This is infection of the endometrium. It can be divided into pregnancy relate(obstetric and non-obstetric, acute and chronic
The accepted wisdom is that infection, usually having travelled from the lower genital tract, attacks the endometrium. Spread occurs from there to the tubes and ovaries, causing salpingoopheritis. More recent work has questioned whether endometritis is a discreet condition or part of a continuum.1
Epidemiology
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 endometritis, but extending coverage, (with doxycycline and azithromycin) has.
- 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. tuberculosis, Chlamydia, bacterial vaginosis and after intra–uterinecontraceptivedevice 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 positive)
- Prolonged rupture of membranes
- Severe meconium staining in liquor – 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 fetalmonitoring
- 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 – postpartumhaemorrhage
- Abnormal vaginaldischarge
- 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.
- If less systemically unwell, oral combinations of amoxicillin, gentamicin and metronidazole.
- Use doxycycline if Chlamydia is suspected.
- Wound infection
- Peritonitis
- Adnexal infection
- Pelvic abscess
- Pelvic haematoma
90% of cases treated with antibiotics improve within 48-72 hours. If this is not the case, the patient should be re-evaluated.
