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I. DEFINITION  It is the inflammation of the endometrial lining of the uterus. In addition to the endometrium, inflammation may involve the myometrium and, occasionally, the parametrium. II. ETIOLOGY  Endometritis is a polymicrobial disease involving, on average, 2-3 organisms. In most cases, it arises from an ascending infection from organisms found in the normal indigenous vaginal flora.  Commonly isolated organisms or the causes include Ureaplasmaurealyticum, Peptostreptococcus, Gardnerellavaginalis, Bacteroidesbivius, and group B Streptococcus. Chlamydia has been associated with late-onset postpartum endometritis. Enterococcus is identified in up to 25% of women who have received cephalosporin prophylaxis. III. PATHOPHYSIOLOGY y Infection of the endometrium, or decidua, usually results from an ascending infection from the lower genital tract. From a pathologic perspective, endometritis can be classified as acute versus chronic. Acute endometritis is characterized by the presence of neutrophils within the endometrial glands. Chronic endometritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stroma. In the nonobstetric population, pelvic inflammatory disease and invasive gynecologic procedures are the most common precursors to acute endometritis. In the obstetric population, postpartum infection is the most common predecessor. Chronic endometritis in the obstetric population is usually associated with retained products of conception after delivery or elective abortion. In the nonobstetric population, chronic endometritis has been seen with infections (eg, chlamydia, tuberculosis, bacterialvaginosis) and the presence of an intrauterine device.

IV. PREDISPOSING FACTORS


y y y y

Cesarean delivery (especially if before 28 weeks' gestation) Prolonged rupture of membranes Long labor with multiple vaginal examinations Severely meconium-stained amniotic fluid

y y y y

Manual placental removal Extremes of patient age Low socioeconomic status Associated cervicitis secondary to gonorrhea or Chlamydia infection

V. LABORATORY TESTS y y y y Inspection of the perineum for evidence of vaginal discharge Manual or speculum examination of the vagina Slightly enlarged reproductive tracts or slightly abnormal discharge at 30 days post partum Following test may be performed:  Endometrial biopsy  ESR  WBC  CBC  Blood cultures  Urine culture y DNA probe for GC/chlamydia  Imaging studies if no response to adequate abx in 48-72h y CT scan abd/pelvis y US abd/pelvis

VI. SIGNS AND SYMPTOMS y y y y y y y Chills and fever Increased pulse Decrease appetite Headache Backache Prolonged afterpains Tender, large uterus y y y Foul odor to lochia or reddishbrown lochia Ileus Elevated white blood cell count with a left shift and immature formed cells

VII. MANAGMENT A. Pharmacologic management y Prophylaxis Prophylactic antibiotics reduce the incidence of postpartum febrile morbidity in patients undergoing cesarean delivery. y Broad spectrum IV abx Clindamycin 900mg IV q8h and Gentamicin 1.5mg/kg IV q8h y Treat until afebrile for 24-48h and clinically improved; oral therapy not necessary y Add ampicillin 2g IV q4h to regimen when not improving to cover resistant enterococci B. Surgical management Is not usually necessary in acute endometritis in the obstetric population. Dilation and curettage may be advised for retained products of conception

C. Nursing management
To prevent infection:  Always adhere to standard precautions  Maintain sterile technique when assisting with or performing a vaginal examination  Limit the number of vaginal examinations performed during labor  Thoroughly wash your hands after each patient contact  Instruct the pregnant patient to call her health care provider immediately when her membranes rupture  Warn the patient to avoid intercourse after rupture or leak of the amniotic sac  Keep the episiotomy site clean and teach patient how to maintain good perineal hygiene  Screen personnel and visitors to keep persons with active infrections away from the maternity patients If the postpartum develops infection:       Monitor vital signs every 4 hours Closely assess intake and output Enforce strict bedrest Frequently inspect perineum Assess and document the type, degree and location of pain Administer an antibiotic or analgesics as ordered.

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