Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Endometritis refers to infection or inflammation of the endometrium, the inner lining of the uterus. It can be divided into pregnancy-related (obstetric) or non-obstetric. Pathologically, it can be described as acute and chronic:
- Acute endometritis is characterised by the presence of more than five neutrophils in a 400 power field in the endometrial glands.
- Chronic endometritis is characterised by the presence of more than one plasma cell, (and lymphocytes) in a 120 power field in the endometrial stroma.
It is assumed that infection, usually having travelled from the lower genital tract, attacks the endometrium. Spread occurs from there to the tubes and ovaries, causing salpingo-oophoritis. It is debatable whether non-obstetric endometritis is a discrete condition or part of a spectrum which may also involve pelvic inflammatory disease (PID).
The rest of this article refers only to postpartum (obstetric) endometritis. For further information about non-obstetric endometritis, please refer to the separate Pelvic Inflammatory Disease article.
- Postpartum endometritis occurs following 1-3% of births.
- Puerperal sepsis causes around 10 maternal deaths a year in the UK.
- It is up to ten times more common after caesarean section.This may depend on risk factors surrounding the decision to operate, and protocol on prophylactic antibiotics. There is evidence that prophylactic antibiotics reduce the risk of endometritis by 66-75%.Vaginal cleansing with povidone-iodine also reduces risk.
- It is the most common cause of postnatal morbidity between day two and day ten.
- Due to the nature of the complaint, it is most common in females of reproductive age.
There is usually a mix of 2-3 organisms involved; some will be found in normal vaginal flora. It is often a mixed aerobic and anaerobic infection. Causative organisms include:
- Gram-positive cocci - Staphylococcus spp., Streptococcus spp. (especially Group B streptococcus and more recently Streptococcus pyogenes).
- Gram-negative - Escherichia coli, Klebsiella spp., Chlamydia trachomatis, Proteus spp., Enterobacter spp., Gardnerella vaginalis, Neisseria spp.
- Anaerobes - Bacteroides spp. Peptostreptococcus spp.
- Others - Mycoplasma spp., Ureaplasma spp., tuberculosis.
Obstetric risk factors
- Caesarean section is the single biggest risk factor.This is further increased if the woman is HIV positive.
- Prolonged rupture of membranes.
- Severe meconium staining in liquor.
- Long labour with multiple examinations.
- Manual removal of placenta.
- Retained products of conception - the most common cause for chronic endometritis.
- Mother's age at extremes of reproductive span.
- Low socio-economic status - eg, home delivery in a poor hygiene environment.
- Maternal anaemia.
- Diabetes or impaired glucose tolerance.
- Prolonged surgery.
- Internal fetal monitoring.
- General anaesthetic.
- History of pelvic infection.
Number and severity of symptoms can vary markedly from patient to patient but usually include:
- Abdominal pain.
- Offensive-smelling lochia.
- Abnormal vaginal bleeding - postpartum haemorrhage.
- Abnormal vaginal discharge.
- General malaise.
- Raised temperature.
- Pain and tenderness, which may radiate to the adnexae.
- Blood cultures should be performed.
- Check midstream urine.
- High vaginal swab, including swab for gonorrhoea/chlamydia.
- Endometrial biopsy is diagnostic, although rarely appropriate.
Ultrasound is unhelpful in this situation.
If sepsis is suspected in the community, urgent referral to hospital is indicated where 'red flag' signs and symptoms are present.
- If the woman appears seriously unwell, transfer by emergency ambulance:
- Pyrexia >38°C.
- Sustained tachycardia (more than 90 bpm).
- Breathlessness (respiratory rate >20 breaths per minute - a serious symptom).
- Abdominal or chest pain.
- Diarrhoea and/or vomiting.
- Uterine or renal angle pain and tenderness.
- Woman is generally unwell or seems unduly anxious/distressed.
- Intravenous (IV) antibiotics if there are signs of severe sepsis. If less systemically unwell, oral treatment may be sufficient. Most women are best managed in a hospital environment.
- Antibiotic choice should be guided by type and likely source of infection, as well as by local prescribing guidelines.
- The Royal College of Obstetricians and Gynaecologists (RCOG) guideline for sepsis following pregnancy recommends IV piperacillin/tazobactam or a carbapenem plus clindamycin for severe sepsis. Other options, for less severe infections include co-amoxiclav, metronidazole and gentamicin. However, it stresses guidelines based on local resistance should be followed.
- Urinary tract infection.
- Other postpartum causes of fever (eg, mastitis, pneumonia, episiotomy or caesarean section scar infection).
- Pelvic thrombophlebitis.
- Wound infection
- Adnexal infection
- Pelvic abscess
- Pelvic haematoma
90% of cases of endometritis following delivery treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.
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Further reading & references
- Hawkey PM, Livermore DM; Carbapenem antibiotics for serious infections. BMJ. 2012 May 31 344:e3236. doi: 10.1136/bmj.e3236.
- Ross JD; What is endometritis and does it require treatment? Sex Transm Infect. 2004 Aug 80(4):252-3.
- French LM, Smaill FM; Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2004 Oct 18 (4):CD001067.
- Bacterial Sepsis following Pregnancy; Royal College of Obstetricians and Gynaecologists (April 2012)
- Smaill FM, Gyte GM; Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Syst Rev. 2010 Jan 20 (1):CD007482.
- Haas DM, Morgan S, Contreras K; Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2013 Jan 31 1:CD007892. doi: 10.1002/14651858.CD007892.pub3.
- Cantwell R, Clutton-Brock T, Cooper G, et al; Saving Mothers' Lives: Reviewing maternal deaths to make motherhood safer: 2006-2008. The Eighth Report of the Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG. 2011 Mar 118 Suppl 1:1-203. doi: 10.1111/j.1471-0528.2010.02847.x.
- Louis J, Landon MB, Gersnoviez RJ, et al; Perioperative morbidity and mortality among human immunodeficiency virus infected women undergoing cesarean delivery. Obstet Gynecol. 2007 Aug 110(2 Pt 1):385-90.
- Siriwachirachai T, Sangkomkamhang US, Lumbiganon P, et al; Antibiotics for meconium-stained amniotic fluid in labour for preventing maternal and neonatal infections. Cochrane Database Syst Rev. 2010 Dec 8 (12):CD007772. doi: 10.1002/14651858.CD007772.pub2.
- Dehbashi S, Honarvar M, Fardi FH; Manual removal or spontaneous placental delivery and postcesarean endometritis and bleeding. Int J Gynaecol Obstet. 2004 Jul 86(1):12-5.
- Maharaj D; Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007 Jun 62(6):393-9.
- Mulic-Lutvica A, Axelsson O; Postpartum ultrasound in women with postpartum endometritis, after cesarean section and after manual evacuation of the placenta. Acta Obstet Gynecol Scand. 2007 86(2):210-7.
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