Postpartum endometritis
For endometritis unrelated to pregnancy, see Pelvic inflammatory disease (PID).
Background[1]
- Any postpartum woman with fever should be assumed to have a genital tract infection
- Postpartum women have a 20-fold increase in invasive group A streptococcal infection compared with nonpregnant women.
- Most often polymicrobial, requiring broad spectrum antibiotics
- Maternal mortality is highest if infection develops within 4 days of delivery
Risk Factors
- Cesarean delivery (most important)
- Prolonged labor
- Prolonged or premature rupture of membranes
- Internal fetal or uterine monitoring
- Large amount of meconium in amniotic fluid
- Manual removal of placenta
- Diabetes Mellitus
- Preterm birth
- Bacterial vaginosis
- Operative vaginal delivery
- Post-term pregnancy
- HIV infection
- Colonization with Group B Strep
Clinical Features
- Fever
- Foul-smelling lochia
- Leukocytosis
- Uterine tenderness
- Only scant discharge may be present (esp with group B strep)
Differential Diagnosis
- Respiratory tract infection
- UTI/urosepsis
- Pyelonephritis
- Intra-abdominal abscess
- Thrombophlebitis
Evaluation
- Evaluate for retained products of conception (e.g. pelvic ultrasound)
Management
<48hrs Post Partum
Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora
- Clindamycin 900mg q8hrs PLUS Gentamicin 1.5mg/kg IV q8hrs OR
- Doxycycline 100mg IV PO q12hrs daily PLUS
- Ampicillin/Sulbactam 3g IV q6hrs
- Cefoxitin 2g IV q6hrs daily
Disposition
- Consult OB/GYN first if are considering outpatient management
- Admit all patients who appear ill, have had a C-section, or underlying comorbid conditions
See Also
References
- Stevens DL and Bryant A. Pregnancy-related group A streptococcal infection.
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