eMedicine Specialties > Obstetrics and Gynecology > General Obstetrics

Endometritis

Gema T Simmons, MD, Consulting Staff, Department of Obstetrics and Gynecology, Alegent Health

Updated: Aug 2, 2009

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 pelvic inflammatory disease [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 most 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. More recent research supports the preoperative administration of prophylactic antibiotics, which was associated with a 53% decrease in endometritis without any impact on suspected or proven neonatal sepsis or NICU admission.¹
• 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.

Differential Diagnoses

Appendicitis
Pelvic Inflammatory Disease

Other Problems to Be Considered

Pyelonephritis
Viral syndrome
Pelvic thrombophlebitis

Workup

Laboratory Studies

• On complete blood count the finding of leukocytosis may be difficult to interpret, secondary to the physiologic leukocytosis of pregnancy.
• Blood culture is positive in 10-30% of cases.
• Urine culture should be ordered.
• Endocervical cultures (or DNA probe) are obtained for gonorrhea and chlamydia.
• Culture of the endometrial cavity usually results in contamination from normal resident cervicovaginal flora.

Imaging Studies

• Perform imaging studies on patients who do not respond to adequate antimicrobial therapy in 48-72 hours.
• CT scanning of the abdomen and pelvis may be helpful for excluding broad ligament masses, septic pelvic thrombophlebitis, ovarian vein thrombosis, and phlegmon.
• Sonographic findings of the abdomen and pelvis may be normal in patients with a clinical diagnosis of endometritis. Abnormal findings overlap with those of retained products of conception and intrauterine hematoma.

Procedures

Endometrial biopsy can be obtained to assess chronic endometritis in the nonobstetric population.

Treatment

Medical Care

Most cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate.

• Combination intravenous clindamycin and gentamicin administered every 8 hours has been considered the criterion standard treatment. Recent studies have revealed adequate efficacy with daily dosing as well.
• Second- or third-generation cephalosporin in combination with metronidazole is another popular choice.
• Improvement is usually noted within 48-72 hours in nearly 90% of women. Parenteral therapy is continued until the patient has been afebrile for longer than 24 hours. Thereafter, oral antibiotics are not usually necessary.

Surgical Care

Surgical management is not usually necessary in acute endometritis in the obstetric population. Dilatation and curettage may be advised for retained products of conception, however.

Medication

After making the diagnosis of endometritis and excluding other sources of infection, broad-spectrum antibiotics should be promptly initiated. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen. For mild cases following vaginal delivery, an oral agent may be adequate.

Antibiotics

A combination therapy with clindamycin and an aminoglycoside is considered the criterion standard by which most antibiotic clinical trials are judged.

A combination regimen of ampicillin, gentamicin, and metronidazole provides coverage against most of the organisms that are encountered in serious pelvic infections.

Doxycycline should be used if Chlamydia is the cause of the endometritis.

Ampicillin sulbactam can be used as monotherapy. Single-agent therapies have been found to be efficacious in 80-90% of patients.

Clindamycin (Cleocin)

Used in combination with gentamicin. Lincosamide useful as a treatment against serious skin and soft tissue infections caused by most staphylococci strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition.

Dosing

Adult

900 mg IV q8h

Pediatric

20-40 mg/kg/d IV divided q6-8h

Interactions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Contraindications

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of Clostridium difficile
American Academy of Pediatrics states that clindamycin is compatible with breastfeeding

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. Used in combination with either clindamycin or in combination with metronidazole and ampicillin.
Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution. Dose may be given IV or IM.

Dosing

Adult

1.5 mg/kg IV q8h

Pediatric

2-2.5 mg/kg/d IV q8h

Interactions

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Contraindications

Documented hypersensitivity; non-dialysis-dependent renal insufficiency

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; data are lacking concerning use while breastfeeding

Ampicillin (Omnipen, Marcillin)

Used in combination with gentamicin and metronidazole. Interferes with bacterial cell-wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms.

Dosing

Adult

2 g IV q6h

Pediatric

50-200 mg/kg/d IV divided qid

Interactions

Probenecid and disulfiram elevate levels; allopurinol decreases effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Metronidazole (Flagyl)

Used in combination with gentamicin and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death.

Dosing

Adult

500 mg IV q6h

Pediatric

15-30 mg/kg/d IV divided bid/tid

Interactions

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
American Academy of Pediatrics states that metronidazole should be used with caution while breastfeeding

Ampicillin/sulbactam sodium (Unasyn)

Has been found to be efficacious as monotherapy in 80-90% of patients. Drug combination that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens.

Dosing

Adult

3 g IV q6h

Pediatric

1.5-3 g IV q8h

Interactions

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; compatible with breastfeeding

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Used if Chlamydia is the cause of the endometritis. Inhibits protein synthesis and thus bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria.

Dosing

Adult

100 mg PO/IV q12h

Pediatric

<8 years: Not recommended
>8 years: 1-2 mg/lb PO/IV q12h

Interactions

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
American Academy of Pediatrics states that doxycycline is compatible with breastfeeding

Ertapenem (Invanz)

Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended spectrum beta-lactamases. Hydrolyzed by metallo-beta-lactamases.

Dosing

Adult

1 g qd for 14 d if given IV and 7 d if given IM; infuse over 30 min if given IV

Pediatric

Not established

Interactions

Probenecid may reduce renal clearance of ertapenem and increase half-life but benefit is minimum and does not justify coadministration

Contraindications

Documented hypersensitivity to drug or amide-type anesthetics

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis may occur; seizures and CNS adverse reactions may occur; when using with lidocaine to administer intramuscularly, avoid inadvertent injection into blood vessel

Follow-up

Inpatient & Outpatient Medications

• Patient may be discharged without antibiotic therapy after being afebrile for at least 24 hours and with a benign physical examination.
• Further outpatient therapy has proved to be unnecessary.

Complications

• Wound infection
• Peritonitis
• Adnexal infection
• Parametrial phlegmon
• Pelvic abscess
• Pelvic hematoma
• Septic pelvic thrombophlebitis

Prognosis

• Nearly 90% of women treated with an approved regimen note improvement in 48-72 hours.

Patient Education

• For excellent patient education resources, see eMedicine's Women's Health Center and Pregnancy and Reproduction Center and Sexually Transmitted Diseases Center and the patient education articles Pelvic Inflammatory Disease, Sexually Transmitted Diseases, Cesarean Childbirth, and Dilation and Curettage (D&C).

Miscellaneous

Medicolegal Pitfalls

• Prophylactic antibiotics reduce the incidence of postpartum febrile morbidity in patients undergoing cesarean delivery. Current research supports the use of preoperative administration of prophylactic antibiotics. A recent joint publication by the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) supports the administration of antibiotics prior to skin incision rather than immediately after cord clamping.
• Single-agent cephalosporin therapy of the first- or second-generation type has been considered the best choice. However, current research is looking into extended-spectrum antibiotics with either azithromycin or metronidazole.²

Special Concerns

Current research is evaluating the timing of administration of cephalosporin prior to skin incision and giving extended-spectrum regimens with either azithromycin or metronidazole after cord clamp.^1,2,3 Head-to-head comparisons between the 2 regimens still need to be done.³

Preoperative use of povidone-iodine vaginal preparation prior to cesarean delivery appears to decrease the incidence of postcesarean endometritis but does not seem to decrease the overall risk of postoperative fever or wound infection.

References

1. 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].

2. Tita AT, Hauth JC, Grimes A, Owen J, Stamm AM, Andrews WW. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstet Gynecol. Jan 2008;111(1):51-6. [Medline].

3. Tita AT, Rouse DJ, Blackwell S, Saade GR, Spong CY, Andrews WW. Emerging concepts in antibiotic prophylaxis for cesarean delivery: a systematic review. Obstet Gynecol. Mar 2009;113(3):675-82. [Medline].

4. Cunningham FG. Infection and disorders of the puerperium. In: Cunningham GF, MacDonald PC, Leven KJ, et al, eds. Williams Obstetrics. 20^th ed. Stamford, Conn: Appleton & Lange; 1997:548-55.

5. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004;CD001067. [Medline].

6. Ledger WJ. Post-partum endomyometritis diagnosis and treatment: a review. J Obstet Gynaecol Res. Dec 2003;29(6):364-73. [Medline].

7. Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. Jun 2007;62(6):393-9. [Medline].

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

Contributor Information and Disclosures

Author

Gema T Simmons, MD, Consulting Staff, Department of Obstetrics and Gynecology, Alegent Health
Gema T Simmons, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Society for Colposcopy and Cervical Pathology, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Anthony Charles Sciscione, DO, Director, Division of Maternal-Fetal Medicine, Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine
Anthony Charles Sciscione, DO is a member of the following medical societies: American College of Obstetricians and Gynecologists and American Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Antonio V Sison, MD, Medical Director, Ob/Gyn Group, Robert Wood Johnson University Hospital at Hamilton
Antonio V Sison, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists and Association of Professors of Gynecology and Obstetrics
Disclosure: Nothing to disclose.

CME Editor

Frederick B Gaupp, MD, Consulting Staff, Department of Family Practice, Hancock Medical Center
Frederick B Gaupp, MD is a member of the following medical societies: American Academy of Family Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD, Professor, Coordinator of Quality Assurance/Quality Improvement, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine
Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, and Royal College of Surgeons of Edinburgh
Disclosure: Nothing to disclose.

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