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Postpartum
endometritis
Dr.F Mardanian MD
Postpartum endometritis
• infection of the decidua (ie,
pregnancy endometrium
• endomyometritis
• Parametritis
• C/S without ruptured membranes
#5-15% infection
• C/s + lengthy labor or ruptured
membranes  >30%
• oral temperature of
≥38.0°c on any two of the
first 10 days postpartum,
exclusive of the first 24
hours
MICROBIOLOGY
• polymicrobial
– GBS-ANAEROBIC STREPTOCOCCIAEROBIC G- BACILLI(E-coli-clebsiella
–proteus)
– 2.5 microbial agens are
contributed(mean)
– If C/S  anaerobics have a role
– 1/3 of infections after C/S 
clamydia
• the role of mycoplasmas in the
pathogenesis of endometritis is unclear.
RISK FACTORS
• Cesarean delivery is the most
important risk factor .
• rates of endometritis after nonelective
cesarean, elective cesarean, and vaginal
delivery are about 30%, 7%, and
less than 3%, respectively, in the
absence of antibiotic prophylaxis
Additional risk factors
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Prolonged labor
Prolonged rupture of membranes
Multiple cervical examinations
Internal fetal or uterine monitoring
Large amount of meconium in amniotic fluid
Manual removal of the placenta
Low socioeconomic status
Maternal diabetes mellitus or severe anemia
Preterm birth
Bacterial vaginosis
Operative vaginal delivery
Postterm pregnancy
HIV infection
Colonization with group B streptococcus
Pathology
• endometrium is :
oedematous
o Hyperemic
o marked inflammatory infiltrates of
the endometrial glands, primarily by
neutrophils.
CLINICAL
MANIFESTATIONS AND
DIAGNOSIS
 fever
 uterine tenderness occurring in a
postpartum woman.
 foul lochia
 chills
 lower abdominal pain
 uterus may be soft and subinvoluted, which
can lead to excessive uterine bleeding.
 Sepsis is an unusual presentation.
Differential diagnosis
Surgical site infection (cesarean
delivery incision, episiotomy incision,
perineal laceration).
Mastitis or breast abscess.
UTI .
Complications of anesthesia, such as
aspiration pneumonia .
Deep vein thrombosis and pulmonary
embolism.
Laboratory
• limited value
– elevated WBC supports the diagnosis,
but can be a normal finding in
postpartum women secondary to the
physiologic leukocytosis of pregnancy
and the effects of labor
– However, a rising neutrophil count
associated with elevated numbers of
bands is suggestive of an infectious
process
Cultures
• Testing for gonorrhea and chlamydia
• General endometrial cultures are
not performed routinely because
of the difficulty in obtaining an
uncontaminated specimen
through the cervix.
Imaging
• used primarily to search for other
causes of an initial postpartum fever
(eg, pneumonia, DVT, or PTE) or
persistent postpartum fever (eg,
abscess, ovarian vein thrombosis,
septic pelvic thrombophlebitis) in
patients refractory to 48 to 72 hours
of antimicrobial therapy.
Drug choice
• Clindamycin (900 mg-Q8h)
gentamicin (1.5 mg/kgQ8h)
cure rates are 90 to 97 percent
• Extended interval dosing of
gentamicin (5 mg/kg every 24
hours) is as efficacious and safe as
the thrice daily dosing .
• Drug treatments reported to be
equivalent to clindamycin plus
gentamicin include :
 cefotetan, cefoxitin, ceftizoxime,
cefotaxime, piperacillin with or without
tazobactam, and ampicillin/sulbactam
Duration
until the patient is
clinically improved and
afebrile for 24 to 48
hours.
Persistent postpartum
fever
•A response to the initial
antibiotic regimen should
be evident within 48 to 72
hours. Then further evaluation
is
indicated