Endometritis and Other Postpartum Infections
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- Endometritis (infection of the endometrium) is the most common postpartum infection.
- Bacterial infection of the genital tract, usually within the 1st week after delivery, but can occur 1–6 weeks postpartum
- Less common are postpartum infections of the myometrium and parametrial tissues, vaginal and cervical infections, perineal cellulitis, pelvic cellulitis, septic pelvic vein thrombophlebitis, and parametrial phlegmon.
- System(s) affected: Reproductive
- Synonym(s): Postpartum infection; Endometritis; Endoparametritis; Endomyometritis; Myometritis; Endomyoparametritis; Metritis; Metritis with pelvic cellulitis
- Predominant age: Women of childbearing years
- Predominant sex: Female only
- Occurs in 1–3% of all births
- 10 times more likely with cesarean section:
- 2–15% prior to labor
- 30–35% after labor without prophylaxis
- 2–15% after labor with prophylaxis
- 5th leading cause of maternal mortality, accounting for 11% of maternal deaths
- Cesarean delivery is the most important risk factor.
- Bacterial vaginosis
- Group B streptococcal colonization of genital tract
- HIV infection
- Prolonged labor
- Prolonged rupture of membranes
- Multiple vaginal examinations
- Internal fetal monitoring during labor
- Operative vaginal delivery
- Manual extraction of the placenta
- Low socioeconomic status
- Vaginal delivery:
- Avoid unnecessary vaginal examinations.
- Treat chorioamnionitis during labor.
- Spontaneous placental extraction
- Avoid retained placental fragments or membranes.
- Antibiotic prophylaxis for 3rd- and 4th-degree laceration (1)[B]
- Use of aseptic technique during operative vaginal delivery.
- No data to support antibiotic prophylaxis for operative vaginal delivery (2)[A]
- Cesarean delivery:
- Preoperative preparation with a 10% povidone-iodine scrub and topical solution has been shown to decrease puerperal infection by 38% (3)[B].
- Administering prophylactic antibiotics before both emergency and scheduled cesarean reduces the prevalence of postpartum infection after cesarean (4)[A]:
- Administering the antibiotics prior to skin incision in cesarean delivery (as opposed to the prior practice of waiting for cord clamping) is considered the standard of care.
- Antibiotics should be administered within 1 hour of the surgery start time.
- There is a 40% reduction in postpartum maternal infections without any increase in neonatal infectious outcomes or difficulty in evaluating the neonate (5)[B].
- Extending the spectrum of coverage to include both a cephalosporin and azithromycin decreases the incidence of infections (6)[A],(7)[B].
- Vaginal preparation with povidone-iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis (8)[A].
- Antibiotic dosage should be increased in obese patients to ensure appropriate tissue concentrations prior to skin incision (9)[B].
- Endometritis commonly follows chorioamnionitis.
- Other infections follow trauma to the perineum, vagina, cervix, and uterus.
- Infection is nearly always polymicrobial and involves organisms that have ascended from the lower genital tract:
- Aerobic isolates in 70%: Streptococcus faecalis, S. agalactiae, S. viridans, Staphylococcus aureus, Escherichia coli
- Anaerobic isolates in 80%: Peptococcus sp., Peptostreptococcus sp., Clostridium sp., Bacteroides bivius, B. fragilis, Fusobacterium sp.
- Other genital mycoplasmata: Very common
- Herpes simplex virus and cytomegalovirus should be considered in immunocompromised patients if antibiotics fail.
Commonly Associated Conditions
- Wound infection