Endometritis 1

INTRODUCTION
Background: Endometritis is an infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. It is the most common cause of fever during the postpartum period.
Pathophysiology: It is infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues.
Frequency:
In the US: Incidence varies depending on the route of delivery and the patient population. After a vaginal delivery, incidence is 1-3%. Following cesarean delivery, incidence ranges from 13-90%, depending on the risk factors present and whether perioperative antibiotic prophylaxis had been given.
Mortality/Morbidity:
Infection of the genital tract is the most common cause of puerperal morbidity.
Puerperal morbidity is defined as a temperature of 100.4°F (38°C) or higher occurring in any 2 of the first 10 days postpartum, exclusive of the first 24 hours.
In the past, infection accounted for up to 16% of maternal mortality.
Age:
This disorder affects females of reproductive age. CLINICAL
History: Diagnosis usually is based on clinical findings.
Fever
Lower abdominal pain
Foul-smelling lochia
Physical:
Fever, usually occurring within 36 hours of delivery
Lower abdominal pain
Uterine tenderness
Foul-smelling lochia
Malaise
Tachycardia
Causes:
Endometritis is a polymicrobial disease involving, on average, 2-3 organisms.
In the majority of cases, it arises from an ascending infection from organisms found in the normal indigenous vaginal flora.
Common isolated organisms include Ureaplasma urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides bivius, and group B Streptococcus.
Chlamydia has been associated with late-onset postpartum endometritis.
Enterococcus is identified in up to 25% of women who have received cephalosporin prophylaxis.
Route of delivery is the most important factor in the development of postpartum endometritis.
Major risk factors include cesarean delivery, prolonged rupture of membranes, long labor with multiple vaginal examinations, extremes of patient age, and low socioeconomic status.
Minor contributing factors include maternal anemia, prolonged internal fetal monitoring, prolonged surgery, and general anesthesia. DIFFERENTIALS
Appendicitis
Other Problems to be Considered:
PyelonephritisViral syndromePelvic thrombophlebitis WORKUP
Lab Studies:
Complete blood count: The finding of leukocytosis may be difficult to interpret, secondary to the physiologic leukocytosis of pregnancy.
Blood culture is positive in 10-30%.
Urine culture should be ordered.
Imaging Studies:
Perform imaging studies on patients who fail to respond to adequate antimicrobial therapy in 48-72 hours.
CT scan of the abdomen and pelvis may be helpful for excluding broad ligament masses, septic pelvic thrombophlebitis, ovarian vein thrombosis, and phlegmon.
Sonogram of abdomen and pelvis
Sonographic findings may be normal in patients with a clinical diagnosis of endometritis.
Abnormal findings overlap with those of retained products from conception and intrauterine hematoma. TREATMENT
Medical Care: 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.