Endometritis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shakiba Hassanzadeh, MD[2]

Synonyms and Keywords: acute endometritis, chronic endometritis, postpartum endometritis, puerperal endometritis

Overview

Endometritis is classified histopathologically into two subtypes: acute endometritis and chronic endometritis (CE). Acute endometritis occurs following abortion, childbirth, menstruation, curettage, or IUD insertion. Symptoms of acute endometritis may include fever, pelvic pain, and vaginal discharge. On histopathology, many neutrophils are seen in the endometrial stroma in acute endometritis. Chronic endometritis may cause infertility. Chronic endometritis (CE) is mostly asymptomatic but may have vague symptoms. On histopathology, plasma cells are seen in the endometrial stroma in chronic endometritis (CE). Endometritis is mostly caused by infection and treated with antibiotics. Pyometra is a rare disorder with pus accumulation in the uterine cavity due to abnormal drainage of the uterus.

Classification

Endometritis may be classified according to histopathology into two subtypes:[1]

Pyometra

Pathophysiology

Postpartum endometritis

Postpartum endometritis is caused by bacteria (vaginal microflora) ascending from the lower genital tract during labor.[9]

Artificial or spontaneous rupture of membranes may also happen without bacterial colonization.[9]

Chronic Endometritis

In the normal endometrium, B-cells are mostly seen in the basal layer.[10]

In chronic endometritis (CE):[11]

Histopathology

Histopathology 
Acute Endometritis Chronic Endometritis
The histopathologic findings in acute endometritis include:[1] The histopathologic findings in chronic endometritis (CE) include:[1][26]

Mycobacterium tuberculosis causes a subtype of chronic endometritis (CE) (chronic granulomatous endometritis) in some developing countries. Histopathologically, chronic granulomatous endometritis has caseating granuloma surrounded by infiltrates of lymphocytes which include endometrial stromal plasmacytes (ESPCs).[4]

Causes

Causes 
Postpartum Endometritis Chronic Endometritis
Postpartum endometritis is caused by bacteria ascending from the lower genital tract into the cervix during labor. These bacteria that are the vaginal microflora include:[9] The most common cause of chronic endometritis (CE) is an infection with microorganisms, including:[27][28][29]

Acute endometritis may be caused by Chlamydia trachomatis and Neisseria gonorrhea.[30]

The rate of infections with Chlamydia trachomatis (2%–7%) and Neisseria gonorrhea (0%–8%) in chronic endometritis (CE) are very low. [27][31][32]

Mycobacterium tuberculosis causes a subtype of chronic endometritis (CE) (chronic granulomatous endometritis) in some developing countries.[4]

The association of viral infections as causes of chronic endometritis (CE) is still unclear.[11]

Differentiating Endometritis from other Diseases

Puerperal endometritis must be differentiated from:[3]

Epidemiology

Puerperal Endometritis

The prevalence of endometritis is 1% to 2% of births and 27% of cesarean births.[33][34]

Chronic Endometritis

The prevalence of chronic endometritis (CE) is about 10% to 11% on biopsies performed from hysterectomies of patients with gynecologic conditions.[20][32]

In a study, the prevalence of CE has been reported to be 15% in infertile women with in vitro fertilization (IVF) and 42% in women with recurrent implantation failure (RIF).[35]

The prevalence of CE has been reported to be 57.8% in women with three or more recurrent pregnancy losses (RPLs).[36]

In one study, the prevalence of CE has been reported to be 14% and 27% in patients with RIF or RPL, respectively.[37]

Risk Factors

Risk Factors 
Puerperal Endometritis Chronic Endometritis
Risk factors associated with puerperal endometritis include:[33][34][38][9] Risk factors that have been reported to be associated with chronic endometritis (CE) include:[20][39][40][41][42][43][44][45][46][47]

Screening

Routine antepartum screening for GBS infection and treatment of genital tract infections are important in preventing puerperal genital tract infection.[48]

There is insufficient evidence to recommend routine screening for chronic endometritis (CE). However, it has been suggested that hysteroscopy may have the potential to be a screening tool for CE.[11]

Natural History, Complications, and Prognosis

Natural History

Studies have suggested that patients with chronic endometritis (CE) may develop:[49][35][36]

Complications

Complications 
Puerperal Endometritis Chronic Endometritis
Complications of puerperal endometritis after cesarean birth may include:[34][50] Common complications of chronic endometritis (CE) include:[51][52][53][49][54]

Prognosis

A study showed that after antibiotic treatment of patients with CE and recurrent pregnancy losses (RPLs), the pre-pregnancy live birth rate increased from 7% (before treatment) to 56% (after treatment).[52]

Another study showed that after antibiotic treatment of patients with CE, the implantation rate and pregnancy rate increased from 4.9% and 7.4% (before treatment) to 18.6% and 29.3% (after treatment), respectively.[55]

Diagnosis

Diagnostic Study of Choice

The histological finding of acute endometritis includes a large number of neutrophils in the endometrial stroma.[56]

The diagnosis of chronic endometritis (CE) is made with endometrial biopsy and the histological diagnostic criterion is plasma cells in the endometrial stroma.[20][57]

History and Symptoms

History and Symptoms 
Acute Endometritis Chronic Endometritis
Symptoms of acute endometritis may include:[58][59] Chronic endometritis (CE) is mostly asymptomatic but may have vague symptoms including:[58][60][61]

Physical Examination

Clinical findings found on physical examination in puerperal endometritis may include:[59]

Laboratory Findings

Laboratory tests in puerperal endometritis include:[48][3]

There is insufficient evidence that suggests obtaining endometrial or cervical cultures in puerperal endometritis due to contamination while obtaining an endometrial culture.[62][63]

Laboratory findings in acute endometritis may include:[64]

Staining used in histological detection of chronic endometritis (CE) include:

Electrocardiogram

There are no ECG findings associated with endometritis.

X-ray

There are no x-ray findings associated with endometritis. However, a chest x-ray should be performed if there is suspicion of a respiratory disorder.[3]

Echocardiography or Ultrasound

There are no echocardiography findings associated with endometritis.

Ultrasound is usually not helpful in the diagnosis of endometritis. However, an ultrasound may be helpful to rule out other disorders in postpartum patients that are nonresponsive to therapy.[67] Ultrasound and CT findings in postpartum endometritis may include:[67][68][69][70][71]

CT scan

Ultrasound and CT findings in postpartum endometritis may include:[67][68][69][70][71]

Compared to ultrasound, CT scan is more helpful in identifying the inflammation of the soft tissues and pelvic abscesses.[72]

MRI

There are no specific MRI findings associated with endometritis. However, MRI may be helpful if there is suspicion of septic pelvic thrombophlebitis.[62]

Other Imaging Findings

Fluid hysteroscopy is helpful in diagnosing chronic endometritis (CE) and the findings include:[18][27]

Treatment

Medical Therapy

Histopathology 
Postpartum Endometritis Chronic Endometritis
Patients with postpartum endometritis are recommended to be treated with either:[73] Patients with chronic endometritis (CE) are treated with:

Surgery

Surgery may be indicated if there is drainable fluid collection due to infection.[62]

Primary Prevention

The American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) recommend antimicrobial prophylaxis 60 minutes prior to incision of cesarean birth.[74][75][76]

A Conchrane study showed that antimicrobial prophylaxis decreases uterine and wound infections.[75]

Some of the measures that should be considered in order to reduce genital tract infections include:[48][75][77][78]

Secondary Prevention

There are no established measures for the secondary prevention of endometritis.

References

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