Postpartum endometritis Dr.F Mardanian MD

Postpartum endometritis infection of the decidua (ie, pregnancy endometrium endomyometritis Parametritis

C/S without ruptured membranes #5-15% infection C/s + lengthy labor or ruptured membranes  >30%

oral temperature of ≥38.0°c on any two of the first 10 days postpartum, exclusive of the first 24 hours

MICROBIOLOGY polymicrobial GBS-ANAEROBIC STREPTOCOCCI-AEROBIC G- BACILLI(E-coli-clebsiella –proteus) 2.5 microbial agens are contributed(mean) If C/S  anaerobics have a role 1/3 of infections after C/S  clamydia the role of mycoplasmas in the pathogenesis of endometritis is unclear.

RISK FACTORS Cesarean delivery is the most important risk factor . rates of endometritis after nonelective cesarean, elective cesarean, and vaginal delivery are about 30%, 7%, and less than 3%, respectively, in the absence of antibiotic prophylaxis

Additional risk factors Prolonged labor Prolonged rupture of membranes Multiple cervical examinations Internal fetal or uterine monitoring Large amount of meconium in amniotic fluid Manual removal of the placenta Low socioeconomic status Maternal diabetes mellitus or severe anemia Preterm birth Bacterial vaginosis Operative vaginal delivery Postterm pregnancy HIV infection Colonization with group B streptococcus

Pathology endometrium is : edematous Hyperemic marked inflammatory infiltrates of the endometrial glands, primarily by neutrophils.

CLINICAL MANIFESTATIONS AND DIAGNOSIS fever uterine tenderness occurring in a postpartum woman. foul lochia chills lower abdominal pain uterus may be soft and subinvoluted, which can lead to excessive uterine bleeding. Sepsis is an unusual presentation.

Differential diagnosis Surgical site infection (cesarean delivery incision, episiotomy incision, perineal laceration). Mastitis or breast abscess. UTI . Complications of anesthesia, such as aspiration pneumonia . Deep vein thrombosis and pulmonary embolism.

Laboratory limited value elevated WBC supports the diagnosis, but can be a normal finding in postpartum women secondary to the physiologic leukocytosis of pregnancy and the effects of labor However, a rising neutrophil count associated with elevated numbers of bands is suggestive of an infectious process

Cultures Testing for gonorrhea and chlamydia General endometrial cultures are not performed routinely because of the difficulty in obtaining an uncontaminated specimen through the cervix.

Imaging  used primarily to search for other causes of an initial postpartum fever (eg, pneumonia, DVT, or PTE) or persistent postpartum fever (eg, abscess, ovarian vein thrombosis, septic pelvic thrombophlebitis) in patients refractory to 48 to 72 hours of antimicrobial therapy.

Drug choice Clindamycin (900 mg-Q8h) gentamicin (1.5 mg/kg- Q8h) cure rates are 90 to 97 percent

Extended interval dosing of gentamicin (5 mg/kg every 24 hours) is as efficacious and safe as the thrice daily dosing . Drug treatments reported to be equivalent to clindamycin plus gentamicin include : cefotetan, cefoxitin, ceftizoxime, cefotaxime, piperacillin with or without tazobactam, and ampicillin/sulbactam

Duration until the patient is clinically improved and afebrile for 24 to 48 hours.

Persistent postpartum fever A response to the initial antibiotic regimen should be evident within 48 to 72 hours. Then further evaluation is indicated