Postpartum Endometritis

ByJulie S. Moldenhauer, MD, Children's Hospital of Philadelphia
Reviewed/Revised Apr 2024
View Patient Education

Incidence of postpartum endometritis is affected mainly by the mode of delivery. Incidences from a study of 32,000 deliveries were (1):

  • Vaginal deliveries: 1% (2)

  • Scheduled caesarean deliveries (done before labor starts): 3%

  • Unscheduled caesarean deliveries (done after labor starts): 5 to 10%

Patient characteristics also affect risk of endometritis.

References

  1. 1. Burrows LJ, Meyn LA, Weber AM: Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 2004;103(5 Pt 1):907-912. doi:10.1097/01.AOG.0000124568.71597.ce

  2. 2. Chaim W, Bashiri A, Bar-David J, Shoham-Vardi I, Mazor M: Prevalence and clinical significance of postpartum endometritis and wound infection. Infect Dis Obstet Gynecol. 2000;8(2):77-82. doi:10.1002/(SICI)1098-0997(2000)8:2<77::AID-IDOG3>3.0.CO;2-6

Risk Factors for Postpartum Endometritis

Endometritis may develop after chorioamnionitis during labor or postpartum. Predisposing conditions include

Pathophysiology of Postpartum Endometritis

Infection tends to be polymicrobial; the most common pathogens include the following:

  • Gram-positive cocci (predominantly group B streptococci, Staphylococcus epidermidis, and Enterococcus species)

  • Anaerobes (predominantly peptostreptococci, Bacteroides species, and Prevotella species)

  • Gram-negative bacteria (predominantly Gardnerella vaginalis, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis)

Infection may occur in the endometrium (endometritis), parametrium (parametritis), and/or myometrium (myometritis).

Uncommonly, peritonitis, pelvic abscess, pelvic thrombophlebitis (with risk of pulmonary embolism), or a combination develops. Rarely, septic shock and its sequelae, including death, occur. Group A streptococci or Clostridium species infections are associated with sepsis. Streptococcal or staphylococcal toxic shock syndrome may occur.

Symptoms and Signs of Postpartum Endometritis

Typically, the first symptoms of postpartum endometritis are lower abdominal pain and uterine tenderness, followed by fever—most commonly within the first 24 to 72 hours postpartum. Chills, headache, malaise, and anorexia are common. Sometimes the only symptom is a low-grade fever.

Pallor, tachycardia, and leukocytosis usually occur, and the uterus is soft, large, and tender. Discharge may be decreased or profuse and malodorous, with or without blood. When parametria are affected, pain and fever are severe; the large, tender uterus is indurated at the base of the broad ligaments, extending to the pelvic walls or posterior cul-de-sac.

Pelvic abscess may manifest as a palpable mass separate from and adjacent to the uterus or fever and abdominal pain that persists despite standard antibiotic therapy.

Diagnosis of Postpartum Endometritis

  • History and physical examination

  • Usually tests to exclude other causes (eg, urinalysis and urine culture)

Diagnosis within 24 hours of delivery is based on clinical findings of pain, tenderness, and temperature > 38° C after delivery.

After the first 24 hours, postpartum endometritis is presumed present if no other cause is apparent in patients with temperature 38° C on 2 successive days. Other causes of fever and lower abdominal symptoms include urinary tract infections (UTIs), wound infection, septic pelvic thrombophlebitis, and perineal infection. Uterine tenderness is often difficult to distinguish from incisional tenderness in patients who have had a cesarean delivery.

Patients with low-grade fever and no abdominal pain are evaluated for other occult causes, such as atelectasis, breast engorgement, breast infection, UTI, and leg thrombophlebitis. Fever due to breast engorgement tends to remain 39° C. If temperature abruptly rises after 2 or 3 days of low-grade fever, the cause is probably an infection rather than breast engorgement.

Urinalysis and urine culture are usually done to exclude other causes.

Endometrial cultures are rarely indicated because specimens collected through the cervix are almost always contaminated by vaginal and cervical flora. Endometrial cultures should be done only when endometritis is refractory to routine antibiotic regimens and no other cause of infection is obvious; sterile technique with a speculum is used to avoid vaginal contamination, and the sample is sent for aerobic and anaerobic cultures.

Blood cultures are routinely indicated, but should be done when a patient is immunocompromised, endometritis is refractory to routine antibiotic regimens, or clinical findings suggest septicemia.

If despite adequate treatment of endometritis, fever persists for >

Pearls & Pitfalls

  • If adequate treatment of postpartum endometritis does not result in a downward trend in peak temperature after 48 to 72 hours, consider pelvic abscess and, particularly if no abscess is evident on scans, septic pelvic thrombophlebitis.

Treatment of Postpartum Endometritis

Treatment of postpartum endometritis is a broad-spectrum antibiotic regimen given IV until women are afebrile for 48 hours.

1

Treatment reference

  1. 1. Mackeen AD, Packard RE, Ota E, Speer L: Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev (2):CD001067, 2015. doi: 10.1002/14651858.CD001067.pub3

Prevention of Postpartum Endometritis

Preventing or minimizing predisposing factors is essential. Vaginal delivery cannot be sterile, but aseptic techniques are used.

When delivery is cesarean, prophylactic antibiotics given within 60 minutes before surgery can reduce risk of endometritis by up to 75%.

Key Points

  • Postpartum endometritis is more common after cesarean delivery, particularly if unscheduled.

  • The infection is usually polymicrobial.

  • Treat based on clinical findings (eg, postpartum pain, fundal tenderness, or unexplained fever), using broad-spectrum antibiotics.

  • Endometrial and blood cultures are not routinely done.

  • For cesarean delivery, give prophylactic antibiotics within 60 minutes before surgery.

quizzes_lightbulb_red
Test your KnowledgeTake a Quiz!
Download the free MSD Manual App iOS ANDROID
Download the free MSD Manual App iOS ANDROID
Download the free MSD Manual App iOS ANDROID