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, pyometra

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

Main article: 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

Classification

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

Pyometra

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

In the normal endometrium, B-cells are mostly seen in the basal layer.[6]

In chronic endometritis (CE):[7]

Histopathology

Histopathology 
Acute Endometritis Chronic Endometritis
The histopathologic findings in acute endometritis include:[4] The histopathologic findings in chronic endometritis (CE) include:[4][22]

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).[23]

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:[5] The most common cause of chronic endometritis (CE) is an infection with microorganisms, including:[24][25][26]

Acute endometritis is mostly caused by Chlamydia trachomatis and Neisseria gonorrhoeae[27].

Mycobacterium tuberculosis causes a subtype of chronic endometritis (CE) (chronic granulomatous endometritis) in some developing countries.[23]

The rate of infections with Chlamydia trachomatis (2%–7%) and Neisseria gonorrhea (0%–8%) in chronic endometritis (CE) are very low. [24][28][29]

The association of viral infections as causes of chronic endometritis (CE) is still unclear.[7]

Differentiating Endometritis from other Diseases

Puerperal endometritis must be differentiated from:[30]

Epidemiology

Puerperal Endometritis

The prevalence of endometritis is 1% to 2% of births and 27% of cesarean births.[31][32]

Chronic Endometritis

The prevalence of chronic endometritis (CE) is about 10% to 11% on biopsies performed from hysterectomies of patients with gynecologic conditions.[16][29]

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).[33]

The prevalence of CE has been reported to be 57.8% in women with three or more recurrent pregnancy losses (RPLs).[34]

In one study, the prevalence of CE has been reported to be 14% and 27% in patients with RIF or RPL, respectively.[35]

Risk Factors

Risk Factors 
Puerperal Endometritis Chronic Endometritis
Risk factors associated with puerperal endometritis include:[31][32][36][5] Risk factors that have been reported to be associated with chronic endometritis (CE) include:[16][37][38][39][40][41][42][43][44][45]

Screening

Routine antepartum screening for GBS infection and treatment of genital tract infections are important in preventing puerperal genital tract infection.[46]

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.[7]

Natural History, Complications, and Prognosis

Natural History

Studies have suggested that patients with chronic endometritis (CE) may develop:[47][33][34]

Complications

Complications 
Puerperal Endometritis Chronic Endometritis
Complications of puerperal endometritis after cesarean birth may include:[32][48] Common complications of chronic endometritis (CE) include:[49][50][51][47][52]

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).[50]

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.[53]

Diagnosis

Diagnostic Study of Choice

The histological finding of acute endometritis includes a large number of neutrophils in the endometrial stroma.[54]

The diagnosis of chronic endometritis (CE) is made with endometrial biopsy and the histological diagnostic criterion is plasma cells in the endometrial stroma.[16][55]

History and Symptoms

History and Symptoms 
Acute Endometritis Chronic Endometritis
Symptoms of acute endometritis may include:[56][57] Chronic endometritis (CE) is mostly asymptomatic but may have vague symptoms including:[56][58][59]

Physical Examination

Clinical findings found on physical examination in puerperal endometritis may include:[57]

Laboratory Findings

Laboratory tests in puerperal endometritis include:[46][30]

There is insufficient evidence that suggests obtaining endometrial or cervical cultures in puerperal endometritis due to contamination while obtaining an endometrial culture.[60][61]

Laboratory findings in acute endometritis may include:[62]

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.[30]

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.[65] Ultrasound and CT findings in postpartum endometritis may include:[65][66][67][68][69]

CT scan

Ultrasound and CT findings in postpartum endometritis may include:[65][66][67][68][69]

Compared to ultrasound, CT scan is more helpful in identifying the inflammation of the soft tissues and pelvic abscesses.[70]

MRI

There are no specific MRI findings associated with endometritis. However, MRI may be helpful if there is suspicion of septic pelvic thrombophlebitis.[60]

Other Imaging Findings

Fluid hysteroscopy is helpful in diagnosing chronic endometritis (CE) and the findings include:[14][24]

Treatment

Medical Therapy

Histopathology 
Postpartum Endometritis Chronic Endometritis
Patients with postpartum endometritis are recommended to be treated with either:[71] Patients with chronic endometritis (CE) are treated with:

Surgery

Surgery may be indicated if there is drainable fluid collection due to infection.[60]

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.[72][73][74]

A Conchrane study showed that antimicrobial prophylaxis decreases uterine and wound infections.[73]

Some of the measures that should be considered in order to reduce genital tract infections include:[46][73][75][76]

Secondary Prevention

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

References

  1. ↑ Template:DorlandsDict
  2. ↑ Hubert Guedj; Baggish, Michael S.; Valle, Rafael Heliodoro (2007). Hysteroscopy: visual perspectives of uterine anatomy, physiology, and pathology. Hagerstwon, MD: Lippincott Williams & Wilkins. p. 488. ISBN 0-7817-5532-8.
  3. ↑ Cohen CR, Manhart LE, Bukusi EA; et al. (2002). "Association between Mycoplasma genitalium and acute endometritis". Lancet. 359 (9308): 765–6. doi:10.1016/S0140-6736(02)07848-0. PMID 11888591. Unknown parameter |month= ignored (help)
  4. ↑ 4.0 4.1 4.2 Kiviat NB, Wølner-Hanssen P, Eschenbach DA, Wasserheit JN, Paavonen JA, Bell TA; et al. (1990). "Endometrial histopathology in patients with culture-proved upper genital tract infection and laparoscopically diagnosed acute salpingitis". Am J Surg Pathol. 14 (2): 167–75. doi:10.1097/00000478-199002000-00008. PMID 2137304.
  5. ↑ 5.0 5.1 5.2 5.3 Faro S (2005). "Postpartum endometritis". Clin Perinatol. 32 (3): 803–14. doi:10.1016/j.clp.2005.04.005. PMID 16085035.
  6. ↑ Yeaman GR, Guyre PM, Fanger MW, Collins JE, White HD, Rathbun W; et al. (1997). "Unique CD8+ T cell-rich lymphoid aggregates in human uterine endometrium". J Leukoc Biol. 61 (4): 427–35. PMID 9103229.
  7. ↑ 7.0 7.1 7.2 Kitaya K, Takeuchi T, Mizuta S, Matsubayashi H, Ishikawa T (2018). "Endometritis: new time, new concepts". Fertil Steril. 110 (3): 344–350. doi:10.1016/j.fertnstert.2018.04.012. PMID 29960704.
  8. ↑ Tabibzadeh SS, Bettica A, Gerber MA (1986). "Variable expression of Ia antigens in human endometrium and in chronic endometritis". Am J Clin Pathol. 86 (2): 153–60. doi:10.1093/ajcp/86.2.153. PMID 3461701.
  9. ↑ 9.0 9.1 Kitaya K, Yasuo T (2010). "Aberrant expression of selectin E, CXCL1, and CXCL13 in chronic endometritis". Mod Pathol. 23 (8): 1136–46. doi:10.1038/modpathol.2010.98. PMID 20495539.
  10. ↑ Matteo M, Cicinelli E, Greco P, Massenzio F, Baldini D, Falagario T; et al. (2009). "Abnormal pattern of lymphocyte subpopulations in the endometrium of infertile women with chronic endometritis". Am J Reprod Immunol. 61 (5): 322–9. doi:10.1111/j.1600-0897.2009.00698.x. PMID 19341383.
  11. ↑ 11.0 11.1 Tortorella C, Piazzolla G, Matteo M, Pinto V, Tinelli R, Sabbà C; et al. (2014). "Interleukin-6, interleukin-1β, and tumor necrosis factor α in menstrual effluents as biomarkers of chronic endometritis". Fertil Steril. 101 (1): 242–7. doi:10.1016/j.fertnstert.2013.09.041. PMID 24314919.
  12. ↑ Salama SA, Kamel MW, Diaz-Arrastia CR, Xu X, Veenstra TD, Salih S; et al. (2009). "Effect of tumor necrosis factor-alpha on estrogen metabolism and endometrial cells: potential physiological and pathological relevance". J Clin Endocrinol Metab. 94 (1): 285–93. doi:10.1210/jc.2008-1389. PMC 2630861. PMID 18957495.
  13. ↑ Kitaya K, Tada Y, Taguchi S, Funabiki M, Hayashi T, Nakamura Y (2012). "Local mononuclear cell infiltrates in infertile patients with endometrial macropolyps versus micropolyps". Hum Reprod. 27 (12): 3474–80. doi:10.1093/humrep/des323. PMID 22951914.
  14. ↑ 14.0 14.1 Cicinelli E, Resta L, Nicoletti R, Zappimbulso V, Tartagni M, Saliani N (2005). "Endometrial micropolyps at fluid hysteroscopy suggest the existence of chronic endometritis". Hum Reprod. 20 (5): 1386–9. doi:10.1093/humrep/deh779. PMID 15734762.
  15. ↑ Kitaya K, Tada Y, Hayashi T, Taguchi S, Funabiki M, Nakamura Y (2014). "Comprehensive endometrial immunoglobulin subclass analysis in infertile women suffering from repeated implantation failure with or without chronic endometritis". Am J Reprod Immunol. 72 (4): 386–91. doi:10.1111/aji.12277. PMID 24898900.
  16. ↑ 16.0 16.1 16.2 16.3 16.4 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.
  17. ↑ Kushnir VA, Solouki S, Sarig-Meth T, Vega MG, Albertini DF, Darmon SK; et al. (2016). "Systemic Inflammation and Autoimmunity in Women with Chronic Endometritis". Am J Reprod Immunol. 75 (6): 672–7. doi:10.1111/aji.12508. PMID 26952510.
  18. ↑ 18.0 18.1 Di Pietro C, Cicinelli E, Guglielmino MR, Ragusa M, Farina M, Palumbo MA; et al. (2013). "Altered transcriptional regulation of cytokines, growth factors, and apoptotic proteins in the endometrium of infertile women with chronic endometritis". Am J Reprod Immunol. 69 (5): 509–17. doi:10.1111/aji.12076. PMID 23351011.
  19. ↑ Mishra K, Wadhwa N, Guleria K, Agarwal S (2008). "ER, PR and Ki-67 expression status in granulomatous and chronic non-specific endometritis". J Obstet Gynaecol Res. 34 (3): 371–8. doi:10.1111/j.1447-0756.2007.00700.x. PMID 18686353.
  20. ↑ Pickartz H, Beckmann R, Fleige B, Düe W, Gerdes J, Stein H (1990). "Steroid receptors and proliferative activity in non-neoplastic and neoplastic endometria". Virchows Arch A Pathol Anat Histopathol. 417 (2): 163–71. doi:10.1007/BF02190535. PMID 2114696.
  21. ↑ 21.0 21.1 Wu D, Kimura F, Zheng L, Ishida M, Niwa Y, Hirata K; et al. (2017). "Chronic endometritis modifies decidualization in human endometrial stromal cells". Reprod Biol Endocrinol. 15 (1): 16. doi:10.1186/s12958-017-0233-x. PMC 5336610. PMID 28259137.
  22. ↑ Greenwood SM, Moran JJ (1981). "Chronic endometritis: morphologic and clinical observations". Obstet Gynecol. 58 (2): 176–84. PMID 7254729.
  23. ↑ 23.0 23.1 Kumar P, Shah NP, Singhal A, Chauhan DS, Katoch VM, Mittal S; et al. (2008). "Association of tuberculous endometritis with infertility and other gynecological complaints of women in India". J Clin Microbiol. 46 (12): 4068–70. doi:10.1128/JCM.01162-08. PMC 2593260. PMID 18842939.
  24. ↑ 24.0 24.1 24.2 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.
  25. ↑ 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.
  26. ↑ 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.
  27. ↑ 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.
  28. ↑ Haggerty CL, Hillier SL, Bass DC, Ness RB, PID Evaluation and Clinical Health study investigators (2004). "Bacterial vaginosis and anaerobic bacteria are associated with endometritis". Clin Infect Dis. 39 (7): 990–5. doi:10.1086/423963. PMID 15472851.
  29. ↑ 29.0 29.1 Polisseni F, Bambirra EA, Camargos AF (2003). "Detection of chronic endometritis by diagnostic hysteroscopy in asymptomatic infertile patients". Gynecol Obstet Invest. 55 (4): 205–10. doi:10.1159/000072075. PMID 12904693.
  30. ↑ 30.0 30.1 30.2 Cunningham, F (2010). Williams obstetrics. New York: McGraw-Hill Medical. ISBN 978-0-07-149701-5. OCLC 495191519.
  31. ↑ 31.0 31.1 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.
  32. ↑ 32.0 32.1 32.2 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.
  33. ↑ 33.0 33.1 Romero R, Espinoza J, Mazor M (2004). "Can endometrial infection/inflammation explain implantation failure, spontaneous abortion, and preterm birth after in vitro fertilization?". Fertil Steril. 82 (4): 799–804. doi:10.1016/j.fertnstert.2004.05.076. PMID 15482749.
  34. ↑ 34.0 34.1 Zolghadri J, Momtahan M, Aminian K, Ghaffarpasand F, Tavana Z (2011). "The value of hysteroscopy in diagnosis of chronic endometritis in patients with unexplained recurrent spontaneous abortion". Eur J Obstet Gynecol Reprod Biol. 155 (2): 217–20. doi:10.1016/j.ejogrb.2010.12.010. PMID 21232841.
  35. ↑ Bouet PE, El Hachem H, Monceau E, Gariépy G, Kadoch IJ, Sylvestre C (2016). "Chronic endometritis in women with recurrent pregnancy loss and recurrent implantation failure: prevalence and role of office hysteroscopy and immunohistochemistry in diagnosis". Fertil Steril. 105 (1): 106–10. doi:10.1016/j.fertnstert.2015.09.025. PMID 26456229.
  36. ↑ 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.
  37. ↑ 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.
  38. ↑ 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.
  39. ↑ 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.
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  45. ↑ 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.
  46. ↑ 46.0 46.1 46.2 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.
  47. ↑ 47.0 47.1 Kitaya K, Matsubayashi H, Yamaguchi K, Nishiyama R, Takaya Y, Ishikawa T; et al. (2016). "Chronic Endometritis: Potential Cause of Infertility and Obstetric and Neonatal Complications". Am J Reprod Immunol. 75 (1): 13–22. doi:10.1111/aji.12438. PMID 26478517.
  48. ↑ Soper DE (2012). "Early recognition of serious infections in obstetrics and gynecology". Clin Obstet Gynecol. 55 (4): 858–63. doi:10.1097/GRF.0b013e3182730f43. PMID 23090454.
  49. ↑ 49.0 49.1 Johnston-MacAnanny EB, Hartnett J, Engmann LL, Nulsen JC, Sanders MM, Benadiva CA (2010). "Chronic endometritis is a frequent finding in women with recurrent implantation failure after in vitro fertilization". Fertil Steril. 93 (2): 437–41. doi:10.1016/j.fertnstert.2008.12.131. PMID 19217098.
  50. ↑ 50.0 50.1 50.2 50.3 McQueen DB, Bernardi LA, Stephenson MD (2014). "Chronic endometritis in women with recurrent early pregnancy loss and/or fetal demise". Fertil Steril. 101 (4): 1026–30. doi:10.1016/j.fertnstert.2013.12.031. PMID 24462055.
  51. ↑ Kitaya K (2011). "Prevalence of chronic endometritis in recurrent miscarriages". Fertil Steril. 95 (3): 1156–8. doi:10.1016/j.fertnstert.2010.09.061. PMID 21030015.
  52. ↑ Ghidini A, Salafia CM (2005). "Histologic placental lesions in women with recurrent preterm delivery". Acta Obstet Gynecol Scand. 84 (6): 547–50. doi:10.1111/j.0001-6349.2005.00694.x. PMID 15901265.
  53. ↑ Yang R, Du X, Wang Y, Song X, Yang Y, Qiao J (2014). "The hysteroscopy and histological diagnosis and treatment value of chronic endometritis in recurrent implantation failure patients". Arch Gynecol Obstet. 289 (6): 1363–9. doi:10.1007/s00404-013-3131-2. PMID 24395012.
  54. ↑ Eckert LO, Hawes SE, Wölner-Hanssen PK, Kiviat NB, Wasserheit JN, Paavonen JA; et al. (2002). "Endometritis: the clinical-pathologic syndrome". Am J Obstet Gynecol. 186 (4): 690–5. doi:10.1067/mob.2002.121728. PMID 11967492.
  55. ↑ 55.0 55.1 Kasius JC, Fatemi HM, Bourgain C, Sie-Go DM, Eijkemans RJ, Fauser BC; et al. (2011). "The impact of chronic endometritis on reproductive outcome". Fertil Steril. 96 (6): 1451–6. doi:10.1016/j.fertnstert.2011.09.039. PMID 22019126.
  56. ↑ 56.0 56.1 Michels TC (1995). "Chronic endometritis". Am Fam Physician. 52 (1): 217–22. PMID 7604765.
  57. ↑ 57.0 57.1 King, Tekoa (2015). Varney's midwifery. Burlington, MA: Jones & Bartlett Learning. ISBN 978-1-284-02541-5. OCLC 855888968.
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  59. ↑ Yörükoğlu K, Kuyucouğlu F (1998). "Chronic nonspecific endometritis". Gen Diagn Pathol. 143 (5–6): 287–90. PMID 9653909.
  60. ↑ 60.0 60.1 60.2 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.
  61. ↑ Maharaj D (2007). "Puerperal Pyrexia: a review. Part II". Obstet Gynecol Surv. 62 (6): 400–6. doi:10.1097/01.ogx.0000266063.84571.fb. PMID 17511894.
  62. ↑ Kimura F, Takebayashi A, Ishida M, Nakamura A, Kitazawa J, Morimune A; et al. (2019). "Review: Chronic endometritis and its effect on reproduction". J Obstet Gynaecol Res. 45 (5): 951–960. doi:10.1111/jog.13937. PMID 30843321.
  63. ↑ Bayer-Garner IB, Nickell JA, Korourian S (2004). "Routine syndecan-1 immunohistochemistry aids in the diagnosis of chronic endometritis". Arch Pathol Lab Med. 128 (9): 1000–3. doi:10.1043/1543-2165(2004)128<1000:RSIAIT>2.0.CO;2. PMID 15335255.
  64. ↑ McQueen DB, Perfetto CO, Hazard FK, Lathi RB (2015). "Pregnancy outcomes in women with chronic endometritis and recurrent pregnancy loss". Fertil Steril. 104 (4): 927–931. doi:10.1016/j.fertnstert.2015.06.044. PMID 26207958.
  65. ↑ 65.0 65.1 65.2 Bennett GL, Harvey WB, Slywotzky CM, Birnbaum BA (2003). "CT of the acute abdomen: gynecologic etiologies". Abdom Imaging. 28 (3): 416–32. doi:10.1007/s00261-002-0052-0. PMID 12719915.
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  70. ↑ Bennett GL, Slywotzky CM, Giovanniello G (2002). "Gynecologic causes of acute pelvic pain: spectrum of CT findings". Radiographics. 22 (4): 785–801. doi:10.1148/radiographics.22.4.g02jl18785. PMID 12110710.
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  75. ↑ 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.
  76. ↑ 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.
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