Postpartum endometritis: Difference between revisions
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==Background== | ''For endometritis unrelated to pregnancy, see [[Pelvic inflammatory disease (PID)]].'' | ||
==Background<ref>Stevens DL and Bryant A. Pregnancy-related group A streptococcal infection.</ref>== | |||
*Any postpartum woman with fever should be assumed to have a genital tract infection | *Any postpartum woman with fever should be assumed to have a genital tract infection | ||
*Most often polymicrobial, requiring broad spectrum | *Postpartum women have a 20-fold increase in invasive group A streptococcal infection compared with nonpregnant women. | ||
*Most often polymicrobial, requiring broad spectrum antibiotics | |||
*Maternal mortality is highest if infection develops within 4 days of delivery | |||
===Risk Factors=== | ===Risk Factors=== | ||
*Cesarean delivery (most important) | *Cesarean delivery (most important) | ||
*Prolonged labor | *Prolonged labor | ||
*Prolonged | *Prolonged or premature rupture of membranes | ||
*Internal fetal or uterine monitoring | *Internal fetal or uterine monitoring | ||
*Large amount of meconium in amniotic fluid | *Large amount of meconium in amniotic fluid | ||
*Manual removal of placenta | *Manual removal of placenta | ||
*[[Diabetes Mellitus]] | *[[Diabetes Mellitus]] | ||
*Preterm birth | *[[preterm delivery|Preterm birth]] | ||
*[[Bacterial vaginosis]] | *[[Bacterial vaginosis]] | ||
*Operative vaginal delivery | *Operative vaginal delivery | ||
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*Colonization with [[Group B Strep]] | *Colonization with [[Group B Strep]] | ||
==Clinical Features== | |||
== | |||
*[[Fever]] | *[[Fever]] | ||
*Foul-smelling lochia | *Foul-smelling [[vaginal discharge|lochia]] | ||
*[[Leukocytosis]] | *[[Leukocytosis]] | ||
*Uterine tenderness | *Uterine tenderness | ||
*Only scant discharge may be present (esp | *Only scant discharge may be present (esp with [[group B strep]]) | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
*Respiratory tract infection | *Respiratory tract infection | ||
*UTI/urosepsis | *[[UTI]]/urosepsis | ||
*Pyelonephritis | *[[Pyelonephritis]] | ||
*Intra-abdominal abscess | *Intra-abdominal abscess | ||
*Thrombophlebitis | *[[Thrombophlebitis]] | ||
{{Postpartum emergencies DDX}} | {{Postpartum emergencies DDX}} | ||
==Evaluation== | |||
*Evaluate for [[retained products of conception]] (e.g. [[pelvic ultrasound]]) | |||
==Management== | ==Management== | ||
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==Disposition== | ==Disposition== | ||
*Consult OB/GYN first if are considering | *Consult OB/GYN first if are considering outpatient management | ||
*Admit all | *Admit all patients who appear ill, have had a C-section, or underlying comorbid conditions | ||
==See Also== | ==See Also== | ||
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==References== | ==References== | ||
<references/> | |||
[[Category:OBGYN]] | [[Category:OBGYN]] | ||
[[Category:ID]] | [[Category:ID]] | ||
Latest revision as of 21:39, 6 July 2022
For endometritis unrelated to pregnancy, see Pelvic inflammatory disease (PID).
Background[1]
- Any postpartum woman with fever should be assumed to have a genital tract infection
- Postpartum women have a 20-fold increase in invasive group A streptococcal infection compared with nonpregnant women.
- Most often polymicrobial, requiring broad spectrum antibiotics
- Maternal mortality is highest if infection develops within 4 days of delivery
Risk Factors
- Cesarean delivery (most important)
- Prolonged labor
- Prolonged or premature rupture of membranes
- Internal fetal or uterine monitoring
- Large amount of meconium in amniotic fluid
- Manual removal of placenta
- Diabetes Mellitus
- Preterm birth
- Bacterial vaginosis
- Operative vaginal delivery
- Post-term pregnancy
- HIV infection
- Colonization with Group B Strep
Clinical Features
- Fever
- Foul-smelling lochia
- Leukocytosis
- Uterine tenderness
- Only scant discharge may be present (esp with group B strep)
Differential Diagnosis
- Respiratory tract infection
- UTI/urosepsis
- Pyelonephritis
- Intra-abdominal abscess
- Thrombophlebitis
3rd Trimester/Postpartum Emergencies
- Acute fatty liver of pregnancy
- Amniotic fluid embolus
- Chorioamnionitis
- Eclampsia
- HELLP syndrome
- Mastitis
- Peripartum cardiomyopathy
- Postpartum endometritis (postpartum PID)
- Postpartum headache
- Postpartum hemorrhage
- Preeclampsia
- Resuscitative hysterotomy
- Retained products of conception
- Septic abortion
- Uterine rupture
Evaluation
- Evaluate for retained products of conception (e.g. pelvic ultrasound)
Management
Antibiotics
<48hrs Post Partum
Treatment is targeted against polymicrobial infections, most often 2-3 organisms of normal vaginal flora
- (Prefered first line) Clindamycin 900mg q8hrs PLUS Gentamicin 5mg/kg IV q24hours (same efficacy and more cost effective vs. 1.5mg/kg) or 1.5mg/kg IV q8hrs[2] OR
- Doxycycline 100mg IV PO q12hrs daily PLUS
- Ampicillin/Sulbactam 3g IV q6hrs
- Cefoxitin 2g IV q6hrs daily
>48hrs Post Partum
- Doxycycline 100mg IV or PO q12hrs + Metronidazole 500mg IV or PO q8hrs daily
- Use Metronidazole with caution in breastfeeding mothers its active is present in breast milk at concentrations similar to maternal plasma concentrations
Disposition
- Consult OB/GYN first if are considering outpatient management
- Admit all patients who appear ill, have had a C-section, or underlying comorbid conditions