Endometritis resident survival guide

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:

• Alpha hemolytic streptococci
• Corynebacterium
• Diphtheroids
• E.coli
• Enterobacter agglomerans, Enterobacter cloacae, Enterobacter aerogenes
• Fusobacterium necrophorum
• Klebsiella pneumoniae
• Lactobacillus crispatus, L casei, L jansei
• Mycoplasma genitalia, Mycoplasma hominis
• Nondescript streptococci
• Prevotella bivia, Prevotella melaninogenicus
• Staphylococcus epidermidis
• Ureaplasma urealyticum

Chronic endometritis:
Common cause of chronic endometritis (CE) is an infection with microorganisms, including:

• Bacteria:
  • Escherichia coli
  • Streptococcus species
  • Staphylococcus species
  • Enterococcus faecalis
  • Mycoplasma or ureaplasma species:
    • Mycoplasma genitalium
    • Mycoplasma hominis
    • Ureaplasma urealyticum
  • Proteus species
  • Klebsiella pneumoniae
  • Pseudomonas aeruginosa
  • Gardnerella vaginalis
  • Corynebacterium
• Yeasts:
  • Candida species
  • Saccharomyces cerevisiae

Acute endometritis:

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

❑ Risk factors associated with puerperal endometritis include:

• Cesarean birth
• Surgical or instrumental birth
• Chorioamnionitis
• Prolonged rupture of membranes
• Retained placental fragments
• Postpartum hemorrhage
• Frequent vaginal examinations
• Colonization with group B Streptococcus

❑ Risk factors that have been reported to be associated with chronic endometritis (CE) include:

• Intrauterine contraceptive devices (continuous use)
• Prolonged menstruation
• Atypical uterine bleeding
• Fallopian tube obstruction
• Multiparity
• Abortion
• Bacterial vaginosis
• Endometrial hyperplasia
• Submucosal fibroids
• Endometriosis
• Endometrial osseous metaplasia
• Tuberculosis

Diagnosis

Shown below is an algorithm summarizing the diagnosis of Endometritis:

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

Pregnant woman comes with Endometritis

Take complete history

Record the vitals: ❑ Blood pressure ❑ Temperature ❑ Respiratory rate ❑ Heart rate

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.

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

• To reduce the risk of endometritis caused by STDs
  • Patient should practise safe sex, such as using condoms.
  • Patient should get routine screening and early diagnosis of suspected STDs, in both herself and partner.
  • She should finish all treatment prescribed for an STD.
• To reduce the risk of endometritis caused by caesarean section prophylactic antibiotics before cesarean deliveries should be given.
• Some of the measures that should be considered in order to reduce genital tract infections include:
  • Routine antepartum screening and treatment of GBS and infections
  • Handwashing
  • Aseptic procedure
  • Decrease in vaginal examinations
  • Limiting use of invasive procedures
  • Limiting episiotomies
  • Synthetic suture use
  • Decrease in cesarean births
  • Rapid repair of lacerations
  • Standard suture techniques
  • Prophylaxis with antibiotics in anal sphincter injuries

Don'ts

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