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 an intrauterine device.

Frequency

United States

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

6c Infection of the genital tract is the most common cause of puerperal morbidity.
Puerperal morbidity is defined as a temperature of 100.4°F (38°C) 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.
6c In the nonobstetric population, concomitant endometritis may occur in up to 70-90%
of documented cases of salpingitis.

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Dhis disorder affects females of reproductive age.

Clinical
History

Diagnosis usually is based on clinical findings.

6c Fever
6c rower abdominal pain
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 6c Foul-smelling lochia in the obstetric population
6c Abnormal vaginal bleeding
6c Abnormal vaginal discharge
6c Dyspareunia (may be present in patients with pelvic inflammatory disease [PID])
6c Dysuria (may be present in patients with PID)
6c ^alaise

Physical

6c Fever, usually occurring within 36 hours of delivery, in the obstetric population

6c rower abdominal pain
6c ¦terine tenderness
6c Adnexal tenderness if there is an associated salpingitis
6c Foul-smelling lochia
6c Dachycardia

Causes

6c Endometritis is a polymicrobial disease involving, on average, 2-3 organisms.

6c In most cases, it arises from an ascending infection from organisms found in the
normal indigenous vaginal flora.
6c Commonly isolated organisms include ¦


 




 
 

 


 and group B Streptococcus 
6c x   has been associated with late-onset postpartum endometritis.
6c 

 is identified in up to 25% of women who have received cephalosporin
prophylaxis.
6c üoute of delivery is the most important factor in the development of postpartum
endometritis. ^ore recent research supports the preoperative administration of
prophylactic antibiotics, which was associated with a 53% decrease in endometritis
without any impact on suspected or proven neonatal sepsis or NIC¦ admission.1
6c ^ajor risk factors include cesarean delivery, prolonged rupture of membranes, long
labor with multiple vaginal examinations, extremes of patient age, and low
socioeconomic status.
6c ^inor contributing factors include maternal anemia, prolonged internal fetal
monitoring, prolonged surgery, and general anesthesia.
6c Bacterial vaginosis has been associated with endometritis after cesarean delivery and
with PID after first trimester elective abortion.

Dreatment
Medical Care

^ost 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.

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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.

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.

Jntibiotics

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 x   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.

Clindamycin (Cleocin)

¦sed in combination with gentamicin. rincosamide useful as a treatment against serious skin
and soft tissue infections caused by most staphylococci strains. Also effective against aerobic
and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by
inhibiting peptide chain initiation at bacterial ribosome where preferentially binds to the 50S
ribosomal subunit, causing bacterial growth inhibition.

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900 mg IV q8h

  

20-40 mg/kg/d IV divided q6-8h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium;

erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment;

antibiotic-associated colitis

 

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals

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Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency;
associated with severe and possibly fatal colitis by allowing overgrowth of x



American Academy of Pediatrics states that clindamycin is compatible with breastfeeding

Îentamicin (Îentacidin, Îaramycin)

Aminoglycoside antibiotic used for gram-negative bacterial coverage. ¦sed in combination

with either clindamycin or in combination with metronidazole and ampicillin.
Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in
the volume of distribution. Dose may be given IV or I^.

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1.5 mg/kg IV q8h

  

2-2.5 mg/kg/d IV q8h

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin

B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking
agents, thus prolonged respiratory depression may occur
Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides;
possible irreversible hearing loss of varying degrees may occur (monitor regularly)

Documented hypersensitivity; non-dialysis-dependent renal insufficiency

 

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may
use if benefits outweigh risk to fetus

 


Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not
on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular
transmission; adjust dose in renal impairment; data are lacking concerning use while
breastfeeding

Jmpicillin (Omnipen, Marcillin)

¦sed in combination with gentamicin and metronidazole. Interferes with bacterial cell-wall
synthesis during active multiplication, causing bactericidal activity against susceptible
organisms.

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2 g IV q6h

  

50-200 mg/kg/d IV divided qid

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Documented hypersensitivity

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B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals

 


Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction

Metronidazole (Flagyl)

¦sed in combination with gentamicin and ampicillin. Imidazole ring-based antibiotic active
against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the
intermediate-metabolized compounds that are formed bind DNA and inhibit protein
synthesis, causing cell death.

Adult

500 mg IV q6h

  

15-30 mg/kg/d IV divided bid/tid

^ay increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase
toxicity; disulfiram reaction may occur with orally ingested ethan

Documented hypersensitivity

 

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals

 


Adjust dose in hepatic disease; monitor for seizures and development of peripheral
neuropathy
American Academy of Pediatrics states that metronidazole should be used with caution while
breastfeeding

Jmpicillin/sulbactam sodium (Unasyn)

[as been found to be efficacious as monotherapy in 80-90% of patients. Drug combination

that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes.
Not ideal for nosocomial pathogens.

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3 g IV q6h

  

1.5-3 g IV q8h

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects
and has additive effects on ampicillin rash; may decrease effects of oral contraceptives

Documented hypersensitivity
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B - Fetal risk not confirmed in studies in humans but has been shown in some studies in
animals

 


Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction;
compatible with breastfeeding

oxycycline (Bio-Dab, oryx, Vibramycin)

¦sed if x   is the cause of the endometritis. Inhibits protein synthesis and thus
bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of
susceptible bacteria.

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100 mg PO/IV q12h

  

   
  
  
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Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or

bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of
anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing
breakthrough bleeding and increased risk of pregnancy

Documented hypersensitivity; severe hepatic dysfunction

 

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

 


Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce
dose in renal impairment; consider drug serum level determinations in prolonged therapy;
tetracycline use during tooth development (last one-half of pregnancy through 8 y) can cause
permanent discoloration of teeth; Fanconilike syndrome may occur with outdated
tetracyclines
American Academy of Pediatrics states that doxycycline is compatible with breastfeeding

rtapenem (Invanz)

Bactericidal activity results from inhibition of cell wall synthesis and is mediated through
ertapenem binding to penicillin binding proteins. Stable against hydrolysis by a variety of
beta-lactamases including penicillinases, cephalosporinases, and extended spectrum beta-
lactamases. [ydrolyzed by metallo-beta-lactamases.

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1 g qd for 14 d if given IV and 7 d if given I^; infuse over 30 min if given IV

  

Not established
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