Endometritis: Difference between revisions

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* [[Acute]] endometritis
* [[Acute]] endometritis
* [[Chronic]] endometritis (CE)
* [[Chronic]] endometritis (CE)
===Pyometria===


==Pathophysiology==
==Pathophysiology==

Revision as of 06:44, 5 October 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Overview

Endometritis refers to inflammation of the endometrium,[1] the inner lining of the uterus. Pathologists have traditionally classified endometritis as either acute or chronic: acute endometritis is characterized by the presence of microabscesses or neutrophils within the endometrial glands, while chronic endometritis is distinguished by variable numbers of plasma cells within the endometrial stroma. The most common cause of endometritis is infection. Symptoms include lower abdominal pain, fever and abnormal vaginal bleeding or discharge. Caesarean section, prolonged rupture of membranes and long labor with multiple vaginal examinations are important risk factors. Treatment is usually with broad-spectrum antibiotics.

The term "endomyometritis" is sometimes used to specify inflammation of the endometrium and the myometrium.[2]

Acute Endometritis

Acute Endometritis is characterized by infection. The organisms isolated are most often infection are believed to be because of compromised abortions, delivery, medical instrumentation, and retention of placental fragments. Histologically, neutrophilic infiltration of the endometrial tissue is present during acute endometritis. The clinical presentation is typically high fever and purulent vaginal discharge. Menstruation after acute endometritis is excessive and in uncomplicated cases can resolve after 2 weeks of clindamycin and gentamicin IV antibiotic treatment.

In certain populations, it has been associated with Mycoplasma genitalium.[3]

Chronic Endometritis

Chronic Endometritis is characterized by the presence of plasma cells in the stroma. Lymphocytes, eosinophils, and even lymphoid follicles may be seen, but in the absence of plasma cells, are not enough to warrant a histologic diagnosis. It may be seen in up to 10% of all endometrial biopsies performed for irregular bleeding. The most common organisms are Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhea), Streptococcus agalactiae (Group B Streptococcus), Mycoplasma hominis, tuberculosis, and various viruses. Most of these agents are capable of causing chronic pelvic inflammatory disease (PID). Patients suffering from chronic endometritis may have an underlying cancer of the cervix or endometrium (although infectious etiology is more common). Antibiotic therapy is curative in most cases (depending on underlying etiology), with fairly rapid alleviation of symptoms after only 2 to 3 days.

Chronic granulomatous endometritis is usually caused by tuberculous. The granulomas are small, sparse, and without caseation. The granulomas take up to 2 weeks to develop and since the endometrium is shed every 4 weeks, the granulomas are poorly formed.

In human medicine, pyometra (also a veterinary condition of significance) is regarded as a form of chronic endometritis seen in elderly women causing stenosis of the cervical os and accumulation of discharges and infection. Symptom in chronic endometritis is blood stained discharge but in pyometra the patient complaints of lower abdominal pain.

Pyometra

Pyometra describes an accumulation of pus in the uterine cavity. In order for pyometra to develop, there must be both an infection and blockage of cervix. Signs and symptoms include lower abdominal pain (suprapubic), rigors, fever, and the discharge of pus on introduction of a sound into the uterus. Pyometra is treated with antibiotics, according to culture and sensitivity.

See also


Overview

Historical Perspective

[Disease name] was first discovered by [name of scientist], a [nationality + occupation], in [year]/during/following [event].

The association between [important risk factor/cause] and [disease name] was made in/during [year/event].

In [year], [scientist] was the first to discover the association between [risk factor] and the development of [disease name].

In [year], [gene] mutations were first implicated in the pathogenesis of [disease name].

There have been several outbreaks of [disease name], including -----.

In [year], [diagnostic test/therapy] was developed by [scientist] to treat/diagnose [disease name].

Classification

Endometritis may be classified according to histopathology into two subtypes:[4]

Pyometria

Pathophysiology

Postpartum endometritis

Postpartum endometritis is caused by bacteria (vaginal microflora) ascending from the lower genital tract during labor.[5]

Artificial or spontaneous rupture of membranes may also happen without bacterial colonization.[5]

Chronic Endometritis

Histopathology

Acute Endometritis

The histopathologic findings in acute endometritis include:[4]

Chronic Endometritis

The histopathologic findings in chronic endometritis (CE) include:[4][6]

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).[7]

Causes

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:[5]

Acute endometritis is mostly caused by Chlamydia trachomatis and Neisseria gonorrhoeae[8].

The most common cause of chronic endometritis (CE) is an infection with microorganisms, including:[9][10][11]

Mycobacterium tuberculosis causes a subtype of chronic endometritis (CE) (chronic granulomatous endometritis) in some developing countries.[7]

The rate of infections with Chlamydia trachomatis (2%–7%) and Neisseria gonorrhea (0%–8%) in chronic endometritis (CE) are very low. [9][12][13]

The association of viral infections as causes of chronic endometritis (CE) is still unclear.[14]

Differentiating Endometritis from other Diseases

Puerperal endometritis must be differentiated from:[15]

Epidemiology

Puerperal Endometritis

The prevalence of endometritis is 1% to 2% of births and 27% of cesarean births.[16][17]

Chronic Endometritis

The prevalence of chronic endometritis (CE) is about 10% to 11% on biopsies performed from hysterectomies of patients with gynecologic conditions.[18][13]

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).[19]

The prevalence of CE has been reported to be 57.8% in women with three or more recurrent pregnancy losses (RPLs).[20]

In one study, the prevalence of CE has been reported to be 14% and 27% in patients with RIF or RPL, respectively.[21]

Risk Factors

Risk factors associated with puerperal endometritis include:[16][17][22][5]

Risk factors that have been reported to be associated with chronic endometritis (CE) include:[18][23][24][25][26][27][28][29][30][31]

Screening

Routine antepartum screening for GBS infection and treatment of genital tract infections are important in preventing puerperal genital tract infection.[32]

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.[14]

Natural History, Complications, and Prognosis

Natural History

Studies have suggested that patients with chronic endometritis (CE) may develop:[33][19][20]

Complications

Complications of puerperal endometritis after cesarean birth may include:[17][34]

Common complications of chronic endometritis (CE) include:[35][36][37][33][38]

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).[36]

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.[39]

Diagnosis

Diagnostic Study of Choice

The histological finding of acute endometritis includes a large number of neutrophils in the endometrial stroma.[40]

The diagnosis of chronic endometritis (CE) is made with endometrial biopsy and the histological diagnostic criterion is plasma cells in the endometrial stroma.[18][41]

History and Symptoms

Symptoms of acute endometritis may include:[42][43]

Chronic endometritis (CE) is mostly asymptomatic but may have vague symptoms including:[42][44][45]

Physical Examination

Clinical findings found on physical examination in puerperal endometritis may include:[43]

Laboratory Findings

Laboratory tests in puerperal endometritis include:[32][15]

There is insufficient evidence that suggests obtaining endometrial or cervical cultures in puerperal endometritis due to contamination while obtaining an endometrial culture.[46][47]

Laboratory findings in acute endometritis may include:[48]

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.[15]

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.[51] Ultrasound and CT findings in postpartum endometritis may include:[51][52][53][54][55]

or

  • Nonspecific findings due to retained products of conception:
    • Intrauterine fluid (with or without internal echoes due to blood, gas, or retained products of pregnancy)
    • Thickened heterogeneous endometrium

CT scan

Ultrasound and CT findings in postpartum endometritis may include:[51][52][53][54][55]

or

  • Nonspecific findings due to retained products of conception:
    • Intrauterine fluid (with or without internal echoes due to blood, gas, or retained products of pregnancy)
    • Thickened heterogeneous endometrium

Compared to ultrasound, CT scan is more helpful in identifying the inflammation of the soft tissues and pelvic abscesses.[56]

MRI

There are no specific MRI findings associated with endometritis. However, MRI may be helpful if there is suspicion of septic pelvic thrombophlebitis.[46]

Other Imaging Findings

Fluid hysteroscopy is helpful in diagnosing chronic endometritis (CE) and the findings include:[57][9]

Treatment

Medical Therapy

Patients with postpartum endometritis are recommended to be treated with either:[58]

Patients with chronic endometritis (CE) are treated with:

Surgery

Surgery may be indicated if there is drainable fluid collection due to infection.[46]

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.[59][60][61]

A Conchrane study showed that antimicrobial prophylaxis decreases uterine and wound infections.[60]

Some of the measures that should be considered in order to reduce genital tract infections include:[32][60][62][63]

Secondary Prevention

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

References

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