Introduction
Background
Endometritis is inflammation of the endometrial lining of the uterus. Endometritis can be divided into pregnancy-related endometritis and endometritis unrelated to pregnancy. When the condition is unrelated to pregnancy, it is referred to as pelvic inflammatory disease (PID). Endometritis is often associated with inflammation of the fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (pelvic peritonitis). This article focuses on pregnancy-related endometritis. In addition to the endometrium, inflammation may involve the myometrium and, occasionally, the parametrium.
Pathophysiology
Inflammation of the endometrium usually results from an ascending infection from the lower genital tract. Differentiating the normal physiologic leucocyte infiltration from an inflammatory process such as endometritis is sometimes difficult. However, most cases of endometritis have a substantially increased number of B lymphocytes compared with less than 1% in normal endometrial samples. Endometritis is often difficult to clinically diagnose. Pathologically, the process involves infiltration of normal architecture with neutrophils, plasma cells, and lymphocytes.
The following factors increase the risk for endometritis in general:
- Presence of an intrauterine device: The vaginal part of the device may serve as a track for the organisms to ascend into the uterus.
- Absence of the normal cervical mucus plug
- Presence of menstrual fluid in the uterus
- Associated cervicitis secondary to gonorrhea or chlamydia
- Associated bacterial vaginosis1,2
- Uterine instrumentation (eg, abortion, dilatation, curettage)
- Postpartum and postabortal states: These patients are particularly vulnerable because of the open nature of the cervical os, presence of large amounts of blood and debris, and instrumentation risks.
- Frequent douching
- Unprotected sexual activity
- Multiple sexual partners
- Cervical ectopy
- Cesarean delivery: Women with cesarean deliveries before 28 weeks' gestation appear to be especially high risk.
- Administration of multiple courses of corticosteroids to women at risk for premature delivery
During the postpartum period, risk factors include duration of labor, time of rupture of membranes prior to delivery, severely meconium-stained amniotic fluid, cesarean delivery, number of vaginal examinations during labor, manual placental removal,3 and postpartum anemia.
Frequency
United States
Postpartum endometritis occurs in fewer than 3% of vaginal deliveries and in 38.4% of emergency cesarean deliveries.
Mortality/Morbidity
Endometritis is associated with increased maternal mortality due to septic shock. However, mortality is rare in the United States because of aggressive antimicrobial management. The association between endometritis and reproductive morbidity was evaluated in the PID Evaluation and Clinical Health (PEACH) study.4 Endometritis was not found to be associated with increased risk of infertility or chronic pelvic pain.
Clinical
History
A pediatrician is most likely to witness pregnancy-related endometritis following a terminated pregnancy.
- In postpartum cases, patients present with fever, chills, lower abdominal pain, and foul-smelling lochia. Often, a history of prolonged rupture of membranes and prolonged labor is present. History of meconium-stained amniotic fluid5 or manual removal of placenta is more likely in patients with endometritis.
- Patients with pelvic inflammatory disease (PID) present with history of lower abdominal pain, vaginal discharge, dyspareunia, dysuria, fever, and other systemic signs. However, PID caused by chlamydia tends to be indolent, with no significant constitutional symptoms.
Physical
- Uterine tenderness is the hallmark of the disease. Adnexal tenderness may be elicited if associated salpingitis is present.
- Lochia may be foul smelling.
- An oral temperature of 38°C or higher within the first 10 days postpartum or 38.7°C within the first 24 hours postpartum is required to make the diagnosis.
- In severe cases, the patient may appear septic. Laboratory criteria are not reliable in patients with endometritis. Because of the physiologic changes associated with pregnancy, the presence of an elevated leukocyte count or neutrophil count does not indicate endometritis. Therefore, clinical findings are more reliable than laboratory findings in diagnosing postpartum endometritis.
- For PID, the minimum diagnostic criteria are lower abdominal tenderness, cervical motion tenderness, or adnexal tenderness.
Causes
- The etiology is polymicrobial; a mixture of aerobic and anaerobic organisms is usually found.
- Gram-positive cocci include Streptococcus agalactiae, Streptococcus viridans, Streptococcus faecalis, Staphylococcus aureus, and Staphylococcus epidermidis.
- Some severe cases have been associated with group A streptococcus.
- Gram-negative organisms include Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter aerogenes, Gardnerella vaginalis, and Neisseria gonorrhae.
- Chlamydia trachomatis and mycoplasmas such as Ureaplasma urealyticum may also be etiological agents.
- Anaerobes include Bacteroides bivius (most common), Peptococcus species, Peptostreptococcus species, and species of Bacteroides and Fusobacterium.
More on Endometritis |
 Overview: Endometritis |
| Differential Diagnoses & Workup: Endometritis |
| Treatment & Medication: Endometritis |
| Follow-up: Endometritis |
| References |
| Next Page » |
References
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Further Reading
Keywords
pelvic inflammatory disease, endometritis, PID, pregnancy-related endometritis, endometrium, fallopian tubes, salpingitis, ovaries, oophoritis, pelvic peritoneum, pelvic peritonitis, cervicitis, bacterial vaginosis, cesarean delivery, postpartum anemia, cervical ectopy, Streptococcus agalactiae, Streptococcus viridans, Streptococcus faecalis, Staphylococcus aureus, Staphylococcus epidermidis, Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter aerogenes, Gardnerella vaginalis, Neisseria gonorrhae, Chlamydia trachomatis, Ureaplasma urealyticum, Bacteroides bivius, Peptococcus, Peptostreptococcus, Bacteroides, Fusobacterium
