Postpartum endometritis

Background

• Infection of the endometrium (uterine lining) within 10 days of delivery

Microbiology

• Usually polymicrobial
• Gram-positives:
  • Streptococcus pyogenes
  • Streptococcus agalactiae
  • Staphylococcus aureus and Staphylococcus epidermidis
  • Viridans group streptococci
  • Other streptococci
• Gram-negatives:
  • Escherichia coli
  • Klebsiella pneumoniae
  • Proteus mirabilis
  • Klebsiella aerogenes
  • Morganella morganii
• Anaerobes:
  • Bacteroides fragilis and other Bacteroides species
  • Clostridium sordellii, and Clostridium perfringens
  • Peptococcus, Peptostreptococcus
  • Fusobacterium
• Others:
  • Gardnerella vaginalis
  • Uncommonly associated with Neisseria gonorrhoeae or Chlamydia trachomatis

Epidemiology

• Most common cause of postpartum fever
• More common after Cesarean section, PROM, preterm or postterm delivery, chorioamnionitis, prolonged labor, maternal anemia, maternal diabetes, multiple vaginal examinations, and bacterial vaginosis

Clinical Manifestations

• Fever within 10 days of delivery
  • Note, however, that low-grade fever can be common within the day after delivery
• Malodorous or purulent vaginal discharge, or per-vaginal bleeding
• Abdominal and pelvic pain
• May become complicated by bacteremia, abscess, toxic shock syndrome, peritonitis, sepsis, myometritis, and septic pulmonary emboli or septic pelvic thrombophlebitis

Diagnosis

• At least two or more of:
  • Fever >= 38 Celsius
  • Pain or tenderness (uterine or abdominal) without other cause
  • Purulent drainage from the uterus (some degree of malodorous yellow-red lochia is normal after delivery, however)

Investigations

• Blood cultures
• Consider cervical swabs for culture
• Consider vaginal swabs for STI NAAT
• Consider imaging to rule out other causes or complications

Management

• Broad-spectrum intravenous antibiotics such as clindamycin and gentamicin