Endometritis




Background Endometritis is an infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis is divided into obstetric and nonobstetric endometritis. It is the most common cause of fever during the postpartum period. Pelvic inflammatory disease (PID) is a common predecessor in the nonobstetric population.

Pathophysiology Endometritis is infection of the endometrium or decidua, with extension into the myometrium and parametrial tissues. Endometritis usually results from an ascending infection from the lower genital tract. From a pathologic perspective, endometritis can be classified as acute versus chronic. Acute endometritis is characterized by the presence of neutrophils within the endometrial glands. Chronic endometritis is characterized by the presence of plasma cells and lymphocytes within the endometrial stroma. In the nonobstetric population, PID and invasive gynecologic procedures are the most common precursors to acute endometritis. In the obstetric population, postpartum infection is the most common predecessor. Chronic endometritis in the obstetric population is usually associated with retained products of conception after delivery or elective abortion. In the nonobstetric population, chronic endometritis has been seen with infections, such as chlamydia, tuberculosis, and bacterial vaginosis, and the presence of an intrauterine device.

Frequency United States Incidence varies depending on the route of delivery and the patient population. After a vaginal delivery, incidence is 1-3%. Following cesarean delivery, incidence ranges from 1390%, depending on the risk factors present and whether perioperative antibiotic prophylaxis had been given.

Mortality/Morbidity Infection of the genital tract is the most common cause of puerperal morbidity. Puerperal morbidity is defined as a temperature of 100.4°F (38°C) or higher occurring in any 2 of the first 10 days postpartum, exclusive of the first 24 hours. In the past, infection accounted for up to 16% of maternal mortality. 6c In the nonobstetric population, concomitant endometritis may occur in up to 70-90% of documented cases of salpingitis.

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Jge Dhis disorder affects females of reproductive age.

Clinical History Diagnosis usually is based on clinical findings. 6c 6c

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Fever rower abdominal pain

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Foul-smelling lochia in the obstetric population Abnormal vaginal bleeding Abnormal vaginal discharge Dyspareunia (may be present in patients with pelvic inflammatory disease [PID]) Dysuria (may be present in patients with PID) ^alaise

Physical 6c 6c 6c 6c 6c 6c

Fever, usually occurring within 36 hours of delivery, in the obstetric population rower abdominal pain ¦terine tenderness Adnexal tenderness if there is an associated salpingitis Foul-smelling lochia Dachycardia

Causes 6c 6c 6c 6c 6c 6c

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Endometritis is a polymicrobial disease involving, on average, 2-3 organisms. In most cases, it arises from an ascending infection from organisms found in the normal indigenous vaginal flora. Commonly isolated organisms include ¦

   
 
      

 

 and group B Streptococcus  x   has been associated with late-onset postpartum endometritis. 
   is identified in up to 25% of women who have received cephalosporin prophylaxis. üoute of delivery is the most important factor in the development of postpartum endometritis. ^ore recent research supports the preoperative administration of prophylactic antibiotics, which was associated with a 53% decrease in endometritis without any impact on suspected or proven neonatal sepsis or NIC¦ admission.1 ^ajor risk factors include cesarean delivery, prolonged rupture of membranes, long labor with multiple vaginal examinations, extremes of patient age, and low socioeconomic status. ^inor contributing factors include maternal anemia, prolonged internal fetal monitoring, prolonged surgery, and general anesthesia. Bacterial vaginosis has been associated with endometritis after cesarean delivery and with PID after first trimester elective abortion.

Dreatment Medical Care ^ost cases of endometritis, including those following cesarean delivery, should be treated in an inpatient setting. For mild cases following vaginal delivery, oral antibiotics in an outpatient setting may be adequate. x
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Surgical Care Surgical management is not usually necessary in acute endometritis in the obstetric population. Dilatation and curettage may be advised for retained products of conception, however.

Medication After making the diagnosis of endometritis and excluding other sources of infection, broadspectrum antibiotics should be promptly initiated. Improvement will be noted within 48-72 hours in nearly 90% of women treated with an approved regimen. For mild cases following vaginal delivery, an oral agent may be adequate.

Jntibiotics A combination therapy with clindamycin and an aminoglycoside is considered the criterion standard by which most antibiotic clinical trials are judged. A combination regimen of ampicillin, gentamicin, and metronidazole provides coverage against most of the organisms that are encountered in serious pelvic infections. Doxycycline should be used if x   is the cause of the endometritis. Ampicillin sulbactam can be used as monotherapy. Single-agent therapies have been found to be efficacious in 80-90% of patients. Clindamycin (Cleocin) ¦sed in combination with gentamicin. rincosamide useful as a treatment against serious skin and soft tissue infections caused by most staphylococci strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where preferentially binds to the 50S ribosomal subunit, causing bacterial growth inhibition. J
 900 mg IV q8h     20-40 mg/kg/d IV divided q6-8h

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis   

 B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

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  Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis by allowing overgrowth of x   
American Academy of Pediatrics states that clindamycin is compatible with breastfeeding c

Îentamicin (Îentacidin, Îaramycin) Aminoglycoside antibiotic used for gram-negative bacterial coverage. ¦sed in combination with either clindamycin or in combination with metronidazole and ampicillin. Dosing regimens are numerous and are adjusted based on creatinine clearance and changes in the volume of distribution. Dose may be given IV or I^. J
 1.5 mg/kg IV q8h     2-2.5 mg/kg/d IV q8h

Coadministration with other aminoglycosides, cephalosporins, penicillins, and amphotericin B may increase nephrotoxicity; aminoglycosides enhance effects of neuromuscular blocking agents, thus prolonged respiratory depression may occur Coadministration with loop diuretics may increase auditory toxicity of aminoglycosides; possible irreversible hearing loss of varying degrees may occur (monitor regularly) Documented hypersensitivity; non-dialysis-dependent renal insufficiency   

 C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus   
  Narrow therapeutic index (not intended for long-term therapy); caution in renal failure (not on dialysis), myasthenia gravis, hypocalcemia, and conditions that depress neuromuscular transmission; adjust dose in renal impairment; data are lacking concerning use while breastfeeding

Jmpicillin (Omnipen, Marcillin) ¦sed in combination with gentamicin and metronidazole. Interferes with bacterial cell-wall synthesis during active multiplication, causing bactericidal activity against susceptible organisms. J
 2 g IV q6h     50-200 mg/kg/d IV divided qid !   c c 


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Documented hypersensitivity c

  

 B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals   
  Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction c

Metronidazole (Flagyl) ¦sed in combination with gentamicin and ampicillin. Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Appears to be absorbed into the cells and the intermediate-metabolized compounds that are formed bind DNA and inhibit protein synthesis, causing cell death. Adult 500 mg IV q6h     15-30 mg/kg/d IV divided bid/tid

^ay increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethan Documented hypersensitivity   

 B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals   
  Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy American Academy of Pediatrics states that metronidazole should be used with caution while breastfeeding c

Jmpicillin/sulbactam sodium (Unasyn) [as been found to be efficacious as monotherapy in 80-90% of patients. Drug combination that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. Not ideal for nosocomial pathogens. J
 3 g IV q6h     1.5-3 g IV q8h

Probenecid and disulfiram elevate ampicillin levels; allopurinol decreases ampicillin effects and has additive effects on ampicillin rash; may decrease effects of oral contraceptives Documented hypersensitivity c

  

 B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals   
  Adjust dose in renal failure; evaluate rash and differentiate from hypersensitivity reaction; compatible with breastfeeding c

oxycycline (Bio-Dab, oryx, Vibramycin) ¦sed if x   is the cause of the endometritis. Inhibits protein synthesis and thus bacterial growth by binding with the 30S and possibly the 50S ribosomal subunits of susceptible bacteria. J
 100 mg PO/IV q12h               c

Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy Documented hypersensitivity; severe hepatic dysfunction   

 D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus   
  Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one-half of pregnancy through 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines American Academy of Pediatrics states that doxycycline is compatible with breastfeeding c

rtapenem (Invanz) Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins. Stable against hydrolysis by a variety of beta-lactamases including penicillinases, cephalosporinases, and extended spectrum betalactamases. [ydrolyzed by metallo-beta-lactamases. J
 1 g qd for 14 d if given IV and 7 d if given I^; infuse over 30 min if given IV     Not established c