Snapshot A 20-year-old, G1P1, recently gave birth to a healthy boy at 39 weeks gestation. He was delivered via cesarean section and the patient is now recovering on the unit. Approximately 2 days after the cesarean section, the nurse reports the patient's temperature is 101°F (38°C). On physical examination, the surgical site is clean, there is mid-abdominal, and uterine tenderness with foul-smelling lochia. Complete blood count reveals a leukocyte count of 18,000 cells/mm3. The patient is started on intravenous antibiotics. Introduction Overview postpartum endometritis is an infection of the decidua (pregnancy endometrium), often polymicrobial, and a common etiology for postpartum fever this is usually a mild to moderate infection but requires urgent treatment as progression can lead to involvement of fallopian tubes and ovaries, peritonitis, and sepsis treatment is with intravenous antibiotics Epidemiology Incidence 1-3% post-vaginal delivery up to 25% post-cesarean section Demographics onset typically within 48-72 hours postpartum Risk factors maternal bacterial vaginosis diabetes anemia immunosuppression obesity group B Streptococcus (GBS) colonization intrapartum and postpartum cesarean section most important risk factor prolonged rupture of membranes prolonged labor multiple pelvic exams during labor chorioamnionitis vaginal infection ETIOLOGY Pathogenesis Ascension of endogenous cervical or vaginal flora into the uterine cavity Presentation Symptoms abdominal pain fever 48-72 hours postpartum chills rigors malaise Physical exam fever uterine tenderness purulent, foul smelling lochia midline abdominal pain tachycardia tachypnea Studies Serum labs leukocytosis Differential Normal postpartum changes key distinguishing features may present with chills, edema, breast tenderness, and abdominal cramping from contracting uterus will have non-purulent lochia Surgical site infection key distinguishing features will present with signs of infection around incision site including localized erythema, swelling, and purulent drainage Pneumonia key distinguishing features will present with shortness of breath, coughing, and opacities on chest radiograph Pyelonephritis key distinguishing features will present with flank pain, costovertebral angle (CVA) tenderness, and pyuria Mastitis key distinguishing features will present with breast pain, swelling, and erythema Treatment Medical intravenous clindamycin with gentamicin indication common initial treatment regimen intravenous ampicillin indication for patients with known GBS colonization used in adjunct with intravenous clindamycin and gentamicin Complications Peritonitis Sepsis Abscess Prognosis Most infections are mild to moderate with a cure rate > 90% following antibiotic therapy