eMedicine Specialties > Obstetrics and Gynecology > General Obstetrics
Endometritis
Updated: Aug 15, 2007
Introduction
Background
Endometritis is an infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis is divided into obstetric and nonobstetric endometritis. It is the most common cause of fever during the postpartum period. Pelvic inflammatory disease (PID) is a common predecessor in the nonobstetric population.
Pathophysiology
Endometritis is infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis usually results from an ascending infection from the lower genital tract. From a pathologic perspective, endometritis can be classified as acute versus chronic. Acute endometritis is characterized by the presence of neutrophils within the endometrial glands. Chronic endometritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stroma.
In the nonobstetric population, PID and invasive gynecologic procedures are the most common precursors to acute endometritis. In the obstetric population, postpartum infection is the most common predecessor. Chronic endometritis in the obstetric population is usually associated with retained products of conception after delivery or elective abortion. In the nonobstetric population, chronic endometritis has been seen with infections, such as chlamydia, tuberculosis, and bacterial vaginosis, and the presence of an intrauterine device.
Frequency
United States
Incidence varies depending on the route of delivery and the patient population. After a vaginal delivery, incidence is 1-3%. Following cesarean delivery, incidence ranges from 13-90%, depending on the risk factors present and whether perioperative antibiotic prophylaxis had been given.
Mortality/Morbidity
- Infection of the genital tract is the most common cause of puerperal morbidity. Puerperal morbidity is defined as a temperature of 100.4°F (38°C) or higher occurring in any 2 of the first 10 days postpartum, exclusive of the first 24 hours. In the past, infection accounted for up to 16% of maternal mortality.
- In the nonobstetric population, concomitant endometritis may occur in up to 70-90% of documented cases of salpingitis.
Age
This disorder affects females of reproductive age.
Clinical
History
Diagnosis usually is based on clinical findings.
- Fever
- Lower abdominal pain
- Foul-smelling lochia in the obstetric population
- Abnormal vaginal bleeding
- Abnormal vaginal discharge
- Dyspareunia (may be present in patients with PID)
- Dysuria (may be present in patients with PID)
- Malaise
Physical
- 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
Causes
- Endometritis is a polymicrobial disease involving, on average, 2-3 organisms.
- In the majority of cases, it arises from an ascending infection from organisms found in the normal indigenous vaginal flora.
- Commonly isolated organisms include Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, and group B Streptococcus.
- Chlamydia has been associated with late-onset postpartum endometritis.
- Enterococcus is identified in up to 25% of women who have received cephalosporin prophylaxis.
- Route of delivery is the most important factor in the development of postpartum endometritis.
- Major risk factors include cesarean delivery, prolonged rupture of membranes, long labor with multiple vaginal examinations, extremes of patient age, and low socioeconomic status.
- Minor contributing factors include maternal anemia, prolonged internal fetal monitoring, prolonged surgery, and general anesthesia.
- Bacterial vaginosis has been associated with endometritis after cesarean delivery and with PID after first trimester elective abortion.
More on Endometritis |
 Overview: Endometritis |
| Differential Diagnoses & Workup: Endometritis |
| Treatment & Medication: Endometritis |
| Follow-up: Endometritis |
| References |
| Next Page » |
References
Cunningham FG. Infection and disorders of the puerperium. In: Cunningham GF, MacDonald PC, Leven KJ, et al, eds. Williams Obstetrics. 20th ed. Stamford, Conn: Appleton & Lange; 1997:548-55.
French L. Prevention and treatment of postpartum endometritis. Curr Womens Health Rep. Aug 2003;3(4):274-9. [Medline].
French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004;CD001067. [Medline].
Ledger WJ. Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. Dec 2003;29(6):364-73. [Medline].
Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. Jun 2007;62(6):393-9. [Medline].
Gudas JM, Fridovich-Keil JL, Datta MW, Bryan J, Pardee AB. Characterization of the murine thymidine kinase-encoding gene and analysis of transcription start point heterogeneity. Gene. Sep 10 1992;118(2):205-16. [Medline].
Sullivan SA, Smith T, Chang E, Hulsey T, Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol. May 2007;196(5):455.e1-5. [Medline].
Further Reading
Keywords
metritis, endomyometritis, endomyoparametritis, myometritis, Cesarean delivery, C section, pelvic inflammatory disease, PID, retained products of conception, obstetric endometritis, nonobstetric endometritis, salpingitis, Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, group B Streptococcus, Chlamydia, Enterococcus, cesarean delivery, bacterial vaginosis
