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Updated: Feb 1 2020

Postpartum Endometritis

  • 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
    • 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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