Skip to content

Endometritis and Other Postpartum Infections

BASICS

DESCRIPTION

  • Infection of the endometrium; most common postpartum infection.
  • Peak incidence postpartum day 7; can occur up to 6 weeks postpartum.
  • Other pelvic infections: myometritis, parametrial infections, vaginal/cervical infections, perianal cellulitis, pelvic cellulitis, abscess, septic pelvic vein thrombophlebitis, parametrial phlegmon (rare).
  • System affected: reproductive.

EPIDEMIOLOGY

  • Occurs after 1-3% of all births.
  • 10x more frequent after cesarean section.
  • 2-15% infections begin prior to labor.
  • 30-35% occur post-labor without prophylaxis; 2-15% even with prophylaxis.
  • Fifth leading cause of maternal mortality (11% of deaths).

ETIOLOGY AND PATHOPHYSIOLOGY

  • More common after chorioamnionitis and traumatic deliveries.
  • Usually polymicrobial, ascending infection from lower genital tract.
  • Aerobic bacteria (70%): Streptococcus faecalis, agalactiae, viridans, Staphylococcus aureus, E. coli.
  • Anaerobic bacteria (80%): Peptococcus, Peptostreptococcus, Clostridium, Bacteroides, Fusobacterium.
  • Other: genital Mycoplasma, herpes simplex, cytomegalovirus (immunocompromised).
  • May cause thrombosis in pelvic veins or phlegmon.

RISK FACTORS

  • Primary: cesarean delivery.
  • Chorioamnionitis, bacterial vaginosis, Group B Strep colonization, HIV.
  • Prolonged labor, membrane rupture, meconium-stained fluid.
  • Multiple vaginal exams, internal monitoring.
  • Episiotomy, severe perineal trauma, operative vaginal delivery, manual placenta extraction.
  • Low socioeconomic status, obesity, anemia.
  • Delayed or inappropriate antibiotic prophylaxis.

GENERAL PREVENTION

  • Prophylaxis for Group B Strep colonization.
  • Vaginal delivery: minimize vaginal exams, treat chorioamnionitis, avoid manual placenta extraction.
  • Operative vaginal delivery: aseptic technique; consider amoxicillin-clavulanic acid prophylaxis.
  • Cesarean delivery: pre-op skin prep (povidone-iodine/alcohol), prophylactic antibiotics within 1 hour of incision; repeat doses for long procedures or heavy bleeding.
  • Extended cephalosporin + azithromycin effective and cost-saving.
  • Vaginal prep immediately before cesarean reduces endometritis risk.
  • Weight-based antibiotic dosing recommended.

COMMONLY ASSOCIATED CONDITIONS

  • Chorioamnionitis, wound infection.

DIAGNOSIS

HISTORY

  • Cesarean delivery or chorioamnionitis history.
  • Fever, chills, malaise, headache, anorexia, abdominal pain.
  • Heavy or foul-smelling vaginal bleeding (lochia).

PHYSICAL EXAM

  • Fever >38°C (100.4°F), tachycardia.
  • Uterine tenderness (key finding).
  • Abdominopelvic tenderness, purulent/malodorous lochia.
  • Heavy bleeding, ileus.

DIFFERENTIAL DIAGNOSIS

  • 5 Ws: Wind (pneumonia), Water (UTI), Wound infection, Wow (mastitis), Wonder drug (medication fever).
  • Viral syndromes, dehydration, pelvic abscess, thrombophlebitis, thyroid storm, appendicitis.

DIAGNOSTIC TESTS & INTERPRETATION

  • CBC (leukocytosis may be physiological up to 20,000).
  • CMP.
  • Genital tract cultures, rapid Group B Strep test during labor.
  • Amniotic fluid Gram stain (polymicrobial).
  • Uterine tissue cultures (difficult; requires shielded specimen collection).
  • If sepsis/SIRS suspected: serum lactate, fluids, blood cultures, broad-spectrum antibiotics.
  • If no improvement in 24-48 hrs: ultrasound for retained products or abscess; CT/MRI for thrombophlebitis or deep infection.
  • Paracentesis/culdocentesis rarely needed.
  • Histology: >5 neutrophils/HPF in endometrium, ≥1 plasma cell in stroma.

TREATMENT

MEDICATION

First Line

  • Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h
  • Side effects: nephrotoxicity, ototoxicity, pseudomembranous colitis (up to 6% diarrhea).

Second Line

  • Ampicillin/sulbactam 3 g IV q6h
  • Metronidazole 500 mg IV/PO q8-12h + penicillin 5 million U IV q6h
  • Ampicillin 2 g IV q6h + gentamicin 5 mg/kg IV q24h
  • Cefoxitin 2 g IV q6h ± ampicillin 2 g IV if no improvement after 48 hrs

  • Cefotetan 2 g IV q12h ± ampicillin 2 g IV if no improvement after 48 hrs

  • Adjust therapy based on cultures and clinical response.

  • Avoid sulfa, tetracyclines, fluoroquinolones before delivery and while breastfeeding; metronidazole relatively contraindicated in breastfeeding.
  • Consider macrolides or ampicillin for persistent infections.
  • Heparin indicated for septic pelvic vein thrombophlebitis (10 days anticoagulation).

SURGERY/OTHER PROCEDURES

  • Ultrasound to evaluate retained products if no improvement.
  • Curettage for retained products.
  • Drain abscess surgically or via image guidance.

INPATIENT AND NURSING

  • Hospital admission for postpartum infections recommended.
  • Educate about signs (fever, pain, bleeding, foul lochia) before discharge.
  • IV antibiotics and close monitoring for severe infections.
  • Drain infected wounds; optimize fluids.

ONGOING CARE

FOLLOW-UP

  • Individualize care severity-based.
  • IV antibiotics until afebrile 24-48 hrs, stop unless bacteremia (then complete 7-day oral course).

DIET

  • As tolerated; may be limited by ileus.

PATIENT EDUCATION

  • Advise urgent physician contact for postpartum fever >38°C, heavy bleeding, foul lochia.
  • Additional information: http://www.healthline.com/health/pregnancy/complications-postpartum-endometritis

PROGNOSIS

  • Most improve rapidly with supportive care and appropriate antibiotics.

COMPLICATIONS

  • Resistant organisms, peritonitis, pelvic abscess.
  • Septic pelvic thrombophlebitis, ovarian vein thrombosis.
  • Sepsis, death.

REFERENCES

  1. Knight M, Chiocchia V, Partlett C, et al. Prophylactic antibiotics in operative vaginal delivery (ANODE trial). Lancet. 2019;393(10189):2395-2403.
  2. Bollig C, Nothacker M, Lehane C, et al. Prophylactic antibiotics before cord clamping in cesarean delivery: systematic review. Acta Obstet Gynecol Scand. 2018;97(5):521-535.
  3. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199: prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2018;132(3):e103-e119.

ADDITIONAL READING

  • Carter EB, Temming LA, Fowler S, et al. Evidence-based bundles for cesarean site infections: meta-analysis. Obstet Gynecol. 2017;130(4):735-746.

CODES

  • ICD10 O86.12 Endometritis following delivery
  • ICD10 O86.4 Pyrexia of unknown origin following delivery
  • ICD10 O86.13 Vaginitis following delivery

CLINICAL PEARLS

  • Postpartum endometritis follows 1-3% of births.
  • Typically polymicrobial ascending infections.
  • Antibiotic prophylaxis before skin incision reduces infection risk for cesarean but not operative vaginal deliveries.
  • Clindamycin + gentamicin recommended first-line therapy.
  • Treat until afebrile 24-48 hrs; extend if bacteremia.
  • Nonresponse should prompt evaluation for retained products, abscess, thrombosis.