What Do I Have?
Postpartum endometritis is an infection that develops within the lining of the uterus after delivery. The likelihood that it will occur depends on several factors. For example:
- 1 to 3% of women who have a vaginal delivery develop postpartum endometritis;
- 5 to 15% of women who have a scheduled cesarean before the onset of labor or rupture of membranes develop endometritis;
- as many as 35% of women who have cesarean delivery after an extended period of labor and ruptured membranes develop endometritis; and
- the frequency of infection in indigent patients may be almost double the figures cited above.
What Causes Endometritis?
Endometritis is caused by several types of bacteria that are normally present on the mucosal surface (lining) of the vagina. The most common organisms are group B streptococci and E. coli. These bacteria gain access to the upper genital tract, abdominal cavity, and, occasionally, the bloodstream as a result of vaginal examinations during labor and manipulations during surgery.
Factors that can increase your risk for postpartum endometritis include:
- cesarean delivery;
- young age;
- low socioeconomic status;
- long duration of labor and ruptured membranes;
- multiple vaginal examinations; and
- pre-existing infection of the lower genital tract (caused by gonorrhea, group B streptococci, or bacterial vaginosis).
What Are the Consequences of Endometritis?
Postpartum endometritis can lead to serious complications, including infection of the bloodstream (bacteremia), septic shock, infection and blood clots of the pelvic blood vessels, and pelvic abscess. Prompt diagnosis and aggressive treatment are essential to prevent these complications.
How Is Endometritis Diagnosed?
A number of symptoms indicate the presence of endometritis. Patients typically have a fever of 100.4? F (38.0? C) or higher within 36 hours of delivery. Malaise (not feeling well), rapid heart rate, lower abdominal pain, uterine tenderness, and a discolored, foul-smelling uterine discharge are other characteristic symptoms. Some patients also develop a tender, thickened mass in the area next to the uterus.
Several other conditions-such as respiratory tract infection, pyelonephritis (infection of the kidneys), and appendicitis-may cause symptoms similar to those seen in postpartum endometritis. Your doctor can distinguish between these disorders by performing a physical exam and a limited number of laboratory tests, such as white blood cell count, blood culture, urinalysis and culture, and imaging such as a scan of the pelvis or chest x-ray.
How Is Endometritis Usually Treated?
If you have a mild to moderately severe infection (particularly after vaginal delivery), you are treated with a short, intravenous course of single antibiotics. The drugs listed in Table 1 have a sufficiently broad spectrum of activity to cover most, but not all, of the bacteria that cause endometritis.
| Type of Drug | Generic Name | Brand Name |
|---|---|---|
| Cephalosporins |
|
|
| Penicillins |
|
|
| Carbapenems |
|
|
If you are more severely ill, and especially if you are in poor health or have had a cesarean delivery, you are likely treated with a combination of antibiotics (Table 2).
| Generic Name | Brand Name | Frequency of Administration |
|---|---|---|
| Combination 1: Clindamycin | Cleocin plus Garamycin | every 8 hours every 8 or 24 hours |
| Combination 2*: Metronidazole | Flagyl plus Penicillin plus Garamycin | every 12 hours every 6 hours every 8 or 24 hours |
*The wholesale cost of this combination is less than combination 1. However, more infusion sets are required and, thus, the total charge to the patient may be greater.
Most likely, the antibiotics clear your infection within two or three days (this occurs in approximately 90% of patients). After you have been without fever or other symptoms for approximately 24 hours, intravenous antibiotics are discontinued and you can leave the hospital. In general, you won't have to continue taking oral antibiotics after going home.
If you do not respond to the antibiotic therapy just described, it is likely due to one of two problems:
- The organism that caused the infection is resistant to the antibiotics prescribed; your doctor gives you a different antibiotic.
- Infection of the abdominal incision has hampered treatment; therefore, infected wounds are opened completely to allow drainage. In addition, an antibiotic with specific coverage against staphylococci, such as nafcillin, is added to your treatment.
Important !
If you have a severe allergy to penicillin or penicillin-like drugs, you should not receive cefazolin. The best alternative is a single dose of clindamycin plus gentamicin immediately after the umbilical cord is clamped. Although these antibiotics are commonly used for treatment of overt infections, their use is still warranted for patients who are allergic to penicillin and at high risk for postoperative infection.
If these measures do not result in clinical improvement and if you do not have a wound infection, several unusual disorders should be considered. Such conditions include pelvic abscess, infected blood clots in the pelvic blood vessels, drug fever, mastitis, infection at the site of administration of epidural or spinal anesthesia, or reactivation of systemic lupus erythematous (SLE).
How Can the Risk of Postpartum Endometritis Be Minimized?
Women having a vaginal delivery are usually not prescribed antibiotics as a preventive measure. However, in those delivering by cesarean, this approach can significantly lower the risk of endometritis, particularly in women having surgery after extended labor and ruptured membranes. To prevent future infection, most doctors prescribe cefazolin, which is administered intravenously immediately after the baby's umbilical cord is clamped. If you are at high risk, a second dose may be given eight hours later.