ENDOMETRITIS- Acute, chronic, Atrophic| Causes , Clinical features, Diagnosis andTreatment

Endometritis is inflammation of the uterine lining. It can affect all layers of the uterus. The uterus is typically aseptic. However, the travel of microbes from the cervix and vagina can lead to inflammation and infection. This condition usually occurs as a result of the rupture of membranes during childbirth. Endometritis is the most common postpartum infection. Puerperal endometritis is 25 times more common in patients that underwent cesarean sections. Most cases of postpartum endometritis are polymicrobial, involving aerobic and anaerobic bacteria.

Etiology

Endometritis results from the travel of normal bacterial flora from the cervix and vagina. The uterus is sterile until the amniotic sac ruptures during childbirth. Bacteria is more likely to colonize uterine tissue that has been devitalized, bleeding, or otherwise damaged (such as during a cesarean section).

Between 60% and 70% of infections are due to both aerobes and anaerobes. Examples of anaerobic species are Peptostreptococcus, Peptococcus, Bacteroides, Prevotella, and Clostridium. Examples of aerobic species are primarily groups A and B Streptococci, Enterococcus, Staphylococcus, Klebsiella pneumoniae, Proteus species, and Escherichia coli. Uterine tissue damaged by cesarean section is particularly susceptible to Streptococcus pyogenes and Staphylococcus aureus. Chlamydia endometritis often presents at a later date, seven or more days postpartum.

Treatment / Management

The threshold for obstetrics should be low in any provider considering a diagnosis of endometritis. Oral antibiotic regimens are an option for mild disease. The options are similar to those used for pelvic inflammatory disease:

Doxycycline 100 mg every 12 hours + metronidazole 500 mg every 12 hours. Doxycycline is not contraindicated in breastfeeding mothers if its use is for less than three weeks.
Levofloxacin 500 mg every 24 hours + metronidazole 500 mg every 8 hours. Levofloxacin should be avoided in breastfeeding mothers.
Amoxicillin-clavulanate 875 mg/125 mg every 12 hours.[11]
For patients with moderate to severe endometritis and/or patients with endometritis s/p cesarean section, intravenous antibiotics and admission are recommended. Options are as follows:

Gentamicin 1.5 mg/kg IV every 8 hours or 5 mg/kg IV every 24 hours and clindamycin 900 mg every 8 hours.
QD gentamicin dosing is associated with a shorter hospitalization time compared with TID and has been shown to be just as effective.
There is no adequate data regarding the effects of this regimen on breastfeeding infants or the effect of gentamicin on maternal renal function.
For patients with endometritis due to GBS resistance to clindamycin, piperacillin-tazobactam and ampicillin-sulbactam may be used.[12][13]
Clinical improvement in response to antibiotics typically occurs in 48 to 72 hours. If there is no clinical improvement within 24 hours, providers should consider adding ampicillin 2 g initially, followed by 1 g every 4 hours for enhanced Enterococcus coverage. For those that do not improve within 72 hours, providers should broaden their differential diagnosis to include other infections such as pneumonia, pyelonephritis, pelvic septic thrombophlebitis. IV antibiotics should continue until the patient becomes afebrile for at least 24 hours in addition to an improvement in the patient’s pain and leukocytosis. At this time, there is no substantial evidence demonstrating that continuing antibiotics in PO form following such clinical improvement improves significant patient-oriented outcomes.[14]

Differential Diagnosis

In the patient with postpartum fever and abdominal pain, diagnoses other than endometritis that merit consideration include urinary tract infections (including pyelonephritis), pneumonia, septic pelvic thrombophlebitis. The clinician should keep an open mind to these diagnoses, especially if antibiotic and/or surgical management for endometritis is not leading to clinical improvement.

Prognosis

If untreated, the fatality rate of endometritis is approximately 17%. Thankfully this is reduced to 2% with proper recognition and treatment. Cesarean deliveries (especially for multifetal gestation) have a 25-fold increase in infection-related mortality.[11]

Complications

Approximately 1% to 4% of patients will have complications such as sepsis, abscesses, hematomas, septic pelvic thrombophlebitis, and necrotizing fasciitis. Such complications can then lead to uterine necrosis, requiring a hysterectomy for infection resolution. Surgical intervention may also be necessary if the infection has produced a drainable fluid collection