Endometritis

BY
TETTI SOLEHATI, SKP.,M.KEP
 A. INTRODUCTION
Background:

Endometritis is an infection of the

endometrium or decidua, with extension
into the myometrium and parametrial
tissues.
Endometritis is divided into obstetric and
nonobstetric endometritis.
 It is the most common cause of fever
during the postpartum period. Pelvic
inflammatory disease (PID) is a
common predecessor in the
nonobstetric population
 Pathophysiology:

Endometritis is infection of the endometrium

or decidua, with extension into the
myometrium and parametrial tissues.
Endometritis 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, PID 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,
such as chlamydia, tuberculosis, and bacterial
vaginosis, and the presence of intrauterine
device.
 Frequency:

In the US: Incidence varies depending on the

route of delivery and the patient population. After
a vaginal delivery, incidence is 1-3%. Following
cesarean delivery, incidence ranges from 13-
90%, depending on the risk factors present and
whether perioperative antibiotic prophylaxis had
been given.
.
 Mortality/Morbidity:
Infection of the genital tract is the most
common cause of puerperal morbidity.
Puerperal morbidity is defined as a
temperature of 100.4F (38C) or higher
occurring in any 2 of the first 10 days
postpartum, exclusive of the first 24 hours.
In the past, infection accounted for up to
16% of maternal mortality
 In the nonobstetric population,
concomitant endometritis may occur in up
to 70-90% of documented cases of
salpingitis.
 Age: This disorder affects females of
reproductive age
B. Definitions of Endometritis

Inflammation of the ENDOMETRIUM,

usually caused by intrauterine infections.
Endometritis is the most common cause of
postpartum fever.
Inflammation of the lining of the uterus (of
the endometrium)
 B. History
Diagnosis usually is based on clinical
findings.
Fever
Lower abdominal pain
Foul-smelling lochia in the obstetric
population
Abnormal vaginal bleeding
 Abnormal vaginal discharge
Dyspareunia (may be present in patients
with PID)
Dysuria (may be present in patients with
PID)
Malaise
 C.Physical

Fever, usually occurring within 36 hours of

delivery, in the obstetric population
Lower abdominal pain
Uterine tenderness
 Adnexal tenderness if there is an
associated salpingitis
Foul-smelling lochia
Tachycardia
 D. Causes

Endometritis is a polymicrobial disease

involving, on average, 2-3 organisms.
In the majority of cases, it arises from an
ascending infection from organisms found in the
normal indigenous vaginal flora.
Common isolated organisms include
Ureaplasma urealyticum, Peptostreptococcus,
Gardnerella vaginalis, Bacteroides bivius, 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.
Route of delivery is the most important
factor in the development of postpartum
endometritis
 Major risk factors include cesarean
delivery, prolonged rupture of membranes,
long labor with multiple vaginal
examinations, extremes of patient age,
and low socioeconomic status.
Minor contributing factors include maternal
anemia, prolonged internal fetal
monitoring, prolonged surgery, and
general anesthesia.
 Bacterial vaginosis has been associated
with endometritis after cesarean delivery
and with PID after first trimester elective
abortion
 E. Lab Studies

On complete blood count the

finding of leukocytosis may be
difficult to interpret, secondary to
the physiologic leukocytosis of
pregnancy.
 Blood culture is positive in 10-30% of
cases.
Urine culture should be ordered.
Endocervical cultures (or DNA probe)
are obtained for gonorrhea and
chlamydia
 F. Imaging Studies

Perform imaging studies on patients who

do not respond to adequate antimicrobial
therapy in 48-72 hours.
CT scanning of the abdomen and pelvis
may be helpful for excluding broad
ligament masses, septic pelvic
thrombophlebitis, ovarian vein thrombosis,
and phlegmon..
 Sonographic findings of the abdomen and
pelvis may be normal in patients with a
clinical diagnosis of endometritis.
Abnormal findings overlap with those of
retained products from conception and
intrauterine hematoma
 G. Procedures

Endometrial biopsy can be

obtained to assess chronic
endometritis in the nonobstetric
population
 H. TREATMENT

Medical Care: Most cases of

endometritis, including those following
cesarean delivery, should be treated
in an inpatient setting. For mild cases
following vaginal delivery, oral
antibiotics in an outpatient setting
may be adequate. .
 Combination intravenous
clindamycin and gentamicin
administered every 8 hours has
been considered the criterion
standard treatment. Recent
studies have revealed adequate
efficacy with daily dosing as well.
 Improvement is usually noted
within 48-72 hours in nearly 90%
of women. Parenteral therapy is
continued until the patient has
been afebrile for longer than 24
hours. Thereafter, oral antibiotics
are not usually necessary
 Surgical Care: Surgical
management is not usually
necessary in acute endometritis in
the obstetric population. Dilatation
and curettage may be advised for
retained products of conception,
however
 I. MEDICATION
After making the diagnosis of endometritis
and excluding other sources of infection,
broad-spectrum antibiotics should be
promptly initiated. Improvement will be
noted within 48-72 hours in nearly 90% of
women treated with an approved regimen.
For mild cases following vaginal delivery,
an oral agent may be adequate.
 Drug Category: Antibiotics -- A
combination therapy with clindamycin and
an aminoglycoside is considered the
criterion standard by which most antibiotic
clinical trials are judged
A combination regimen of ampicillin,
gentamicin, and metronidazole provides
coverage against most of the organisms
that are encountered in serious pelvic
infections.
 Doxycycline should be used if Chlamydia
is the cause of the endometritis.
Ampicillin sulbactam can be used as
monotherapy. Single-agent therapies have
been found to be efficacious in 80-90% of
patients
 J. Complications

Wound infection
Peritonitis
Adnexal infection
 Pelvic abscess
Pelvic hematoma
Septic pelvic
thrombophlebitis
 K. Prognosis

Nearly 90% of women

treated with an approved
regimen note improvement
in 48-72 hours.
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