Postpartum endometritis

Background

• Any postpartum woman with fever should be assumed to have a genital tract infection

Risk Factors

1. Cesarean delivery (most important)
2. Prolonged labor
3. Prolonged ROM
4. Internal fetal or uterine monitoring
5. Large amount of meconium in amniotic fluid
6. Manual removal of placenta
7. Diabetes Mellitus
8. Preterm birth
9. Bacterial vaginosis
10. Operative vaginal delivery
11. Post-term pregnancy
12. HIV infection
13. Colonization with Group B Strep

Diagnosis

1. Fever
2. Foul-smelling lochia
3. Leukocytosis
4. Uterine tenderness
5. Only scant discharge may be present (esp w/ group B strep)
6. Evaluate for retained products of conception

Differential Diagnosis

1. Respiratory tract infection
2. UTI/urosepsis
3. Pyelonephritis
4. Intra-abdominal abscess
5. 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 outpt management
• Admit all pts who appear ill, have had a C-section, or underlying comorbid conditions

See Also

• Post-Partum Emergencies

Source

• Tintinalli
• Rosen's
• Watts D et al. Bacterial vaginosis as a risk factor for post-cesarean endometritis. Obstet Gynecol. 1990 Jan; 75(1): 52-8.