Endometritis Treatment & Management
- Author: Michel E Rivlin, MD; Chief Editor: Michel E Rivlin, MD more...
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.
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.
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. In rare instances of overwhelming infection nonresponsive to conservative therapy, hysterectomy may be necessary as a life-saving intervention.
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.[17, 18, 19, 20] 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.
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.[22, 23, 24, 25] 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.[26, 27, 28] 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.
A study by Ward et al found that the combination of cefazolin plus azithromycin when administered before skin incision was significantly more effective than the administration of cefazolin after cord clamping.
A Cochrane database systematic review concluded that the use of vaginal chlorhexidine douching during labor does not prevent endometritis. 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.
A Cochrane review evaluating different skin preparation agents, timing, and application was not able to identify the most efficient method for preventing infection following cesarean delivery.
Workowski KA, Bolan GA, Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015 Jun 5. 64 (RR-03):1-137. [Medline].
Hardeman J, Weiss BD. Intrauterine devices: an update. Am Fam Physician. 2014 Mar 15. 89(6):445-50. [Medline].
Farley TM, Rosenberg MJ, Rowe PJ, Chen JH, Meirik O. Intrauterine devices and pelvic inflammatory disease: an international perspective. Lancet. 1992 Mar 28. 339 (8796):785-8. [Medline].
Grimes DA. Intrauterine device and upper-genital-tract infection. Lancet. 2000 Sep 16. 356 (9234):1013-9. [Medline].
McGill AL, Bavaro MF, You WB. Postpartum herpes simplex virus endometritis and disseminated infection in both mother and neonate. Obstet Gynecol. 2012 Aug. 120(2 Pt 2):471-3. [Medline].
Onuigbo W, Esimai B, Nwaekpe C, Chijioke G. Tubercular endometritis detected through Pap smear campaign in Enugu, Nigeria. Pan Afr Med J. 2012. 11:47. [Medline].
Saracoglu OF, Mungan T, Tanzer F. Pelvic tuberculosis. Int J Gynaecol Obstet. 1992 Feb. 37(2):115-20. [Medline].
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. 2001 Apr. 28(4):240-5. [Medline].
Dehbashi S, Honarvar M, Fardi FH. Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding. Int J Gynaecol Obstet. 2004 Jul. 86(1):12-5. [Medline].
Tuuli MG, Liu L, Longman RE, et al. Infectious morbidity is higher after second-stage compared with first-stage cesareans. Am J Obstet Gynecol. 2014 Mar 18. [Medline].
Asicioglu O, Güngördük K, Yildirim G, et al. Second-stage vs first-stage caesarean delivery: Comparison of maternal and perinatal outcomes. J Obstet Gynaecol. 2014 Oct. 34(7):598-604. [Medline].
Haggerty CL, Hillier SL, Bass DC, Ness RB. Bacterial vaginosis and anaerobic bacteria are associated with endometritis. Clin Infect Dis. 2004 Oct 1. 39(7):990-5. [Medline].
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. 2002 Nov. 81(11):1006-10. [Medline].
Kasius JC, Broekmans FJ, Sie-Go DM, et al. The reliability of the histological diagnosis of endometritis in asymptomatic IVF cases: a multicenter observer study. Hum Reprod. 2012 Jan. 27(1):153-8. [Medline].
Dehaene I, Loccufier A, Temmerman M, De Keersmaecker B, De Baene L. Creatine kinase as an indicator for hysterectomy in postpartum endomyometritis due to group A streptococci: a hypothesis illustrated by a case report. Gynecol Obstet Invest. 2012. 73(1):82-8. [Medline].
French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18. CD001067. [Medline].
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. 2003 Jan. 188(1):149-52. [Medline].
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. 2005 Sep. 272(3):201-6. [Medline].
Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2. 2:CD001067. [Medline].
Brown KR, Williams SF, Apuzzio JJ. Ertapenem compared to combination drug therapy for the treatment of postpartum endometritis after cesarean delivery. J Matern Fetal Neonatal Med. 2012 Jun. 25(6):743-6. [Medline].
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. 2008 Sep. 199(3):301.e1-6. [Medline].
Owens SM, Brozanski BS, Meyn LA, Wiesenfeld HC. Antimicrobial prophylaxis for cesarean delivery before skin incision. Obstet Gynecol. 2009 Sep. 114(3):573-9. [Medline].
Smaill FM, Gyte GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev. 2010 Jan 20. CD007482. [Medline].
Thinkhamrop J, Hofmeyr GJ, Adetoro O, Lumbiganon P, Ota E. Antibiotic prophylaxis during the second and third trimester to reduce adverse pregnancy outcomes and morbidity. Cochrane Database Syst Rev. 2015 Jan 26. 1:CD002250. [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. 2007 May. 196(5):455.e1-5. [Medline].
Tita AT, Hauth JC, Grimes A, Owen J, Stamm AM, Andrews WW. Decreasing incidence of postcesarean endometritis with extended-spectrum antibiotic prophylaxis. Obstet Gynecol. 2008 Jan. 111(1):51-6. [Medline].
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. 2009 Mar. 113(3):675-82. [Medline]. [Full Text].
Ward E, Duff P. A comparison of 3 antibiotic regimens for prevention of postcesarean endometritis: an historical cohort study. Am J Obstet Gynecol. 2016 Feb 18. [Medline].
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. 2004 Oct 18. CD004070. [Medline].
Hadiati DR, Hakimi M, Nurdiati DS. Skin preparation for preventing infection following caesarean section. Cochrane Database Syst Rev. 2012. 9:CD007462. [Medline].