Endometritis Clinical Presentation
- Author: Michel E Rivlin, MD; Chief Editor: Michel E Rivlin, MD more...
History
Diagnosis usually is based on clinical findings, as follows:
- Fever
- Lower abdominal pain
- Foul-smelling lochia in the obstetric population
- Abnormal vaginal bleeding
- Abnormal vaginal discharge
- Dyspareunia (may be present in patients with pelvic inflammatory disease [PID])
- Dysuria (may be present in patients with PID)
- Malaise
In postpartum cases, patients present with fever, chills, lower abdominal pain, and foul-smelling lochia. Patients with PID present with lower abdominal pain, vaginal discharge, dyspareunia, dysuria, fever, and other systemic signs. However, PID caused by Chlamydia tends to be indolent, with no significant constitutional symptoms.
Physical Examination
Physical examination findings include the following:
- Fever, usually occurring within 36 hours of delivery, in the obstetric population
- Lower abdominal pain
- Uterine tenderness
- Adnexal tenderness if there is an associated salpingitis
- Foul-smelling lochia
- Tachycardia
Uterine tenderness is the hallmark of the disease.
An oral temperature of 38°C or higher within the first 10 days postpartum or 38.7°C within the first 24 hours postpartum is required to make the diagnosis of postpartum endometritis. For PID, the minimum diagnostic criteria are lower abdominal tenderness, cervical motion tenderness, or adnexal tenderness. In severe cases, the patient may appear septic.
Risk Factors
Women are particularly vulnerable to endometritis after birth or abortion. In both the postpartum and postabortal state, risk is increased because of the open cervical os, presence of large amounts of blood and debris, and uterine instrumentation.
Major risk factors for obstetric endometritis include the following:
- Cesarean delivery (especially if before 28 weeks' gestation)
- Prolonged rupture of membranes
- Long labor with multiple vaginal examinations
- Severely meconium-stained amniotic fluid
- Manual placental removal[3]
- Extremes of patient age
- Low socioeconomic status
Minor risk factors include the following:
- Absence of the normal cervical mucus plug
- Administration of multiple courses of corticosteroids for prevention of premature delivery
- Prolonged internal fetal monitoring
- Prolonged surgery
- Postpartum anemia
The following factors increase the risk for endometritis in general:
- Presence of an intrauterine device: the vaginal part of the device may serve as a track for the organisms to ascend into the uterus
- Presence of menstrual fluid in the uterus
- Associated cervicitis secondary to gonorrhea or Chlamydia infection
- Associated bacterial vaginosis[4, 5]
- Frequent douching
- Unprotected sexual activity
- Multiple sexual partners
- Cervical ectopy
Potential Complications
Potential complications of endometritis include the following:
- Adnexal infection
- Parametrial phlegmon
- Pelvic abscess
- Pelvic hematoma
Spread of infection from the endometrium to the fallopian tubes, ovaries, or the peritoneal cavity may result in salpingitis, oophoritis, localized peritonitis, or tubo-ovarian abscesses. Salpingitis subsequently leads to tubal dysmotility and adhesions that result in infertility, higher incidence of ectopic pregnancy, and chronic pelvic pain.
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