Endometritis

Taylor M, Pillarisetty LS.

Publication Details

Continuing Education Activity

Endometritis is inflammation of the uterine lining. It can affect all layers of the
uterus. The uterus is typically aseptic. However, the travel of microbes from the
cervix and vagina can lead to inflammation and infection. This activity describes
the background, typical clinical presentation, diagnosis, treatment, and possible
complications of endometritis. It specifically highlights the role of the healthcare
team in treating this disease.
Objectives:

• Identify the etiology and epidemiology of endometritis.

• Describe how to perform appropriate history, physical, and evaluation of a patient
with endometritis.
• Review the treatment and management options available for patients with
endometritis.
• Summarize interprofessional team strategies for improving care coordination and
communication to better diagnose and treat endometritis.

Access free multiple choice questions on this topic.

Introduction
Endometritis is inflammation of the uterine lining. It can affect all layers of the
uterus. The uterus is typically aseptic. However, the travel of microbes from the
cervix and vagina can lead to inflammation and infection. This condition usually
occurs as a result of the rupture of membranes during childbirth. Endometritis is the
most common postpartum infection. Puerperal endometritis is 25 times more
common in patients that underwent cesarean sections. Most cases of postpartum
endometritis are polymicrobial, involving aerobic and anaerobic bacteria.

Etiology
Endometritis results from the travel of normal bacterial flora from the cervix and
vagina. The uterus is sterile until the amniotic sac ruptures during childbirth.
Bacteria is more likely to colonize uterine tissue that has been devitalized, bleeding,
or otherwise damaged (such as during a cesarean section).[1]
Between 60% and 70% of infections are due to both aerobes and
anaerobes. Examples of anaerobic
species are Peptostreptococcus, Peptococcus, Bacteroides, Prevotella,
and Clostridium. Examples of aerobic species are
primarily groups A and B Streptococci, Enterococcus, Staphylococcus, Klebsiella
pneumoniae, Proteus species, and Escherichia coli. Uterine tissue damaged by
cesarean section is particularly susceptible to Streptococcus
pyogenes and Staphylococcus aureus. Chlamydia endometritis often presents at a
later date, seven or more days postpartum.[2][3]

Epidemiology
Puerperal endometritis is the most common postpartum infection.[4] In patients
without risk factors, following normal spontaneous vaginal delivery, there is an
incidence of 1% to 2%. Risk factors, however, can increase this rate to a 5% to 6%
risk of infection following vaginal delivery. Risk factors include chorioamnionitis,
low socioeconomic status, prolonged labor, membrane rupture, multiple cervical
examinations, internal fetal monitoring, young maternal age, nulliparity, obesity,
meconium-stained amniotic fluid, and bacterial colonization of the lower genital
tract with bacteria such as Group B streptococcus (GBS), Chlamydia
trachomatis, Mycoplasma hominis, Ureaplasma urealyticum, or Gardnerella
vaginalis. The route of delivery is the most significant risk factor for endometritis,
with cesarean deliveries (especially for multifetal gestation) having a much higher
likelihood of leading to endometritis and a 25-fold increase in infection-related
mortality.[5][6]

Pathophysiology
Most cases of endometritis result from childbirth. Specifically, the rupture of the
amniotic sac allows the translocation of normal bacterial flora from the cervix and
vagina to the usually aseptic uterus. This bacteria is more likely to colonize uterine
tissue that has been devitalized, bleeding, or otherwise damaged (such as during a
cesarean section). This bacteria can invade the endometrium-, myometrium-, and
perimetrium, causing inflammation and infection.

History and Physical

Patients with endometritis often have fever as their first sign of infection. Additional
common complaints are abdominal pain (commonly suprapubic in location), foul-
smelling and purulent lochia. Like many infections, the grade of the fever is often
indicative of the severity of the infection. On physical exam, suprapubic and uterine
tenderness are often present on abdominal and pelvic exams, respectively. Vital sign
abnormalities such as fever, tachycardia, and hypotension may also be present.
Endometritis caused by Group A streptococcus is often particularly severe, resulting
in a clinical picture consisting of sepsis, diarrhea, pain out of proportion. This
condition
can quickly develop into toxic shock and necrotizing fasciitis, so great care is
necessary when looking after such patients.
 Evaluation
Endometritis is primarily a clinical diagnosis based on the history, physical, and
presence of risk factors. In equivocal cases or to establish the severity of infection,
laboratory and imaging evaluation can be helpful.
A leukocytosis of 15000 to 30000 cells/microL is common. Vaginal delivery, and
cesarean section particularly, however, can cause inflammatory leukocytosis. The
CBC, therefore, is just one set of values in the greater clinical picture that will help
aid the correct diagnosis. Cervical cultures obtained before antibiotic administration
can be helpful for appropriate antibiotic selection. Vaginal cultures are often
contaminated and can mislead providers to inadequate antibiotic coverage. Blood
cultures should be obtained if there is a high enough clinical suspicion for sepsis
and/or bacteremia.
For imaging, ultrasound often helps rule out other diagnoses in the postpartum
patient with abdominal pain and fever. Such diagnoses include retained products of
conception, infected hematoma, and uterine abscesses. For patients with
endometritis, findings consist of a thickened, heterogeneous endometrium,
intracavitary fluid, and foci of air. However, some of these findings may be present
as normal variants, so a good clinical acumen is necessary when comparing
ultrasound results to other diagnostic findings. For instance, up to 24% of normal
postpartum patients may have clots and debris in the uterus. Gas in the endometrium
may also be normal for up to 3 weeks postpartum. Conversely, patients with
endometritis may have a normal pelvic ultrasound. Computed tomography can show
the same positive findings as ultrasound plus possible perimetrium and/or
intrauterine inflammation and infection.[7][8][9][10]

Treatment / Management
The threshold for obstetrics should be low in any provider considering a diagnosis
of endometritis. Oral antibiotic regimens are an option for mild disease. The options
are similar to those used for pelvic inflammatory disease:

• Doxycycline 100 mg every 12 hours + metronidazole 500 mg every 12 hours.

Doxycycline is not contraindicated in breastfeeding mothers if its use is for less than
three weeks.
• Levofloxacin 500 mg every 24 hours + metronidazole 500 mg every 8 hours.
Levofloxacin should be avoided in breastfeeding mothers.

• Amoxicillin-clavulanate 875 mg/125 mg every 12 hours.[11]

For patients with moderate to severe endometritis and/or patients with endometritis
s/p cesarean section, intravenous antibiotics and admission are recommended.
Options are as follows:

• Gentamicin 1.5 mg/kg IV every 8 hours or 5 mg/kg IV every 24 hours

and clindamycin 900 mg every 8 hours.
o QD gentamicin dosing is associated with a shorter hospitalization time compared
with TID and has been shown to be just as effective.
o There is no adequate data regarding the effects of this regimen on breastfeeding
infants or the effect of gentamicin on maternal renal function.
• For patients with endometritis due to GBS resistance to clindamycin, piperacillin-
tazobactam and ampicillin-sulbactam may be used.[12][13]

Clinical improvement in response to antibiotics typically occurs in 48 to 72 hours.

If there is no clinical improvement within 24 hours, providers should consider
adding ampicillin 2 g initially, followed by 1 g every 4 hours for
enhanced Enterococcus coverage. For those that do not improve within 72 hours,
providers should broaden their differential diagnosis to include other infections such
as pneumonia, pyelonephritis, pelvic septic thrombophlebitis. IV antibiotics should
continue until the patient becomes afebrile for at least 24 hours in addition to an
improvement in the patient’s pain and leukocytosis. At this time, there is no
substantial evidence demonstrating that continuing antibiotics in PO form following
such clinical improvement improves significant patient-oriented outcomes.[14]

Differential Diagnosis
In the patient with postpartum fever and abdominal pain, diagnoses other than
endometritis that merit consideration include urinary tract infections (including
pyelonephritis), pneumonia, septic pelvic thrombophlebitis. The clinician should
keep an open mind to these diagnoses, especially if antibiotic and/or surgical
management for endometritis is not leading to clinical improvement.

Prognosis
If untreated, the fatality rate of endometritis is approximately 17%. Thankfully this
is reduced to 2% with proper recognition and treatment. Cesarean deliveries
(especially for multifetal gestation) have a 25-fold increase in infection-related
mortality.[11]

Complications
Approximately 1% to 4% of patients will have complications such as sepsis,
abscesses, hematomas, septic pelvic thrombophlebitis, and necrotizing
fasciitis. Such complications can then lead to uterine necrosis, requiring a
hysterectomy for infection resolution. Surgical intervention may also be necessary
if the infection has produced a drainable fluid collection.[6]

Deterrence and Patient Education

Due to the increased prevalence and mortality of endometritis secondary to cesarean
sections, ACOG recommends prophylactic antibiotics before cesarean deliveries. A
recent Cochrane review showed a significant reduction in the risk of postpartum
infections, including endometritis, when such antibiotics were given. Furthermore,
obstetricians should have a thoroughly informed consent conversation regarding the
cesarean section, specifically including the risks of postpartum infections. Risks and
benefits regarding vaginal vs. cesarean delivery should undergo review, and the
patient should make a properly-educated decision.
 Pearls and Other Issues
• Endometritis is an inflammation and infection of the uterus.
• Postpartum endometritis is the most common postpartum infection.
• Fever is the most common symptom. Abdominal pain, vaginal bleeding, and vaginal
discharge in febrile postpartum patients should raise clinical suspicion for this
diagnosis.
• Early identification and obstetric consultation are essential.
• The severity of the disease can vary. If necessary, resuscitation, including early
antibiotic administration, should be the primary focus.

Enhancing Healthcare Team Outcomes

Endometritis is the most common postpartum infection. Disease severity can range
from mild to severe, with treatment regimens ranging from outpatient PO antibiotics
with adequate obstetrics follow-up and return precautions to inpatient
hospitalization with IV antibiotics and surgery (e.g., hysterectomy, fluid drainage).
Patients will often present to generalists: non-obstetrics primary care providers,
urgent care centers, and emergency departments. Early obstetric consultation is
critical. Such a consult can help aid efficient and appropriate diagnostics and
treatment. If imaging is needed, ultrasonographers, radiology technicians, and
diagnostic radiologists may all prove useful. This is why an interprofessional team
approach to patient care is necessary. For ideal antibiotic choice, dosing, and
administration, a clinical pharmacist may help validate antimicrobial therapy
against the latest antibiogram data, check for interactions, and alert the staff to the
potential adverse effects. If operative intervention is required, an anesthesiologist is
also necessary for a successful surgery.
To ensure that a patient with endometritis receives optimal care, an effective
interprofessional approach is crucial. Prompt involvement of appropriate specialists
and strong communication between providers can make a significant difference in
the patient's clinical course, morbidity, and mortality. Obstetrical nurses should
promptly report fevers to the managing providers, administer treatment, and educate
patients. With interprofessional collaboration, patient outcomes will improve.
[Level 5]

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References
1.
Sherman D, Lurie S, Betzer M, Pinhasi Y, Arieli S, Boldur I. Uterine flora at
cesarean and its relationship to postpartum endometritis. Obstet
Gynecol. 1999 Nov;94(5 Pt 1):787-91. [PubMed]
2.
Morgan J, Roberts S. Maternal sepsis. Obstet Gynecol Clin North Am. 2013
Mar;40(1):69-87. [PubMed]
3.
Dalton E, Castillo E. Post partum infections: A review for the non-
OBGYN. Obstet Med. 2014 Sep;7(3):98-102. [PMC free article] [PubMed]
4.
Chaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M. Prevalence
and clinical significance of postpartum endometritis and wound
infection. Infect Dis Obstet Gynecol. 2000;8(2):77-82. [PMC free article]
[PubMed]
5.
Boggess KA, Tita A, Jauk V, Saade G, Longo S, Clark EAS, Esplin S, Cleary
K, Wapner R, Letson K, Owens M, Blackwell S, Beamon C, Szychowski JM,
Andrews W., Cesarean Section Optimal Antibiotic Prophylaxis Trial
Consortium. Risk Factors for Postcesarean Maternal Infection in a Trial of
Extended-Spectrum Antibiotic Prophylaxis. Obstet Gynecol. 2017
Mar;129(3):481-485. [PMC free article] [PubMed]
6.
Karsnitz DB. Puerperal infections of the genital tract: a clinical review. J
Midwifery Womens Health. 2013 Nov-Dec;58(6):632-42. [PubMed]