Endometritis resident survival guide

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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

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

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 endometritis are

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Endometritis:[6][7]

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.[8][9][10][11]
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Treatment

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

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 ❑ 875 mg/125 mg every 12 hours.


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

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.


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


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.

Dos

Don'ts

  • The content in this section is in bullet points.

References

  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. 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.
  7. Olive DL, Schwartz LB (June 1993). "Endometriosis". N Engl J Med. 328 (24): 1759–69. doi:10.1056/NEJM199306173282407. PMID 8110213.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. "Endometritis: Causes, Symptoms, and Diagnosis".


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