Updated: 2/1/2020

Postpartum Endometritis

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  • 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
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(M2.OB.17.4740) A 27-year-old G2P2002 is recovering in the hospital on postpartum day 3 after a low transverse C-section. During morning rounds, she reports a “pus-like” discharge and shaking chills overnight. She also endorses increased uterine cramping compared to the day before, but her postpartum course has otherwise been uneventful with a well-healing incision and normal vaginal bleeding. The patient’s prenatal care was complicated by HIV with a recent viral load of 400 copies/mL, type I diabetes well controlled on insulin, and a history of herpes simplex virus encephalitis in her first child. She did not have any genital lesions during the most recent pregnancy. Four days ago, she presented to the obstetric triage unit after spontaneous rupture of membranes and onset of labor. She made slow cervical change and reached full dilation after 16 hours, but there was limited fetal descent. Cephalopelvic disproportion was felt to be the reason for arrest of descent, so prophylactic ampillicin was administered and C-section was performed. A vaginal hand was required to dislodge the fetus’s head from the pelvis, and a healthy baby boy was delivered. On postpartum day 3, her temperature is 101.5°F (38.6°C), blood pressure is 119/82 mmHg, pulse is 100/min, and respirations are 14/min. Her incision looks clean and dry, there is mild suprapubic tenderness, and a foul yellow discharge tinged with blood is seen on her pad. Which of the following is the most significant risk factor for this patient’s presentation?

QID: 108648
1

HIV positive status

11%

(8/75)

2

Prolonged rupture of membranes

63%

(47/75)

3

C-section after onset of labor

17%

(13/75)

4

History of herpes simplex virus in previous pregnancy

0%

(0/75)

5

Maternal diabetes

9%

(7/75)

M 6 C

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(M2.OB.16.4687) 29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?

QID: 107452
1

Endometrial culture

8%

(1/12)

2

Blood culture

0%

(0/12)

3

Intravenous clindamycin and gentamicin treatment

92%

(11/12)

4

Intramuscular cefotetan treatment

0%

(0/12)

5

Prophylactic intravenous cefazolin treatment

0%

(0/12)

M 7 D

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(M2.OB.14.80) A 24-year-old woman presents to the labor and delivery floor in active labor at 40 weeks gestation. She has a prolonged course but ultimately vaginally delivers an 11 pound boy. On post operative day 2, she is noted to have uterine tenderness and decreased bowel sounds. She states she has been urinating more frequently as well. Her temperature is 102°F (38.9°C), blood pressure is 118/78 mmHg, pulse is 111/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable for a non-distended abdomen and a tender uterus. Pulmonary exam reveals minor bibasilar crackles. Initial laboratory studies and a urinalysis are pending. Which of the following is the most likely diagnosis?

QID: 106944
1

Atelectasis

7%

(5/69)

2

Chorioamnionitis

9%

(6/69)

3

Deep vein thrombosis

1%

(1/69)

4

Endometritis

65%

(45/69)

5

Urinary tract infection

16%

(11/69)

M 7 E

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