Endometritis Treatment & Management

  • Author: Michel E Rivlin, MD; Chief Editor: Michel E Rivlin, MD   more...
 
Updated: Jun 14, 2011
 

Approach Considerations

After making the diagnosis of endometritis and excluding other sources of infection, the physician should promptly initiate broad-spectrum antibiotics. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen.

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. Pregnant women with symptoms of bacterial vaginosis (BV) should be treated because BV is associated with adverse pregnancy outcomes. Although treatment has not been demonstrated to prevent these outcomes, treatment does reduce signs and symptoms of vaginal infection.[1]

In adolescents who undergo termination of pregnancy, subsequent endometritis with associated salpingitis poses a significant risk of infertility. Therefore, earlier and more aggressive antibiotic therapy is warranted in this group.

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Antibiotic Therapy

The combination of clindamycin and gentamicin administered intravenously every 8 hours has been considered the criterion standard treatment. Some studies have revealed adequate efficacy with once-daily dosing, as well.[6, 7, 8] The combination of a second- or third-generation cephalosporin with metronidazole is another popular choice.

In teenagers, postabortion endometritis may be caused by organisms that cause pelvic inflammatory disease (PID). The initial treatment regimen in these patients usually includes intravenous cefoxitin and doxycycline, in the same doses as for PID.

A trend toward the use of broad-spectrum monotherapy has emerged; these agents are generally effective in 80-90% of patients. Cephalosporins, extended-spectrum penicillins, and fluoroquinolones are used as monotherapy.

Improvement is 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. If the physical examination findings are benign, the patient may be discharged at that time. Further outpatient antibiotic therapy has proved to be unnecessary. If the patient does not improve in the expected 48- to 72-hour period, reevaluate for complications such as abscess.

Prophylaxis

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.[9, 10, 11] Single-agent therapy with a first- or second-generation cephalosporin (eg, cefazolin) has been considered the best choice.

A 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. However, current research is also assessing the use of extended-spectrum regimens with a cephalosporin plus either azithromycin or metronidazole after cord clamping.[12, 13, 14] Head-to-head comparisons between narrow-spectrum prophylaxis given before skin incision and extended-spectrum prophylaxis given after cord clamping still need to be done.[14]

A Cochrane database systematic review concluded that the use of vaginal chlorhexidine douching during labor does not prevent endometritis.[15] 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.

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Surgical Care

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

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Contributor Information and Disclosures
Author

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.

Coauthor(s)

Elizabeth Alderman, MD  Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Professor, Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Merck Honoraria Speaking and teaching

Latha Chandran, MBBS, MD, MPH  Professor of Pediatrics, Vice Dean for Undergraduate Medical Education, Stony Brook University School of Medicine, New York

Latha Chandran, MBBS, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Joseph A Puccio, MD, FAAP  Director, Division of Adolescent Medicine, Stony Brook University Hospital; Assistant Professor, Department of Pediatrics, Stony Brook University School of Medicine

Joseph A Puccio, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

Anthony Charles Sciscione, DO  Professor, Department of Obstetrics and Gynecology, Drexel University College of Medicine; Director, Maternal and Fetal Medicine, Christiana Care Health System; Director, Delaware Center for Maternal and Fetal 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Andrea L Zuckerman, MD  Assistant Professor of Obstetrics/Gynecology and Pediatrics, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center

Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

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.

References
  1. [Guideline] Workowski KA, Berman S. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. Dec 17 2010;59:1-110. [Medline]. [Full Text].

  2. Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al. Douching and endometritis: results from the PID evaluation and clinical health (PEACH) study. Sex Transm Dis. Apr 2001;28(4):240-5. [Medline].

  3. Dehbashi S, Honarvar M, Fardi FH. Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding. Int J Gynaecol Obstet. Jul 2004;86(1):12-5. [Medline].

  4. Haggerty CL, Hillier SL, Bass DC, Ness RB. Bacterial vaginosis and anaerobic bacteria are associated with endometritis. Clin Infect Dis. Oct 1 2004;39(7):990-5. [Medline].

  5. Jacobsson B, Pernevi P, Chidekel L, Jörgen Platz-Christensen J. Bacterial vaginosis in early pregnancy may predispose for preterm birth and postpartum endometritis. Acta Obstet Gynecol Scand. Nov 2002;81(11):1006-10. [Medline].

  6. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. Oct 18 2004;CD001067. [Medline].

  7. Livingston JC, Llata E, Rinehart E, Leidwanger C, Mabie B, Haddad B, et al. Gentamicin and clindamycin therapy in postpartum endometritis: the efficacy of daily dosing versus dosing every 8 hours. Am J Obstet Gynecol. Jan 2003;188(1):149-52. [Medline].

  8. Sifakis S, Angelakis E, Makrigiannakis A, Orfanoudaki I, Christakis-Hampsas M, Katonis P, et al. Chemoprophylactic and bactericidal efficacy of 80 mg gentamicin in a single and once-daily dosing. Arch Gynecol Obstet. Sep 2005;272(3):201-6. [Medline].

  9. Costantine MM, Rahman M, Ghulmiyah L, Byers BD, Longo M, Wen T, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol. Sep 2008;199(3):301.e1-6. [Medline].

  10. Owens SM, Brozanski BS, Meyn LA, Wiesenfeld HC. Antimicrobial prophylaxis for cesarean delivery before skin incision. Obstet Gynecol. Sep 2009;114(3):573-9. [Medline].

  11. Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev. Jan 20 2010;CD007482. [Medline].

  12. 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].

  13. 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].

  14. 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]. [Full Text].

  15. Lumbiganon P, Thinkhamrop J, Thinkhamrop B, Tolosa JE. Vaginal chlorhexidine during labour for preventing maternal and neonatal infections (excluding Group B Streptococcal and HIV). Cochrane Database Syst Rev. Oct 18 2004;CD004070. [Medline].

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