Endometritis Clinical Presentation

Updated: Apr 25, 2019
  • Author: Michel E Rivlin, MD; Chief Editor: Michel E Rivlin, MD  more...
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Presentation

History

Diagnosis usually is based on clinical findings, as follows:

  • 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

In postpartum cases, patients present with fever, chills, lower abdominal pain, and foul-smelling lochia. Patients with PID present with 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.

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Physical Examination

Physical examination findings include the following:

  • 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

Uterine tenderness is the hallmark of the disease.

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 of postpartum endometritis. For PID, the minimum diagnostic criteria are lower abdominal tenderness, cervical motion tenderness, or adnexal tenderness. In severe cases, the patient may appear septic.

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Risk Factors

Women are particularly vulnerable to endometritis after birth or abortion. In both the postpartum and postabortal state, risk is increased because of the open cervical os, presence of large amounts of blood and debris, and uterine instrumentation.

Major risk factors for obstetric endometritis include the following:

  • Cesarean delivery (especially if before 28 weeks' gestation)

  • Prolonged rupture of membranes

  • Long labor with multiple vaginal examinations

  • Severely meconium-stained amniotic fluid

  • Manual placental removal [10]

  • Extremes of patient age

  • Low socioeconomic status

A study by Tuuli et al indicated that the risk of endometritis is significantly higher in cesarean deliveries performed during the second stage of labor (10 cm cervical dilation) than in those performed during the first stage (less than 10 cm dilation). Comparing 400 second-stage deliveries with 2105 first-stage procedures, the investigators found endometritis rates of 4.25% and 1.52%, respectively. A study by Asicioglu et al also found a higher endometritis rate, along with greater risk of other complications, in second-stage cesarean deliveries. [11, 12]

Minor risk factors include the following:

  • Absence of the normal cervical mucus plug

  • Administration of multiple courses of corticosteroids for prevention of premature delivery

  • Prolonged internal fetal monitoring

  • Prolonged surgery

  • Postpartum anemia

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

    • The intrauterine device as a factor in the etiology of pelvic inflammatory disease was associated with early forms of the device, in particular, the Dalkon Shield. The incidence of pelvic inflammatory disease is not higher in users of modern intrauterine devices than in non-users. [3, 4, 5]
  • Presence of menstrual fluid in the uterus

  • Associated cervicitis secondary to gonorrhea or Chlamydia infection

  • Associated bacterial vaginosis [13, 14]

  • Frequent douching

  • Unprotected sexual activity

  • Multiple sexual partners

  • Cervical ectopy

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Potential Complications

Potential complications of endometritis include the following:

Spread of infection from the endometrium to the fallopian tubes, ovaries, or the peritoneal cavity may result in salpingitis, oophoritis, localized peritonitis, or tubo-ovarian abscesses. Salpingitis subsequently leads to tubal dysmotility and adhesions that result in infertility, higher incidence of ectopic pregnancy, and chronic pelvic pain.

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