Postpartum endometritis

A. Endometritis in the postpartum period refers to infection of the decidua (ie, pregnancy endometrium), frequently with extension into the myometrium (endomyometritis) and parametrial tissues (parametritis).

B. The single most important risk factor for postpartum endometritis is route of delivery. The incidence of endometritis after a vaginal birth is less than three percent, but is 5 to 10 times higher after cesarean delivery.

C. Other proposed risk factors include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, maternal diabetes, presence of meconium, and low socioeconomic status.

D. Microbiology. Postpartum endometritis is usually a polymicrobial infection, produced by a mixture of aerobes and anaerobes from the genital tract.

Type and Frequency of Bacterial Isolates in Postpartum Endometritis*

Isolate

Frequency (percent)

Gram positive

Group B streptococci

Enterococci

S. epidermidis

Lactobacilli

Diphtheroids

S. Aureus

8 7 9 4 2 1

Gram negative G. vaginalis E. Coli

Enterobacterium spp. P. mirabilis Others

S. bivius

Other Bacteroides spp. Peptococci-peptostreptocc

U. urealyticum M. hominis

39 11

C. trachomatis

2

E. Vaginal colonization with group B streptococcus (GBS) is a risk factor for postpartum endometritis; GBS colonized women at delivery have an 80 percent greater likelihood of developing postpartum endometritis.

F. Clinical manifestations and diagnosis. Endometritis is characterize, by fever, uterine tenderness, foul lochia, and leukocytosis that develop within five days of delivery. A temperature greater than or equal to l0o.4 °F (38 °C) in the absence of other causes of fever, such as pneumonia, wound cellulitis, and urinary tract infection is the most common sign.

G. Laboratory studies are not diagnostic since leukocytosis occurs frequently in all postpartum patients. However, a rising neutrophil count associated with elevated numbers of bands is suggestive of infectious disease. Bacteremia occurs in 10 to 20 percent of patients; usually a single organism is identified despite polymicrobial infection. Blood cultures should be obtained in febrile patients following delivery.

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