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Endometritis Treatment & Management

  • Author: Michel E Rivlin, MD; Chief Editor: Michel E Rivlin, MD  more...
 
Updated: Mar 20, 2016
 

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.[2]

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.[16]

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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.[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.[21]

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.[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.[28]

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.[29]

A Cochrane database systematic review concluded that the use of vaginal chlorhexidine douching during labor does not prevent endometritis.[30] 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.[31]

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Contributor Information and Disclosures
Author

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Coauthor(s)

Elizabeth Alderman, MD Director, Pediatric Residency Program, Director of Fellowship Training Program, Adolescent Medicine, Professor of 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, Society for Adolescent Health and 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, Society of Laparoendoscopic Surgeons, American Society for Colposcopy and Cervical Pathology

Disclosure: Nothing to disclose.

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.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

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

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, 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, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

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, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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.

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