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9/1/2019

Persistent Postpartum Endometritis

When patients with postpartum endometritis do not respond to initial broad-spectrum antibiotic therapy  and either demonstrate  persistent temperatures over 38° Celsius after 48 hours or who are critically ill,   further work-up to confirm the diagnosis is warranted while more intensive therapy is initiated. 

General risk factors for infection include obesity, diabetes, smoking and immunosuppression.  Risk fac-tors specific to obstetrics are Group B Streptococcus carrier status, presence of sexually transmitted infections, chorioamnionitis, prolonged rupture of membranes, multiple cervical exams, operative vaginal delivery, and cesarean delivery.  Retained products of conception or a retained cerclage could also serve as a nidus for persistent infection. After vaginal delivery, particularly an operative delivery, an infected vulvar hematoma should be considered.  After cesarean section, an infected hematoma, pelvic abscess, or injury to visceral structures such as bowel or bladder is possible.  These etiologies can be evaluated via CT scan of the abdomen and pelvis. Patients should also be evaluated for other infectious or inflammatory etiologies, including pyelonephritis, appendicitis, pancreatitis or cholecystitis.  Atypical organisms such as Mycoplasma, Ureaplasma, herpes simplex virus and Clostridium perfringens should be considered in patients with severe or resistant endometritis.  Also, if the clinical picture improves, but fevers persist, septic pelvic thrombophlebitis should be considered.  Consultation with an infectious disease specialist may be valuable in refractory fever.

As the diagnosis is being re-evaluated, the patient should be continued on broad-spectrum antibiotics with polymicrobial coverage.  If sepsis is diagnosed, it should be managed according to established rapid response protocols that include blood and urine cultures, lactate levels and early fluid resuscitation. Escalation of care to an ICU may be indicated.  Consideration should be given to performing a postpartum D&C if products of conception are suspected or if the patient’s condition is not improving.  In rare cases, the uterine infection may not respond to medical management and the patient is at increased risk for severe maternal morbidity or mortality due to peritonitis, severe sepsis and septic shock.  This is most often due to endomyometritis, myonecrosis or secondary to an intra-abdominal abscess.  If abscess is identified, drainage by surgical exploration or interventional radiology may be appropriate.  Lack of response may lead to further surgical intervention including a laparotomy with “wash out” or occasionally a hysterectomy.  

An important organism to consider is Group A Streptococcus (GAS) or Streptococcus pyogenes.  This is a virulent organism that produces exotoxin and can result in rapid development of high fever, invasive disease with tissue necrosis, and maternal death.  GAS typically presents with abdominal pain, fever, tachycardia and sometimes hypotension.  The latter finding is consistent with toxic shock syndrome, which carries significant mortality.  GAS is also implicated in the rare but life-threatening development of necrotizing fasciitis.  This may result as a complication of severe endometritis.  A high index of suspicion, aggressive medical and surgical debridement, and source control may avoid catastrophic outcomes.

Further Reading:

Society for Maternal-Fetal Medicine (SMFM). Plante LA, Pacheco LD, Louis JM; SMFM Consult Series #47: Sepsis during pregnancy and the puerperium. Am J Obstet Gynecol. 2019 Apr;220(4):B2-B10. doi: 10.1016/j.ajog.2019.01.216. Epub 2019 Jan 23.

Mackeen AD, Packard RE, Ota E, Speer L. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev. 2015 Feb 2;(2):CD001067

Initial Approval July 2019; Published September 2019; originally titled “Severe Postpartum Endometritis”, Minor revision and name change to current title May 2021

 

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This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

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