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Introduction

Postpartum endometritis is a term used to describe inflammation (usually due to infection) in the uterus. It typically due to pregnancy, and can occur up to 6 weeks after delivery. It is more common after caesarian section.

  • There is also a non-pregnancy related type of endometritis – although there is debate as to whether this is its own condition, or part of the spectrum that also includes PID.
  • Normally when referring the¬†endometritis¬†we are referring to the pregnancy related variant – which is typically associated with pelvic inflammatory disease. Unless otherwise specified, this is the type referred to in this article.

It is thought that infection arises from the genital tract and travels up to the uterus, and can also progress onto the ovaries and fallopian tubes Рcausing saplingo-oophpritis.

  • It is typically caused by the bugs that live in the lower genital tract, such as:
    • Group B Streptococcus
    • Peptostreptococcus
    • E. Coli
    • Klebsiella

Endometritis can be acute or chronic.

Epidemiology

  • Occurs in 1-3% of vaginal births, but¬†25% of caesarian sections
    • Greater risk if HIV-positive
  • Prophylactic antibiotics reduce the risk by 60-70%
    • All women undergoing caesarian section should receive¬†prophylactic¬†antibiotics and vaginal cleaning with a¬†povisdone-iodine solution.
    • Neither of these things is recommended for women with vaginal delivery

Aetiology

  • Usually 2 or 3 different organisms are involved in the infection, often a mix of both¬†aerobic¬†and¬†anaerobic¬†bacteria
  • Common organisms include:
    • Gram positive –¬†Staph aureus,¬†Group A and Group B¬†streptococcus
    • Gram negative –¬†E. Coli, Klebsiella, chalmydia, enterobacter, Neisseria
    • Anaerobic –¬†bacteroides, Peptostreptococcus
  • Risk factors:
    • HIV
    • Prolonged rupture of membranes
    • Severe meconium staining
    • Long labour
    • Retained products of conception
    • Obesity
    • Maternal anaemia
    • Diabetes
    • History of previous pelvic infection
    • Bacterial vaginosis
    • Group B strep infection

Pathophysiology

  • Usually, the uterus is sealed-off from the lower genital tract (vagina and cervix) by a mucus plug in the cervix
  • This creates both a physical barrier, and also has antibiotic properties
  • In normal delivery during labour, the mucus plug is passed through the cervix into the vagina around the same time that the membranes rupture
  • It is around this time that bacteria may enter the uterus and cause endometritis
  • As such, certain conditions around labour increase the risk of endometritis. These include:
    • Prolonged rupture of membranes (PROM) / prolonged labour
    • Retained products (of pregnancy)
    • Caesarian section

Presentation

  • Fever
  • Pelvic pain
  • Offensive vaginal discharge
    • Lochia” is the name given to the physiological vaginal discharge seen after pregnancy
    • In endometritis – this often becomes purulent and foul smelling
  • PV bleeding (postpartum haemorrhage)
  • Dyspareunia
  • Dysuria
  • Tachycardia

It can also exists in a chronic form:

  • Often asymptomatic
  • May occasionally present with features of the acute presentation

Late onset endometritis is defined at >7 days since delivery

  • Accounts for about 15% of cases
  • More likely to be due to chlamydia

Investigations

Typically a clinical diagnosis. Investigations may support the diagnosis, or an endometrial biopsy can be definitive but is rarely required.

  • FBC (raised WCC)
  • Blood culture
  • MSU
  • High vaginal swab for chlamydia / gonorrhoea
  • Endometrial biopsy is occasionally performed
    • Will typically show neutrophil (or in chronic cases, plasma cell) infiltration into the endometrium
  • USS is not usually useful but often performed as it may rule out other differentials –¬†and can usually see retained products if present

Differential Diagnosis

Management

  • Antibiotics
    • Local guidelines vary – consult yours for most accurate information
    • Typical regimen might include¬†clindamycin¬†and/or¬†gentamicin.¬†For example eTG Australia recommends:
      • Gentamicin 3-5mg/Kg, PLUS
      • Metronidazole 500mg IB BD, PLUS
      • Amp/amoxicillin 2g IV QID
    • Or, in penicillin allergy:
      • Gentamicin 3-5mg/Kg IV
      • Clindamicin 600mg IV TDS
    • In those suitable for oral treatment, co-amoxiclav (augmentin) may be used
  • Usually hospital admission and IV antibiotics are required
    • Presence of fever, tachycardia, hypotension or other abnormal vital signs usually indicate the need for hospital admission
  • Patients usually improve rapidly – within 48-72 hours
  • In mild cases, patients may be treated as an outpatient with amoxicillin + clavulanate 875 + 125mg (co-amoxiclav / augmentin) PO BD for 7 days
  • Dilation and curettage (D&C)
    • May be required if there are any retained products
    • A procedure where a curette is inserted into the uterus via the vagina and is used to remove retained profits of pregnancy

Complications

  • Sepsis
  • Peritonitis
  • Pelvic absces
  • Haematoma

Non-pregnancy related endometritis

  • Typical causes might include chlamydia, gonorrhoea or TB
  • Often asymptomatic
  • Often associated with PID
  • In chronic endometritis – often causes by TB,¬†Asherman’s syndrome¬†can result.
    • This causes fibrosis, scarring and adhesions of the endometrium, which can prevent the normal endometrial response to hormonal changes (and amenorrhoea), and can completely obliterate the endometrial cavity – both of which can cause infertility

References

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