Endometritis resident survival guide

Jump to navigation Jump to search


Endometritis Resident Survival Guide Microchapters
Overview
Causes
Diagnosis
Treatment
Dos
Don'ts


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Rinky Agnes Botleroo, M.B.B.S.

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

Overview

Endometritis is inflammation of the uterine lining which can affect all layers of the uterus. The uterus is usually aseptic but the travel of microbes from the cervix and vagina can lead to inflammation and infection. 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.It commonly occurs as a result of the rupture of membranes during childbirth. It 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.

Causes

Postpartum endometritis

Postpartum endometritis is caused by bacteria ascending from the lower genital tract into the cervix during labor. These bacterias that are the vaginal microflora include:[1]


Chronic endometritis:
Common cause of chronic endometritis (CE) is an infection with microorganisms, including:[2][3][4]

Acute endometritis:

Acute endometritis may be caused by Chlamydia trachomatis and Neisseria gonorrhea.[5]

❑ Risk factors associated with puerperal endometritis include:[6][7][8][1]

Risk factors that have been reported to be associated with chronic endometritis (CE) include:[9][10][11][12][13][14][15][16][17][18]

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Endometritis:[19][20]

Abbreviations: BP: Blood pressure; RR=Respiratory rate; HR=Heart Rate, IV= Intravenous

 
 
 
 
 
 
Pregnant woman comes with Endometritis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Take complete history
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions about menstrual history :

❑ Age of menarche

❑ Last menstrual period

❑ Is the menstrual flow normal? How many pads she has to use in a day?

❑ Is there any foul smell or colour change?

❑ How many days does the menstruation stay?

Contraceptive history for example oral contraceptives, intrauterine device

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask the following questions :

❑ Do you have painful periods or menstrual cramps or excessive pain during menstruation?

❑ Have you experienced pain during sexual intercourse?

❑ Is there any pain in pelvis or abdomen?

❑ Have you experienced low back pain recently which is not due to mechanical problems?

❑ Have you noticed irregular bleeding?

❑ Have you felt abdominal pain on urination?

❑ Is there any urinary symptoms not specified as with cycle (frequency, dysuria, haematuria, presumed urinary tract infection)?

❑ Is there any menstrual haematuria?

❑ Have you had any pain on defecation which is not due to haemorrhoids or anal fissure?

❑ Is there any rectal bleeding not due to haemorrhoids or anal fissure?

❑ Is there any cyclical extrapelvic pain?

❑ Have you experienced postcoital bleeding?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Look if the following symptoms are present :

Fever,the grade of the fever is often indicative of the severity of the infection.

Abdominal pain (commonly suprapubic in location)

❑ Foul-smelling and purulent lochia.

Tachycardia

Hypotension.

Sepsis, diarrhoea, pain out of proportion in case of endometritis caused by Group A Streptococcus which may develop into toxic shock and necrotizing fasciitis.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Ask about previous obstetric history if she was previously pregnant :

❑ Ask about previous pregnancies including miscarriages and terminations.

❑ Length of gestation.

❑ Ask about mode of delivery.

❑ Was there any complications throughout the pregnancy or during delivery such as shoulder dystocia, postpartum haemorrhage ?

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Perform the physical examination :

Suprapubic and uterine tenderness are often present on abdominal and pelvic exams.

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do the laboratory tests:

Complete blood count : A leukocytosis of 15000 to 30000 cells/microL is commonly seen.

Cervical cultures taken before antibiotic administration can be helpful for appropriate antibiotic selection.

Vaginal cultures are often contaminated and can mislead to inadequate antibiotic coverage.

Blood cultures should be obtained if there is a high enough clinical suspicion for sepsis or bacteremia.

Ultrasound can be used to rule out retained products of conception, infected hematoma, and uterine abscesses. Patients with endometritis, findings consist of a thickened, heterogeneous endometrium, intracavitary fluid, and foci of air.

Computed tomography can show the same positive findings as ultrasound plus possible perimetrium or intrauterine inflammation and infection.[21][22][23][24]
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

Shown below is an algorithm summarizing the treatment of mild endometritis.[25]

Drugs Dose Specific considration
Doxycycline
+
Metronidazole

❑ 100 mg orally every 12 hourly.

+

❑ 500 mg every 12 hours


Doxycycline is not contraindicated in breastfeeding mothers if its use is for less than three weeks.
Levofloxacin
+
Metronidazole

❑ 500 mg every 24 hours.

+

❑ 500 mg every 08 hours.

Levofloxacin should be avoided in breastfeeding mothers.
Amoxicillin-clavulanate[26]


❑ 875 mg/125 mg every 12 hours.



Shown below is an algorithm summarizing the treatment of moderate to severe endometritis.[25]

Drugs Dose Specific considration
Gentamicin
+
Clindamycin

❑ 1.5 mg/kg IV every 8 hours
or
5 mg/kg IV every 24 hours.

+

❑ 900 mg every 8 hours.


Gentamicin dosing once a day is associated with a shorter hospitalization time compared with three times a day dosing and is as effective.[27]


❑ Patients with endometritis due to GBS resistant to Clindamycin, piperacillin-tazobactam and ampicillin-sulbactam may be used.[28]



Endometritis can cause complications including sepsis, abscesses, hematoma, septic pelvic thrombophlebitis and necrotizing fasciitis. Such complications can lead to uterine necrosiswhich may need a hysterectomy for infection resolution.

Surgical intervention may also be necessary if the infection has produced a drainable fluid collection.[29]

Dos

Don'ts

  • Do not hesitate to contact the physician if there are any signs of infection.

References

  1. 1.0 1.1 Faro S (2005). "Postpartum endometritis". Clin Perinatol. 32 (3): 803–14. doi:10.1016/j.clp.2005.04.005. PMID 16085035.
  2. Cicinelli E, De Ziegler D, Nicoletti R, Colafiglio G, Saliani N, Resta L; et al. (2008). "Chronic endometritis: correlation among hysteroscopic, histologic, and bacteriologic findings in a prospective trial with 2190 consecutive office hysteroscopies". Fertil Steril. 89 (3): 677–84. doi:10.1016/j.fertnstert.2007.03.074. PMID 17531993.
  3. Cicinelli E, De Ziegler D, Nicoletti R, Tinelli R, Saliani N, Resta L; et al. (2009). "Poor reliability of vaginal and endocervical cultures for evaluating microbiology of endometrial cavity in women with chronic endometritis". Gynecol Obstet Invest. 68 (2): 108–15. doi:10.1159/000223819. PMID 19521097.
  4. Kitaya K, Matsubayashi H, Takaya Y, Nishiyama R, Yamaguchi K, Takeuchi T; et al. (2017). "Live birth rate following oral antibiotic treatment for chronic endometritis in infertile women with repeated implantation failure". Am J Reprod Immunol. 78 (5). doi:10.1111/aji.12719. PMID 28608596.
  5. Vicetti Miguel RD, Chivukula M, Krishnamurti U, Amortegui AJ, Kant JA, Sweet RL; et al. (2011). "Limitations of the criteria used to diagnose histologic endometritis in epidemiologic pelvic inflammatory disease research". Pathol Res Pract. 207 (11): 680–5. doi:10.1016/j.prp.2011.08.007. PMC 3215901. PMID 21996319.
  6. French LM, Smaill FM (2004). "Antibiotic regimens for endometritis after delivery". Cochrane Database Syst Rev (4): CD001067. doi:10.1002/14651858.CD001067.pub2. PMID 15495005.
  7. Sweet, Richard (2009). Infectious diseases of the female genital tract. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 978-0-7817-7815-2. OCLC 268792315.
  8. Belfort MA, Clark SL, Saade GR, Kleja K, Dildy GA, Van Veen TR; et al. (2010). "Hospital readmission after delivery: evidence for an increased incidence of nonurogenital infection in the immediate postpartum period". Am J Obstet Gynecol. 202 (1): 35.e1–7. doi:10.1016/j.ajog.2009.08.029. PMID 19889389.
  9. Kitaya K, Yasuo T (2011). "Immunohistochemistrical and clinicopathological characterization of chronic endometritis". Am J Reprod Immunol. 66 (5): 410–5. doi:10.1111/j.1600-0897.2011.01051.x. PMID 21749546.
  10. Moyer DL, Mishell DR, Bell J (1970). "Reactions of human endometrium to the intrauterine device. I. Correlation of the endometrial histology with the bacterial environment of the uterus following short-term insertion of the IUD". Am J Obstet Gynecol. 106 (6): 799–809. doi:10.1016/0002-9378(70)90470-9. PMID 4984305.
  11. Smith M, Hagerty KA, Skipper B, Bocklage T (2010). "Chronic endometritis: a combined histopathologic and clinical review of cases from 2002 to 2007". Int J Gynecol Pathol. 29 (1): 44–50. doi:10.1097/PGP.0b013e3181ae81bb. PMID 19952932.
  12. Chen YQ, Fang RL, Luo YN, Luo CQ (2016). "Analysis of the diagnostic value of CD138 for chronic endometritis, the risk factors for the pathogenesis of chronic endometritis and the effect of chronic endometritis on pregnancy: a cohort study". BMC Womens Health. 16 (1): 60. doi:10.1186/s12905-016-0341-3. PMC 5477816. PMID 27596852.
  13. Cicinelli E, Trojano G, Mastromauro M, Vimercati A, Marinaccio M, Mitola PC; et al. (2017). "Higher prevalence of chronic endometritis in women with endometriosis: a possible etiopathogenetic link". Fertil Steril. 108 (2): 289–295.e1. doi:10.1016/j.fertnstert.2017.05.016. PMID 28624114.
  14. Takebayashi A, Kimura F, Kishi Y, Ishida M, Takahashi A, Yamanaka A; et al. (2014). "The association between endometriosis and chronic endometritis". PLoS One. 9 (2): e88354. doi:10.1371/journal.pone.0088354. PMC 3928198. PMID 24558386.
  15. Korn AP, Bolan G, Padian N, Ohm-Smith M, Schachter J, Landers DV (1995). "Plasma cell endometritis in women with symptomatic bacterial vaginosis". Obstet Gynecol. 85 (3): 387–90. doi:10.1016/0029-7844(94)00400-8. PMID 7862377.
  16. Peipert JF, Montagno AB, Cooper AS, Sung CJ (1997). "Bacterial vaginosis as a risk factor for upper genital tract infection". Am J Obstet Gynecol. 177 (5): 1184–7. doi:10.1016/s0002-9378(97)70038-3. PMID 9396917.
  17. Jindal UN, Verma S, Bala Y (2012). "Favorable infertility outcomes following anti-tubercular treatment prescribed on the sole basis of a positive polymerase chain reaction test for endometrial tuberculosis". Hum Reprod. 27 (5): 1368–74. doi:10.1093/humrep/des076. PMID 22419745.
  18. Degani S, Gonen R, de Vries K, Sharf M (1983). "Endometrial ossification associated with repeated abortions". Acta Obstet Gynecol Scand. 62 (3): 281–2. doi:10.3109/00016348309155810. PMID 6414236.
  19. Pugsley Z, Ballard K (June 2007). "Management of endometriosis in general practice: the pathway to diagnosis". Br J Gen Pract. 57 (539): 470–6. PMC 2078174. PMID 17550672.
  20. Olive DL, Schwartz LB (June 1993). "Endometriosis". N Engl J Med. 328 (24): 1759–69. doi:10.1056/NEJM199306173282407. PMID 8110213.
  21. Plunk M, Lee JH, Kani K, Dighe M (February 2013). "Imaging of postpartum complications: a multimodality review". AJR Am J Roentgenol. 200 (2): W143–54. doi:10.2214/AJR.12.9637. PMID 23345378.
  22. Nalaboff KM, Pellerito JS, Ben-Levi E (2001). "Imaging the endometrium: disease and normal variants". Radiographics. 21 (6): 1409–24. doi:10.1148/radiographics.21.6.g01nv211409. PMID 11706213.
  23. Laifer-Narin SL, Kwak E, Kim H, Hecht EM, Newhouse JH (2014). "Multimodality imaging of the postpartum or posttermination uterus: evaluation using ultrasound, computed tomography, and magnetic resonance imaging". Curr Probl Diagn Radiol. 43 (6): 374–85. doi:10.1067/j.cpradiol.2014.06.001. PMID 25041975.
  24. Vandermeermd FQ, Wong-You-Cheong JJ (July 2010). "Imaging of acute pelvic pain". Top Magn Reson Imaging. 21 (4): 201–11. doi:10.1097/RMR.0b013e31823d7feb. PMID 22082769.
  25. 25.0 25.1 "Endometritis - StatPearls - NCBI Bookshelf".
  26. Meaney-Delman D, Bartlett LA, Gravett MG, Jamieson DJ (April 2015). "Oral and intramuscular treatment options for early postpartum endometritis in low-resource settings: a systematic review". Obstet Gynecol. 125 (4): 789–800. doi:10.1097/AOG.0000000000000732. PMID 25751198.
  27. Del Priore G, Jackson-Stone M, Shim EK, Garfinkel J, Eichmann MA, Frederiksen MC (June 1996). "A comparison of once-daily and 8-hour gentamicin dosing in the treatment of postpartum endometritis". Obstet Gynecol. 87 (6): 994–1000. doi:10.1016/0029-7844(96)00054-3. PMID 8649712.
  28. Mackeen AD, Packard RE, Ota E, Speer L (February 2015). "Antibiotic regimens for postpartum endometritis". Cochrane Database Syst Rev (2): CD001067. doi:10.1002/14651858.CD001067.pub3. PMC 7050613 Check |pmc= value (help). PMID 25922861.
  29. Karsnitz DB (2013). "Puerperal infections of the genital tract: a clinical review". J Midwifery Womens Health. 58 (6): 632–42. doi:10.1111/jmwh.12119. PMID 24406036.
  30. "Endometritis: Causes, Symptoms, and Diagnosis".
  31. Maharaj D (2007). "Puerperal pyrexia: a review. Part I." Obstet Gynecol Surv. 62 (6): 393–9. doi:10.1097/01.ogx.0000265998.40912.5e. PMID 17511893.
  32. Smaill FM, Gyte GM (2010). "Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section". Cochrane Database Syst Rev (1): CD007482. doi:10.1002/14651858.CD007482.pub2. PMC 4007637. PMID 20091635.
  33. Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J (2010). "Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis". Am J Obstet Gynecol. 203 (3): 243.e1–8. doi:10.1016/j.ajog.2010.05.028. PMID 20598284.
  34. National Collaborating Centre for Primary Care (UK) (2006). "Postnatal Care: Routine Postnatal Care of Women and Their Babies". National Institute for Health and Clinical Excellence: Guidance. PMID 21834192.