Postpartum Endometritis in the ED setting: presentation, evaluation, and management
- Jan 4th, 2018
- Jason Arthur
Authors: Jason Arthur, MD, MPH (EM Resident Physician, Department of Emergency Medicine, University of Florida College of Medicine – Jacksonville) and Andrew Schmidt, DO, MPH (Assistant Professor, Department of Emergency Medicine, University of Florida College of Medicine – Jacksonville) // Edited by: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)
A 28-year-old female with no past medical history presents 4 days after delivery of a full-term child with a complaint of lower abdominal pain for the last 24 hours. She reports the pain is dull and achy, non-radiating, and without exacerbating or alleviating factors. She reports it is associated with chills and fever to 101°F. She reports that during this time her lochia has become malodorous. Physical exam is remarkable for tachycardia to 114, respiratory rate of 18, and a blood pressure of 110/74. Abdominal exam is remarkable for tenderness over the suprapubic region with voluntary guarding to deep palpation. Pelvic exam is remarkable for scant discharge, uterine tenderness, and cervical motion tenderness.
Endometritis is a generalized infection of the uterus.1 Infection may occur through many different mechanisms. Most commonly infection occurs through bacterial ascension through the lower genital tract. Menstruation results in a loss of the normal endocervical barriers protecting the upper genital tract from infection.2 This is the mechanism by which pelvic inflammatory disease (PID) is thought to develop: spread from the cervix to the uterus, followed by the fallopian tubes and ultimately the peritoneal cavity.3 Endometritis may also extend directly from GI inflammation, such as appendicular or diverticular abscesses. Patients suffering from tuberculosis may develop tubercular endometritis thought to result from hematogenous spread. Chronic endometritis is related to infection, endometrial polyps, intrauterine devices, and submucosal leiomyomas.2
In the Emergency Department, we are likely to encounter endometritis as either a post-partum infection or as a point along the continuum from cervicitis to PID. This review will cover post-partum endometritis. Endometritis occurs in 2-3% of vaginal deliveries, 15-20% of cesarean sections, and 20% of surgical abortions4 and is the most common cause of post-partum fever.5 Prolonged labor or rupture of membranes, invasive fetal monitoring, and increasing number of peri-delivery vaginal exams increase the risk of endometritis.1
Microbes implicated in endometritis are those that colonize the patient’s genitourinary region. Infections may be polymicrobial and include gram-positive and gram-negative aerobes, as well as anaerobes. Group B streptococci, Enterococcus, Escherichia, Enterobacter, Bacteroides, Peptostreptococcus, coli Mycoplasma hominis, Gardnerella vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis and even methicillin-resistant Staphylococcus aureus have all been implicated.1,6
There are multiple complications of post-partum endometritis, including surgical, incisional, and pelvic abscesses and parametrial phlegmons. Additionally, septic pelvic thrombophlebitis, peritonitis, and necrotizing fasciitis may also occur.6
Evaluation & Management
In febrile (>38.0°C/100.4°F) post-partum women, endometritis should be assumed until ruled out.6 The clinical presentation of post-partum endometritis is classically described as fever, lower abdominal pain, uterine tenderness, and foul-smelling lochia.1 Notably, vaginal discharge may be scant.6
Role of imaging
Endometritis is a clinical diagnosis. Imaging is not required for diagnosis; however, it may be useful to assess for retained products of conception or abscess formation. Imaging should also be considered in cases which do not respond to treatment.5 Ultrasound findings of endometritis include uterine enlargement, endometrial thickening, fluid within the endometrial cavity, indistinctness of the endomyometrial junction, and a subserosal hypoechoic rim. Many of these features are thought to overlap with a normal post-partum uterus. Air within the endometrial cavity is not diagnostic of infection and may be seen for several weeks post-partum.4, 5 Computed Tomography (CT) shows similar findings but carries the benefit of identifying abscesses outside the uterus.5
Role of Cultures
Vaginal cultures are unlikely to be clinically useful due to contamination with vaginal flora.6 Cervical cultures are recommended as they may be helpful in treatment failure, and implication of Chlamydia as an etiology may change antibiotic choice.1 There is debate about the utility of blood cultures in post-partum endometritis. One study found a 5.1% rate of bacteremia among all suspected cases of peripartum sepsis and demonstrated a rate of bacteremia 4.3 times higher in antepartum than post-partum patients. Among the post-partum patients who underwent cesarean delivery, the relative risk of bacteremia was 3.2 compared to vaginal delivery.7 Another study of 538 blood cultures among patients with chorioamnionitis showed a rate of bacteremia of 7.2%, but found only a single case during which a positive blood culture changed management.8 While there is no consensus, blood cultures should be considered in patients in whom there is a concern for sepsis or who have undergone cesarean section.
Treatment and Disposition
Patients with mild cases may be treated as an outpatient with close obstetrical follow up. The decision to treat as an outpatient should be made in consultation with the patient’s obstetrician. Clindamycin 300mg q8h for 10 days or Doxycycline 100mg q12h for 10 days are common treatment options. Of note, doxycycline should not be used in breastfeeding women due to the risk of transmission to the child.6 Amoxicillin/clavulanate 875/125mg q12h or amoxicillin 500mg q8h plus metronidazole 500mg q8h may also be an effective therapy.9,10
Patients with moderate or severe illness, cesarean section, underlying comorbidities, or those in whom obstetrical follow up cannot be arranged should be admitted for parenteral antibiotics with obstetric consultation.6 There are multiple parenteral antibiotic regimens which are acceptable for treatment. A 2015 Cochrane Review found fewer treatment failures with clindamycin plus an aminoglycoside than compared to penicillins or cephalosporins.11 For this reason, we recommend first line therapy with IV clindamycin 600mg q6h or 900mg q8h and IV gentamicin 5mg/kg q24h or 1mg/kg q8h for women with normal renal function. The same review found no difference in treatment failure but a decreased hospital length of stay among women treated with daily gentamicin rather than every eight hours.11 Clindamycin combined with Gentamicin has a 90-97% efficacy.12 Other treatment options for endometritis include cefoxitin, cefotetan, cefotaxime, ampicillin/sulbactam, piperacillin/tazobactam, amoxicillin plus gentamicin, and metronidazole plus ampicillin plus an aminoglycoside, among others.6,12,13 In patients with renal insufficiency, clindamycin plus aztreonam may be used.12,14 Vancomycin may be considered if Staphylococcus is thought to be the cause. If there is no improvement after 24-48 hours, some advocate adding ampicillin as this may be more effective against Enterococcus.12 Cephalosporins and ampicillin/sulbactam allow for fewer parenteral administrations. Additionally, some Obstetricians prefer ampicillin/sulbactam initially as it allows for patients to be observed as an inpatient and then discharged on amoxicillin/clavulanate rather than remaining inpatient for the duration of their therapy.
-Endometritis should be assumed in febrile post-partum women until ruled out.
-Endometritis is a clinical diagnosis. Imaging is most useful to rule out complications or when the diagnosis is uncertain.
–Bacteremia is relatively common, however blood cultures are unlikely to change management. Blood cultures should be reserved for septic patients or those with significant co-morbidities.
-Decisions regarding management should be shared between the Emergency Physician, Obstetrician, and Patient. Obstetrical consultation should be obtained in all cases.
–Mild cases of endometritis may be discharged home on oral antibiotics with close Obstetrical follow up and strict return precautions.
-When in doubt, Obstetrical consultation, IV antibiotics, and admission are the safest strategy.
–IV Clindamycin plus Gentamicin carries the highest cure rate (know your local antibiogram).
References / Further Reading
- Gorgas, DL. Infections related to pregnancy. Emerg Med Clin North Am. 2008;26(2):345-366.
- Hoffman BL, Schorge JO, Bradshaw KD, Halvorson LM, Schaffer JI, Corton MM. Williams Gynecology. 3rd ed. New York: McGraw-Hill Education; 2008.
- Crossman SH. The Challenge of Pelvic Inflammatory Disease. American Family Physician. 2006;73(5):859-864.
- Gillies R, Ashley L, Bergin C. Sonographic findings in acute puerperal endometritis: The hypoechoic rim sign and endomyometrial junction indistinctness. Australasian Journal of Ultrasound in Medicine. 2017;20(3):123-128.
- Vandermeer FQ, Wong-You-Cheong JJ. Imaging of Acute Pelvic Pain. Clinical Obstetrics and Gynecology. 2009;52(1):2-20.
- Tintinalli JE. Emergency medicine: a comprehensive study guide. 11th ed. New York: McGraw-Hill; 2011.
- Kankuri E, Kurki T, Carlson P, Hiilesmaa V. Incidence, treatment and outcome of peripartum sepsis. Acta Obstetricia et Gynecologica Scandinavica. 2003;82(8):730-735.
- Locksmith GJ, Duff P. Assessment of the value of routine blood cultures in the evaluation and treatment of patients with chorioamnionitis. Infectious Diseases in Obstetrics and Gynecology. 1994;2(3):111-114.
- Fernandez HCA, Claquin C, Guibert M, Papiernik E. Suspected postpartum endometritis: a controlled clinical trial of single-agent antibiotic therapy with Amox-CA (Augmentin) vs. ampicillin-metronidazole ± aminoglycoside. European Journal of Obstetrics & Gynecology and Reproductive Biology. 1990;36(1-2):69-74.
- Meaney-Delman D, Bartlett LA, Gravett MG, Jamieson DJ. Oral and intramuscular treatment options for early postpartum endometritis in low-resource settings. Obstetrics & Gynecology. 2015;125(4):789-800.
- Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database of Systematic Reviews. February 2015.
- Puerperal Complications. In: Cunningham F, Leveno KJ, Bloom SL, Spong CY, Dashe JS, Hoffman BL, Casey BM, Sheffield JS. eds.Williams Obstetrics, Twenty-Fourth Edition New York, NY: McGraw-Hill; 2013. http://accessmedicine.mhmedical.com.lp.hscl.ufl.edu/content.aspx?bookid=1057§ionid=59789180.
- Gall S, Koukol DH. Ampicillin/sulbactam vs. clindamycin/gentamicin in the treatment of postpartum endometritis. The Journal of Reproductive Medicine. 1996;41(8):575-580.
- Gibbs RS, Blanco JD, Lipscomb KA, St Clair PJ. Aztreonam versus gentamicin, each with clindamycin, in the treatment of endometritis. Obstetrics & Gynecology. 1985;65(6):825-829.