Postpartum endometritis is often caused by retainment of lochia, which is ideal for bacterial growth. This can lead to postpartum endometritis and sepsis.
Cesarean delivery is a risk factor for postpartum endometritis, increasing the incidence by 27% compared to vaginal birth. Other risk factors associated with postpartum endometritis include prolonged labor, retained products after conception/delivery/abortion, multiple cervical examinations, meconium in the amniotic fluid, and low socioeconomic status.
Clinical features associated with postpartum endometritis include fever, chills, and malaise. These infections are likely polymicrobial (e.g. Gardnerella, S. epidermidis). A fever associated with endometritis can also indicate the development of peritonitis or pelvic abscesses.
Other clinical features associated with postpartum endometritis include uterine tenderness, lower abdominal pain, subinvolution (failure of the uterus to return to normal size following birth), and foul smelling lochia.
Acute endometritis involves non-obstetric inflammation of the endometrium and is usually related to pelvic inflammatory disease.
Non-obstetric acute endometritis involves the presence of neutrophils within endometrial glands. Neutrophilic infiltrate is common after bacterial infection (e.g. Neisseria gonorrhoeae, Chlamydia spp.)
Non-obstetric acute endometritis has a similar symptomatic presentation to postpartum endometritis. Additionally, as non-obstetric acute endometritis is unrelated to pregnancy, it is referred to as or considered a component of PID.
Chronic endometritis is idiopathic though can be associated with infections, radiation therapy and/or intrauterine growths.
Non-obstetric chronic endometritis involves the presence of plasma cells along with lymphocytes within the endometrial stroma. Specifically, this includes the presence of five or more neutrophils in the superficial endometrium on the high-powered field (400x) and involvement of 1 or more plasma cells in the endometrial stroma on high-power field (120x).
Non-obstetric chronic endometritis is considered idiopathic. However, there are associations with retained products of conception, deliveries, and abortions. It is also associated with infections along with the presence of an intrauterine device (IUD).
The administration of IV gentamicin plus clindamycin every 8 hours is standard treatment for inpatients. Mild-moderate disease can be treated outpatient with ceftriaxone and doxycycline.
In the event that there is resistance to clindamycin, an alternative treatment involves ampicillin-sulbactam (Unasyn) along with a 10-day course of PO doxycycline in chronic cases. The addition of metronidazole could also be considered if the patient recently had a gynecological procedure performed.
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