Postpartum Postpartum endometritisendometritis

Dr.F Mardanian MDDr.F Mardanian MD

Postpartum Postpartum endometritisendometritis

Dr.F Mardanian MDDr.F Mardanian MD

Postpartum endometritisPostpartum 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

MICROBIOLOGYMICROBIOLOGY • 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 FACTORSRISK FACTORS   RISK FACTORSRISK 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 factorsAdditional 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

PathologyPathology   • endometrium is :

oedematous edematous

o HyperemicHyperemic

o marked inflammatory infiltrates of marked inflammatory infiltrates of the endometrial glands, primarily by the endometrial glands, primarily by neutrophils. neutrophils.

CLINICAL CLINICAL MANIFESTATIONS AND MANIFESTATIONS AND

DIAGNOSISDIAGNOSIS fever uterine tenderness occurring in a

postpartum woman. foul lochiachills 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 valuelimited 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 search for other

causescauses of an initial postpartum fever (eg, pneumonia, pneumonia, DVTDVT, or , or PTEPTE) or persistent postpartum fever (eg, abscessabscess, , ovarian vein thrombosisovarian vein thrombosis, , septic pelvic thrombophlebitisseptic pelvic thrombophlebitis) in patients refractory to 48 to 7248 to 72 hours of antimicrobial therapy.

Drug choice   

• Clindamycin (900 mg-Q8h) gentamicin (1.5 mg/kg- Q8h)

cure rates are cure rates are 90 to 9790 to 97 percent 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

DurationDuration

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