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9/1/2019

Persistent Postpartum Endometritis

Postpartum endometritis complicates up to 3% of vaginal deliveries and up to 27% of cesarean deliveries. Initial broad-spectrum antibiotic therapy, most commonly with intravenous (IV) gentamicin and clindamycin, is usually both successful and rapid in treatment onset. Patients who do not respond to this initial therapy by either demonstrating persistent temperatures over 38° Celsius after 48 hours and/or deteriorating to sepsis are diagnosed with “persistent” postpartum endometritis and warrant further diagnostic work-up and a modified to treatment regimen. “Chronic” endometritis is a separate diagnosis that is less severe in symptomology and requires a longer timeframe for diagnosis than “persistent” endometritis which remains an acute condition.

General risk factors for postpartum endometritis include maternal obesity, diabetes, tobacco use and immunosuppression. Obstetric risk factors include Group β Streptococcus carrier status, concurrent sexually transmitted infections, intraamniotic infection/inflammation, prolonged rupture of membranes, operative vaginal delivery, and cesarean delivery.  Retained products of conception or cerclage in situ could also serve as a nidus for infection.

Vaginal deliveries complicated by vulvar hematomas can become superinfected and should raise suspicion in the presence of persistent postpartum endometritis. After cesarean delivery, an infected hematoma, pelvic abscess, or sequelae from an unrecognized injury to visceral structures such as bowel or bladder remains on the differential diagnosis. Either mode of delivery may result in retained products of conception, although the incidence is higher with vaginal deliveries than cesarean deliveries.

These etiologies can be evaluated via computed tomography (CT) of the abdomen and pelvis. Patients should also be evaluated for other infectious etiologies, including pyelonephritis and appendicitis.  Atypical organisms such as Mycoplasma, Ureaplasma, herpes simplex virus and Clostridium perfringens should be considered in patients with severe and persistent symptoms. 

If the patient constitutionally improves but fevers persist, septic pelvic thrombophlebitis (SPT) should be considered, with subcutaneous anticoagulation being the mainstay of treatment with either low molecular weight or unfractionated heparin. Diagnostic imaging is not required for the diagnosis of SPT. Pelvic ultrasonography should be conducted to rule out retained products of conception, with dilation & curettage with suction performed if retained products are identified. 

If postpartum endometritis remains persistent, the patient should be switched to IV antibiotics with a broader spectrum of coverage such as piperacillin-tazobactam or meropenum in addition to consultation with an infectious disease specialist.  If sepsis is diagnosed, the patient should be managed according to established sepsis protocols that include blood and urine cultures, lactate levels and aggressive fluid resuscitation with escalation of care to an ICU if indicated. 

Severe symptoms with rapid onset should raise suspicion for infection via Group A Streptococcus (GAS) or Streptococcus pyogenes.  These organisms produce exotoxin and can result in rapid development and worsening of symptoms of toxic shock including high fevers, necrotizing fasciitis, and maternal death.  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:

San-Juan R, Sanz-Prieto A, Contreras-Mora J, et al. Comprehensive analysis of current epidemiology, clinical features and prognostic factors of puerperal endometritis: A retrospective cohort analysis. Eur J Obstet Gynecol Reprod Biol X. 2023 May 16;18:100199. doi: 10.1016/j.eurox.2023.100199. PMID: 37234795; PMCID: PMC10206829.

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

Martingano D, Renson A, Rogoff S, et al. Daily gentamicin using ideal body weight demonstrates lower risk of postpartum endometritis and increased chance of successful outcome compared with traditional 8-hour dosing for the treatment of intrapartum chorioamnionitis. J Matern Fetal Neonatal Med. 2019 Oct;32(19):3204-3208. doi: 10.1080/14767058.2018.1460348. Epub 2018 Apr 12. PMID: 29642754.

Initial Approval July 2019; Published September 2019; originally titled “Severe Postpartum Endometritis”, Minor revision and name change to current title May 2021.  Minor revision January 2023. Revised November 2024.

 

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