Postpartum endometritis

Background

• Any postpartum woman with fever should be assumed to have a genital tract infection
• Most often polymicrobial, requiring broad spectrum antibiotics

Risk Factors

• Cesarean delivery (most important)
• Prolonged labor
• Prolonged rupture of membranes
• Internal fetal or uterine monitoring
• Large amount of meconium in amniotic fluid
• Manual removal of placenta
• Diabetes Mellitus
• Preterm birth
• Bacterial vaginosis
• Operative vaginal delivery
• Post-term pregnancy
• HIV infection
• Colonization with Group B Strep

Evaluation

• Fever
• Foul-smelling lochia
• Leukocytosis
• Uterine tenderness
• Only scant discharge may be present (esp with group B strep)
• Evaluate for retained products of conception

Differential Diagnosis

• Respiratory tract infection
• UTI/urosepsis
• Pyelonephritis
• Intra-abdominal abscess
• Thrombophlebitis

3rd Trimester/Postpartum Emergencies

• Acute fatty liver of pregnancy
• Amniotic fluid embolus
• Chorioamnionitis
• Eclampsia
• HELLP syndrome
• Mastitis
• Peripartum cardiomyopathy
• Postpartum endometritis (postpartum PID)
• Postpartum headache
• Postpartum hemorrhage
• Preeclampsia
• Resuscitative hysterotomy
• Retained products of conception
• Septic abortion
• Uterine rupture

Management

Antibiotics

<48hrs Post Partum

Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora

• (Prefered first line) Clindamycin 900mg q8hrs PLUS Gentamicin 5mg/kg IV q24hours (same efficacy and more cost effective vs. 1.5mg/kg) or 1.5mg/kg IV q8hrs OR
• Doxycycline 100mg IV PO q12hrs daily PLUS
  • Ampicillin/Sulbactam 3g IV q6hrs
  • Cefoxitin 2g IV q6hrs daily

>48hrs Post Partum

• Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs daily
  • Use Metronidazole with caution in breastfeeding mothers its active is present in breast milk at concentrations similar to maternal plasma concentrations

Disposition

• Consult OB/GYN first if are considering outpatient management
• Admit all patients who appear ill, have had a C-section, or underlying comorbid conditions

See Also

• Post-Partum Emergencies

References

• Watts D et al. Bacterial vaginosis as a risk factor for post-cesarean endometritis. Obstet Gynecol. 1990 Jan; 75(1): 52-8.
• Smaill F et al. Antibiotic prophylaxis for cesarean section. Cochrane Database Syst Rev. 2002;(3):CD000933.