Endometritis

Incidence

• 1-3% after spontaneous (uncomplicated) vaginal delivery.
• May rise as high as 19-40% after caesarean section, depending on risk factors surrounding the decision to operate, and protocol on prophylactic antibiotics. Prophylaxis with cephalosporin has not been shown to reduce risk of endometritis², but extending coverage, (with doxycycline and azithromycin) has.³

It is the most common cause of postnatal morbidity between day 2 and day 10. Due to the nature of the complaint it is most common in females of reproductive age.

• Acute endometritis is diagnosed by the presence of more than 5 neutrophils in a 400 power field in the endometrial glands.
• Chronic endometritis is diagnosed by the presence of more than 1 plasma cell, (and lymphocytes)in a 120 power field in the endometrial stroma. Chronic (obstetric) endometritis usually occurs after delivery or termination of pregnancy, secondary to retained products of conception.

Usually non-obstetric causes are infections e.g. tuberculosis⁴, chlamydia, bacterial vaginosis and after intra-uterine contraceptive device fitting. There is usually a mix of 2-3 organisms involved, some will be found in normal vaginal flora. Chlamydia and Gonococcus are NOT common.⁵ Commonly found organisms include:

• Gram positive cocci - Staphylococcus spp., Streptococcus spp. (Peptostreptococcus, Group B streptococcus)
• Gram negative - E.Coli, Klebsiella spp., Proteus spp., Enterobacter spp., Gardnerella spp., Neisseria spp.
• Anaerobes - Bacteroides spp.

Risk factors

Obstetric risk factors

• Caesarean section (particularly if HIV positive⁶)
• Prolonged rupture of membranes
• Severe meconium staining in liquor⁷ - although this has been disputed⁸
• Long labour with multiple examinations
• Manual removal of placenta⁹
• Mothers age at extremes of reproductive span
• Low socio-economic status e.g. home delivery in poor hygiene environment¹⁰
• Maternal anaemia
• Prolonged surgery
• Internal fetal monitoring
• General anaesthetic

Non-obstetric risk factors

• Intra-uterine contraceptive device
• Absence of normal cervical mucus plug
• Menstrual fluid within cavity
• Instrumentation of the uterus
• Douching¹¹
• Unprotected sexual intercourse
• Multiple sexual partners

Symptoms

Number and severity of symptoms can vary markedly from patient to patient, but usually include:

• Fever
• Abdominal pain
• Offensive smelling lochia
• Abnormal vaginal bleeding - postpartum haemorrhage
• Abnormal vaginal discharge
• Dyspareunia
• Dysuria
• General malaise

Signs

• Raised temperature
• Pain and tenderness, which may radiate to the adnexae
• Tachycardia

• Blood cultures are positive in 10-30%
• Check MSU
• High vaginal swab for gonorrhoea/chlamydia

There is nothing to be gained from ultrasound.¹²

Drugs

• IV clindamycin and gentamicin tds until afebrile for greater than 24 hours. Oral follow up treatment is not required.^13,14
• If less systemically unwell, oral combinations of amoxicillin, gentamicin and metronidazole.
• Use doxycycline if chlamydia is suspected.

• Appendicitis
• Pelvic Inflammatory disease
• Pyelonephritis
• Urinary tract infection
• Viral syndrome

• Wound infection
• Peritonitis
• Adnexal infection
• Pelvic abscess
• Pelvic haematoma

90% of cases treated with antibiotics improve within 48-72 hours.¹⁴ If this is not the case, the patient should be re-evaluated.