266
SECTION VIII  •  Uterine Pathology
129  ENDOMETRITIS
INTRODUCTION
Description: Endometritis is an acute or chronic inflammation,
usually of infectious origin, of the lining of the uterus. This is a
general term that is used for this condition in either nonpregnant
or recently pregnant patients; chorioamnionitis or endomyome-
tritis are the terms commonly used for pregnant patients. Chronic
endometritis is often characterized as an intermediate state in
ascending infections.
Prevalence: 75% of patients with pelvic inflammatory disease; 40%
of patients with mucopurulent cervicitis.
Predominant Age: Reproductive age.
Genetics: No genetic pattern.
ETIOLOGY AND PATHOGENESIS
Causes: Aseptic inflammation of the endometrium is commonly
found in users of intrauterine contraceptive devices (IUCDs).
Infection by organisms ascending from the cervix and lower tract
are common (most often Chlamydia trachomatis, Neisseria gon-
orrhoeae, Ureaplasma urealyticum, and Streptococcus agalactiae).
Less common are infections by Actinomyces israelii or
tuberculosis.
Risk Factors: IUCD use, intrauterine instrumentation (biopsy,
hysterosalpingography), cervicitis, sexually transmitted infection
(STI), retained products of conception.
SIGNS AND SYMPTOMS
• Asymptomatic
• Dysfunctional uterine bleeding (typically intermenstrual)
• Postcoital bleeding
• Foul-smelling cervical/vaginal discharge
• Pelvic inflammatory disease
• Chronic pelvic pain
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• Tubo-ovarian abscess
• Infertility (rare cause)
DIAGNOSTIC APPROACH
Differential Diagnosis
• Accidents of pregnancy
• Trophoblastic disease
• Endometrial cancer
• Estrogen-producing tumors or exogenous estrogen
• Leiomyomata
• Cervical lesion/cervicitis
• Forgotten IUCD
Associated Conditions: Chronic pelvic pain, tubo-ovarian abscess,
cervicitis, and STI.
Workup and Evaluation
Laboratory: Complete blood count, cervical cultures for C. tracho-
matis and N. gonorrhoeae. Tests for other STIs as indicated.
Imaging: No imaging indicated. Ultrasonography with saline con-
trast may demonstrate a thickened endometrium but risks
spreading an infection to the fallopian tubes, ovaries, and perito-
neal cavity. Consequently, this should be reserved until the pos-
sibility of active infection has been evaluated.
Special Tests: Endometrial biopsy is generally confirmatory.
Diagnostic Procedures: Endometrial biopsy and culture.
Pathologic Findings
Inflammatory infiltrates (monocytes and plasma cells) in the basal
layers and stroma of the endometrium. Acute endometritis—
microabscesses or neutrophils within the endometrial glands.
Chronic endometritis—variable numbers of plasma cells within the
 129  •  Endometritis 267

5
5

Parametritis with abscess

(dissection from behind)
Parametritis

1
3 2
4

Dissemination of septic endometritis:

(1) Peritonitis
gonorrheal (2) Parametritis (via lymphatics)
nongonorrheal (3) Pelvic thrombophlebitis
(generally puerperal, (4) Femoral thrombophlebitis
Pathways of gonorrheal and (5) Pulmonary infarct or abscess (septic embolus)
postabortal, or traumatic) nongonorrheal infection

Figure 129.1  Endometritis: parametritis and septic endometritis

endometrial stroma. Sulfur granules may be present in Actinomyces Alternative Drugs

infections.
Metronidazole or erythromycin may be substituted for
MANAGEMENT AND THERAPY doxycycline.
Nonpharmacologic
FOLLOW-UP
General Measures: Evaluation, counseling about STIs (cervicitis).
Specific Measures: Antibiotic therapy (see later), removal of IUCD Patient Monitoring: Normal health maintenance, screening for
(if present). STIs as needed.
Diet: No specific dietary changes indicated. Prevention/Avoidance: Reduce risk of cervicitis or STIs, asepsis
Activity: Pelvic rest (no tampons, douches, or intercourse) until during intrauterine procedures.
therapy has been completed. Possible Complications: Ascending infection resulting in salpingi-
Patient Education: American College of Obstetricians and Gyne- tis, tubo-ovarian abscesses, hydrosalpinx, peritonitis, and chronic
cologists Patient Education Pamphlet AP095 (Abnormal Uterine pelvic pain.
Bleeding), AP099 (Chronic Pelvic Pain), and AP077 (Pelvic Expected Outcome: Good with treatment.
Inflammatory Disease).
MISCELLANEOUS
Drug(s) of Choice Pregnancy Considerations: Generally not applicable. U. urealyti-
Doxycycline (Vibramycin) 200 mg PO initially, 100 mg PO daily for cum infection has been implicated as a rare cause of early preg-
10 days. If Actinomyces is found in a tubo-ovarian abscess, oral nancy loss.
penicillin therapy should be continued for 12 weeks. ICD-10-CM Codes: N71.0 (Acute inflammatory disease of uterus)
Contraindications: Known or suspected allergy to tetracycline. and N71.1 (Chronic inflammatory disease of uterus). Codes for
Precautions: Photosensitivity may occur in patients taking infections following pregnancy are specific to trimester and other
doxycycline. factors.
Interactions: Doxycycline may enhance the effect of warfarin.
Doxycycline absorption is inhibited by most antacids and bismuth
subsalicylate (Pepto-Bismol).

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REFERENCES
LEVEL I
Starr RV, Zurawski J, Ismail M. Preoperative vaginal preparation with
povidone-iodine and the risk of postcesarean endometritis. Obstet
Gynecol. 2005;105:1024.
Sullivan SA, Smith T, Chang E, et al. 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;196:455.e1.
LEVEL III
American College of Obstetricians and Gynecologists. Antibiotic prophy-
laxis for gynecologic procedures. ACOG Practice Bulletin No. 104.
Obstet Gynecol. 2009;113:1180.
American College of Obstetricians and Gynecologists. Use of prophylactic
antibiotics in labor and delivery. Practice Bulletin No. 120. Obstet
Gynecol. 2011;117:1472.
Crossman SH. The challenge of pelvic inflammatory disease. Am Fam
Physician. 2006;73:859.

LEVEL II
Ness RB, Hillier SL, Kip KE, et al. Bacterial vaginosis and risk of pelvic
inflammatory disease. Obstet Gynecol. 2004;104:761.

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For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved.