. ( rate of 40-80%)
• bacterial vaginosis significantly increased the risk of developing post cesarean endometritis

Other risk factors for postpartum endometritis include

• Chorioamnionitis- infection can start in the vagina, anus, or rectum and move up into the uterus where the fetus is located
• Prolonged labor
• Prolonged rupture of membranes( >24 hours)
• Low socioeconomic status
• Maternal diabetes mellitus or severe anemia
• Preterm or post term birth

More risk factors can be found on UpToDate

 

Incidence

Incidence of postpartum endometritis varies depending on the route of delivery:

• Vaginal deliveries: 1 to 3%
• Scheduled caesarean deliveries (done before labor starts): 5 to 15%
• Unscheduled caesarean deliveries (done after labor starts): 15 to 20%

 

Clinical Findings:

The first symptoms of endometritis are lower abdominal pain that does not localize and soft tender uterus tenderness, followed by fever and tachycardia—most commonly within the first 24 to 72 h postpartum.

• Motion of the cervix and uterus may cause increased pain.
• Purulent lochia with/w/o foul odor
• The uterus may be slightly soft and sub involuted, which can lead to excessive uterine bleeding.
• Adnexal masses palpable on abdominal or pelvic examination are not seen in uncomplicated endometritis, but tubo-ovarian abscess may be a later complication of an infection originally confined to the uterus.

Labs:

CBC: elevated white blood cell (WBC) count higher than 20,000/µL

• A left shift and a rising neutrophil count postpartum are suggestive of an infectious process.
• An elevated lactic acid concentration is a marker for serious infection.
• Urinalysis and urine culture are usually done.
• Endometrial cultures are rarely indicated because specimens collected through the cervix are almost always contaminated by vaginal and cervical flora.

 

Imaging:

There are no characteristic sonographic findings associated with postpartum endometritis

Diagnoses:

Diagnosis of postpartum endometritis is clinical and largely based upon the presence of postpartum fever that cannot be attributed to another cause

• The United States Joint Commission on Maternal Welfare defines postpartum febrile morbidity as an oral temperature of ≥38.0°C (≥100.4°F) on any two of the first 10 days postpartum, exclusive of the first 24 hours. The first 24 hours are excluded because low grade fever during this period is common and often resolves spontaneously, especially after vaginal birth

Treatment:

Broad-spectrum antibiotic regimen given IV until women are afebrile for 48 h.

• Clindamycin plus gentamicin, with or without ampicillin
• The first-line choice is clindamycin 900 mg IV q 8 h plus gentamicin 1.5 mg/kg IV q 8 h or 5 mg/kg once/day (1); ampicillin 1 g q 6 h is added if enterococcal infection is suspected or if no improvement occurs by 48 h. Continuing treatment with oral antibiotics is not necessary.

 

Prevention:

Single dose antibiotic prophylaxis within 60 minutes prior to making the skin incision significantly helps reduce the prevalence of post-cesarean delivery endometritis.

Regimen — For all women undergoing cesarean delivery,  administer a single dose of cefazolin in the 60 minutes before making the skin incision and add a single dose of azithromycin 500 mg intravenously for those in labor or with ruptured membranes.

Source:

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/postpartum-endometritis?search=post%20partum%20endometritis%20epidemiology&source=search_result&selectedTitle=3~53&usage_type=default&display_rank=3

https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?sectionid=206960406&bookid=2559#206960574

https://www.merckmanuals.com/professional/gynecology-and-obstetrics/postpartum-care-and-associated-disorders/puerperal-endometritis