Postpartum Endometritis

Epidemiology

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Risk Factors for Postpartum Endometritis

Chorioamnionitis (Intra-Amniotic Infection) (see Intra-Amniotic Infection)
Heavy Vaginal Escherichia ColiColonization (see Escherichia Coli)
Human Immunodeficiency Virus (HIV) (see Human Immunodeficiency Virus)
Internal Fetal or Uterine Monitoring
Large Amount of Meconium in Amniotic Fluid
Low Socioeconomic Status
Manual Removal of the Placenta
Maternal Diabetes Mellitus (see Diabetes Mellitus)
Maternal Severe Anemia (see Anemia)
Multiple Cervical Examinations
Nasal Carriage of Staphylococcus Aureus (see Staphylococcus Aureus)
Operative Vaginal Delivery
Postterm Pregnancy
Preterm Birth
Prolonged Labor
Prolonged Rupture of Membranes
Vaginal Streptococcus Agalactiae (Group B Streptococcus) Colonization (see Streptococcus Agalactiae)

Microbiology

General Comments
- Most Cases are Polymicrobial: involving 2-3 aerobic and/or anaerobic organisms from the genital tract
  - In One Series, >70% of Cases Had More than One Organism Isolated (J Infect Dis, 1986) [MEDLINE]: 60% of the isolates were facultative Gram-positive and Gram-negative bacteria, 40% were anaerobes, and 30% were Mycoplasma species
Bacteroides Bivius (see Bacteroides Bivius)
Chlamydia Trachomatis (see Chlamydia Trachomatis)
- Epidemiology
  - Chlamydia Trachomatis is an Uncommon Etiology of Postpartum Endometritis: however, it is a common etiology of endometritis unassociated with pregnancy (see Acute Endometritis)
  - Chlamydia Trachomatis is Associated with Late-Onset Postpartum Endometritis (Occurring ≥2 wks Postpartum) (J Reprod Med, 1987) [MEDLINE]
Clostridium Perfringens (see Clostridium Perfringens and Necrotizing Soft Tissue Infection)
- Prognosis: high mortality rate
Clostridium Sordellii (see Clostridium Sordellii and Necrotizing Soft Tissue Infection
- Prognosis: high mortality rate
Cytomegalovirus (CMV) (see Cytomegalovirus)
- Epidemiology
  - CMV is a Rare Etiology of Postpartum Endometritis
  - CMV Endometritis May Occur in Patients with HIV Infection (see Human Immunodeficiency Virus)
Enterococcus (see Enterococcus)
Gardnerella Vaginalis (see Gardnerella Vaginalis)
Herpes Simplex Virus (HSV) (see Herpes Simplex Virus)
- Epidemiology
  - HSV is a Rare Etiology of Postpartum Endometritis
  - HSV Endometritis May Occur in Patients with HIV Infection (see Human Immunodeficiency Virus)
Mycoplasma (see Mycoplasma)
- Epidemiology: although Mycoplasma species are often isolated from the endometrial cavity, their role in causing endometritis is currently unclear
Neisseria Gonorrhoeae (see Neisseria Gonorrhoeae)
- Epidemiology
  - Neisseria Gonorrhoeae is an Uncommon Etiology of Postpartum Endometritis: however, it is a common etiology of endometritis unassociated with pregnancy (see Acute Endometritis)
Peptostreptococcus (see Peptostreptococcus)
Staphylococcus (see Staphylococcus)
- General Comments
  - Prognosis: high mortality rate
- Staphylococcus Aureus (see Staphylococcus Aureus)
- Staphylococcus Lugdunensis (see Staphylococcus Lugdunensis)
Streptococcus (see Streptococcus)
- General Comments
  - Prognosis: high mortality rate
- Streptococcus Agalactiae (Group B) (see Streptococcus Agalactiae and Necrotizing Soft Tissue Infection
- Streptococcus Pyogenes (Group A) (see Streptococcus Pyogenes and Necrotizing Soft Tissue Infection
Ureaplasma Urealyticum (see Ureaplasma Urealyticum)

Physiology

Ascending Infection from Vaginal Canal: most cases

Diagnosis

Complete Blood Count (CBC) (see Complete Blood Count)

Leukocytosis (see Leukocytosis): non-specific (since leukocytosis may be normally observed in postpartum period)

Serum Lactate (see Serum Lactate)

May Be Elevated in Patients with Severe Postpartum Endometritis

Abdominal-Pelvic Ultrasound (see Abdominal-Pelvic Ultrasound)

No Characteristic Findings (Acta Obstet Gynecol Scand, 2007) [MEDLINE]

Abdominal-Pelvic CT (see Abdominal-Pelvic Computed Tomography)

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Clinical Manifestations

General Comments

Time Course of Illness is Variable, Depending on the Microbiologic Etiology and the Time of Infection (Antepartum, Intrapartum, or Postpartum) (Clin Perinatol, 2005) [MEDLINE]
- Streptococcus Pyogenes Infection Typically Results in an Early Onset with High Fever

Cardiovascular Manifestations

Sinus Tachycardia (see Sinus Tachycardia)

Gastrointestinal Manifestations

Abdominal Pain (see Abdominal Pain)
- Location: lower, midline
- Exam
  - Uterine Tenderness
  - Soft, Involuted Uterus: may be associated with excessive uterine bleeding

Infectious Manifestations

Necrotizing Soft Tissue Infection (see Necrotizing Soft Tissue Infection)

Epidemiology
- Postpartum Endometritis May Be Associated with Necrotizing Fasciitis
Clinical
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Toxic Shock Syndrome

Epidemiology
- Postpartum Endometritis May Be Associated with Toxic Shock Syndrome
Associated Organisms
- Staphylococcus (see Staphylococcal Toxic Shock Syndrome)
  - Erythroderma with Desquamation (see Erythroderma, )
  - Early Onset with High Fever (see Fever): may occur as early as within 24 hrs of delivery
  - Hypotension (see Hypotension)
  - Multi-Organ Involvement: with hepatic/renal/pulmonary involvement, coagulopathy
- Streptococcus Pyogenes (Group A β-Hemolytic Streptococcus) (see Streptococcal Toxic Shock Syndrome], [[Streptococcal Toxic Shock Syndrome]]
  - Early Onset with High Fever (see Fever)
  - Erythroderma with Desquamation (see Erythroderma)
  - Hypotension (see Hypotension)
  - Multi-Organ Involvement: with hepatic/renal/pulmonary involvement, coagulopathy
  - Necrotizing Myometritis: uterus may be boggy and non-tender (due to decreased innervation)
  - Soft Tissue Necrosis

Septic Shock (see Sepsis)

Epidemiology
- Postpartum Endometritis May Be Associated with Sepsis
Associated Organisms
- Clostridium Perfringens (see Clostridium Perfringens): case reported in association with a medical abortion
  - Necrotizing Myometritis
- Clostridium Sordellii (see Clostridium Sordellii): may occur within the first week postpartum (and may be rapidly fatal)
  - Absence of Rash/Fever
  - Anasarca (see Anasarca)
  - Hemoconcentration
  - Hypotension (see Hypotension)
  - Limited Uterine Myonecrosis
  - Severe Leukocytosis (see Leukocytosis): WBC count may be as high as 93k

Other Manifestations

Anorexia (see Anorexia)
Chills (see Chills)
Fever (see Fever)
Headache (see Headache)
Malaise
Purulent Lochia

Treatment

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References

Subacute staphylococcal meningitis secondary to postpartum endometritis. South Med J. 1977 Mar;70(3):368-9 [MEDLINE]
Streptococcal infections in pregnancy. A study of 48 bacteremias. Am J Obstet Gynecol. 1981;140(4):405 [MEDLINE]
Toxic-shock syndrome associated with post-partum staphylococcal endometritis. Ir Med J. 1983;76(2):90 [MEDLINE]
Polymicrobial early postpartum endometritis with facultative and anaerobic bacteria, genital mycoplasmas, and Chlamydia trachomatis: treatment with piperacillin or cefoxitin. J Infect Dis. 1986;153(6):1028 [MEDLINE]
Microbiology and treatment of late postpartum endometritis. Obstet Gynecol. 1986;68(2):226 [MEDLINE]
Role of Chlamydia trachomatis in postpartum endometritis. J Reprod Med. 1987;32(4):280 [MEDLINE]
Streptococcal toxic shock syndrome in a postpartum woman. Case report and review of the literature. Infection. 1996;24(2):164 [MEDLINE]
Postpartum endometritis. Clin Perinatol. 2005 Sep;32(3):803-14 [MEDLINE]
Postpartum ultrasound in women with postpartum endometritis, after cesarean section and after manual evacuation of the placenta. Acta Obstet Gynecol Scand. 2007;86(2):210 [MEDLINE]