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Endometritis

Endometritis is inflammation of the endometrium, the inner lining of the uterus.


Presentation

The cardinal presenting features of endometritis are fever and lower abdominal pain. The other features are abdominal swelling, lower abdominal pain or discomfort, abnormal bleeding from the vagina, abnormal discharge from the vagina which could be offensive, constipation or discomfort during a bowel movement, and pelvic pain or discomfort. These symptoms are also almost always associated with malaise or a general feeling of sickness. It is seen that endometritis infection caused by Chlamydia seems to follow an indolent course with no significant constitutional symptoms. Postpartum endometritis manifests with significant fever with chills and more often than not is associated with foul smelling lochia [7]. A rise in temperature of more than 38.7° Celsius in the first 24 hours after delivery or more than 38° Celsius in the first 10 days after delivery is diagnosed as postpartum endometritis.

Infection that is unrelated to pregnancy or delivery or pelvic inflammatory disease also presents with dyspareunia and dysuria. Dysuria is often misdiagnosed as a urinary tract infection whereas the source of infection can frequently be the genital tract. Physical examination of a woman with post partum endometritis reveals pyrexia, tachycardia, lower abdominal tenderness or uterine tenderness. Adnexal tenderness usually points out to affection of the adnexal tissues by way of salpingitis, oophoritis or pelvic peritonitis [8]. Pelvic inflammatory disease usually is found in women with concurrent bacterial vaginosis, multiple sexual partners or from unprotected sexual activity. An improperly treated infection can give rise to complications like peritonitis, pelvic abscess, and pelvic hematoma. A severe case of endometritis can result in septic shock calling for emergency hospital admission.

Infertility
  • We compared the results in infertile women diagnosed with CE with those in unexplained infertile women without any sign of CE.[ncbi.nlm.nih.gov]
  • PROBLEM: The correlations between chronic endometritis and unexplained infertility are unexplored. METHOD OF STUDY: We performed a retrospective study on consecutive patients referred to our hysteroscopy service due to unexplained infertility.[ncbi.nlm.nih.gov]
  • CONCLUSIONS: The interobserver agreement in diagnosing chronic endometritis in asymptomatic infertile patients was found to be substantial.[ncbi.nlm.nih.gov]
  • STUDY DESIGN: We selected 435 asymptomatic infertility patients submitted to office-based diagnostic hysteroscopy and endometrial biopsy.[ncbi.nlm.nih.gov]
  • SETTING: Two tertiary infertility care units. PATIENT(S): A total of 678 asymptomatic infertile women with a normal transvaginal ultrasound (TVS) who underwent diagnostic hysteroscopy before a first IVF/ICSI treatment cycle.[ncbi.nlm.nih.gov]
Secondary Amenorrhea
  • In this article, we discuss a rare case of a 40-year-old Nigerian female presenting with abdominal pain, distension and secondary amenorrhea, and show that a high clinical suspicion combined with minimally invasive procedures can help physicians make[ncbi.nlm.nih.gov]

Workup

The diagnosis of endometritis is primarily done on clinical grounds based on the signs and symptoms of the disease. However, there are many tests and laboratory investigations that help in confirmation of the diagnosis and also as a prognostic tool for judging the response to treatment.

Complete blood count (CBC) reveals leukocytosis. Here, one needs to be careful as this may coincide with the physiological leukocytosis of the postpartum phase and hence, may not prove of much use. A CBC may also detect anemia which may be a coexisting factor and a risk to develop endometritis. ESR may be raised above 50 just like in any other bacterial infection and can also help as a prognostic criterion. A blood culture will usually demonstrate the organism responsible for the infection and turns out positive in about 10 – 30% of the patients [9]. Endocervical culture is not always advised unless a probable infection with gonorrhea or chlamydia is suspected. A urine culture might be necessary to rule out an associated urinary tract infection which is a common occurrence. A wet stain of the vaginal discharge may be sent for a gram stain study. 95% of the times an absence of pus cells in a gram stain of the vaginal discharge can be used to rule out endometritis.

An endometrial biopsy is rarely done unless absolutely necessary and usually reveals the presence of neutrophils in acute endometritis and the presence of plasma cells in chronic endometritis. An ultrasonography of the uterus is not of much value unless in the presence of retained products of conception or an intra uterine hematoma. A hysteroscopy and a laparoscopy though done rarely to avoid invasive procedures are reliable investigations in the diagnosis of endometritis [10]. A CT scan of the abdomen and pelvis is mostly done to rule out other conditions like ovarian vein thrombosis, broad ligament mass and septic pelvic thrombophlebitis.

Streptococcus Pneumoniae
  • A case is described in which neonatal sepsis and puerperal endometritis were documented by isolating Streptococcus pneumoniae type 3 from both mother and child. Clinical implications and a review of relevant literature are briefly discussed.[ncbi.nlm.nih.gov]
  • Abstract A recent case of postpartum maternal endometritis and neonatal sepsis due to Streptococcus pneumoniae prompted this report and a review of previous citations.[ncbi.nlm.nih.gov]
Treponema Pallidum
  • Silver staining using the Steiner technique showed numerous spirochetes, morphologically consistent with Treponema pallidum, in the decidualized endometrial tissues.[ncbi.nlm.nih.gov]
Vibrio Vulnificus
  • Abstract Vibrio vulnificus most frequently causes wound infections contracted after exposure to seawater or primary septicemias resulting from the consumption of raw oysters. We report a case of endometritis caused by V. vulnificus.[ncbi.nlm.nih.gov]
Foam Cell
  • Abstract A case of chronic endometritis with unusual histological features due to the presence of abundant foam cells and lipid material is described.[ncbi.nlm.nih.gov]
  • The foam cells would appear to be macrophages, components of a nonspecific inflammatory reaction, which have phagocytosed breakdown elements of retained endometrial hemorrhage.[ncbi.nlm.nih.gov]

Treatment

Endometritis is best managed by starting antibiotics as soon as it is diagnosed. One must carefully evaluate the response to antibiotics to avoid worsening or complications. A mild infection especially after a vaginal delivery or a mild pelvic inflammatory disease unrelated to childbirth may need oral antibiotics like ofloxacin, doxycycline or clindamycin. In chlamydial infection, the antibiotic therapy can be combined with metronidazole. Most other cases of endometritis, especially those following a caesarean delivery will require hospitalization with administration of parenteral antibiotics. The recommended therapy of first choice is IV clindamycin with IV gentamycin [11]. A combination of cephalosporin with extended spectrum penicillin may also be used. The second therapy of choice is use of second or third generation cephalosporin combined with the use of IV metronidazole. A recently recommended antibiotic choice which can be used as a monotherapy is the use of fluoroquinolones like norfloxacin, ciprofloxacin, and ofloxacin. An early and aggressive treatment with IV cefoxitin and IV doxycycline is strongly recommended in the management of adolescents undergoing termination of pregnancy.

Antibiotic therapy is required to be continued till the patient becomes afebrile for more than 24 hours. A prophylactic course of antibiotics before any procedure needs to be given which may be a single agent of the first or second generation cephalosporin. A procedure may be required to evacuate the retained products of conception like a D&C. The hospitalization stay will also require administering symptomatic treatment like antipyretics and intravenous fluids. Adequate rest and a healthy diet are important to assure quick recovery. A hysterectomy is the last treatment of choice as a life saving intervention in cases of severe infection.

Prognosis

Endometritis is a simple infection which when well controlled with antibiotics, is completely curable with a very good outcome. 90% of the women respond well to antibiotics within a period of 48 to 72 hours from the initiation of antibiotic therapy which may be in the inpatient setting or in the outpatient department. Complications arise when treatment is not started on time, immediately on diagnosis or when inadequate treatment is received in terms of lower antibiotics or if incomplete course of the antibiotics is taken. This results in worsening of the disease, consequently advancing to septic shock. This usually is the commonest cause of maternal mortality especially encountered in developing countries.

Maternal mortality due to endometritis is rare in the US owing to the use of better antibiotics and antimicrobial therapy. It has also been seen that there could be some corelation between chronic endometritis and the reproductive outcome in young females. The failure of implantation leading to early loss of pregnancy has been commonly found to be due to the presence of chronic endometritis [6]. However, this condition too seems to respond to a successful antibiotic treatment.

Etiology

The causative factor for endometritis is infection-causing bacteria. However, the predisposing factors that facilitate the entry of these organisms differ in different types of endometritis. Postpartum endometritis usually occurs after caesarean delivery, prolonged rupture of the membranes, prolonged labor, repeated digital examination, retention of placental fragments in the uterus, postpartum hemorrhage, and an abortion which has not been managed properly [1].

Endometritis not related to pregnancy and childbirth is common after any procedure that opens entry of vaginal flora into the uterus. The procedures that put women at risk of endometritis are placement of an intra uterine device, dilation and curettage (D&C), endometrial biopsy, and hysteroscopy. Anemia, young maternal age, and low socioeconomic status further increase the risk of colonization of the lower genital tract, ascending to the upper genital tract resulting in endometritis. It has been seen that many a times more than one organism is accountable for endometritis making it polymicrobial in origin. The common organisms are Gram-positive cocci like Staphylococcus, group B Streptococcus and Streptococcus pyogenes. The Gram-negative bacteria that are commonly encountered are Escherichia coli, Klebsiella, Chlamydia trachomatis, Proteus, Enterobacter, Gardnerella vaginalis, and Neisseria. Anaerobes responsible are Bacteroides, and Peptostreptococcus [2]. Others pathogens that cause endometritis but are relatively uncommon are Mycoplasma, Ureaplasma, and Mycobacterium tuberculosis.

Epidemiology

Endometritis is a widely occurring infection in women since it is common practice to undergo vaginal procedures for diagnostic and therapeutic reasons. Pelvic inflammatory disease related to the procedure of insertion of intrauterine contraceptive device is more common in younger women and decreases with the increasing duration of use [3]. It has been seen that 70% of the women population is affected by mild or severe endometritis. The incidence of this uterine infection is about 1% to 3% after vaginal deliveries. After caesarean deliveries, the incidence is higher, around 13% to 90%. In this case, incidence in elective caesarean deliveries is 5% to 15% while that in unscheduled caesarean deliveries done after the onset of labor is around 15% to 20%. Endometritis causing puerperal sepsis is also a common cause of maternal deaths the incidence of which is 13 in 100,000 deliveries. However, with the advent of antibiotics maternal deaths have been significantly reduced.

Sex distribution
Age distribution

Pathophysiology

Endometritis results from inflammation and infection of endometrium produced by various types of causative organisms. A study of the infected tissue reveals that 60% of the infections are caused by Gram-positive and Gram-negative bacteria, 40% are caused by anaerobes, and around 30% are caused by mycoplasma [4]. The invasion of the endometrial tissue with pathogens results in various changes amounting to the activation of the immune system. Acute and chronic endometritis can be differentiated by the histological features. Neutrophils in the endometrium characterize acute endometritis histologically.

The neutrophilic infiltration of the endometrium found in the endometrial biopsy tissue is what separates it from a chronic infection. Chronic endometritis is characterized by presence of lymphocytes as well as plasma cells within the stroma. Along with the presence of plasma cells the endometrial tissue also reveals the presence of lymphocytic follicles, eosinophils, and lymphocytes. Hysteroscopic findings have also shown the presence of hyperemia with proliferation of the endometrial tissue with development of micropolyps to give a polypoid appearance [5].

Prevention

The use of sterile and aseptic precaution during any procedure involving the vagina, cervix or the uterus is the first step to prevent endometritis. Douching of the vagina with a povidone-iodine solution before a cesarean delivery especially after onset of labor or when associated with prolonged rupture of membranes can significantly decrease the risk of developing postpartum endometritis [12]. An antibiotic coverage before a cesarean delivery is mandatory to avoid complications. Sexually transmitted diseases should be adequately treated including the treatment of the partner to reduce the further chances of developing endometritis.

Summary

Endometritis refers to the inflammation of the endometrium and occasionally, the myometrium and parametrium. It may be related to pregnancy or delivery and women undergoing a caesarean section are at a higher risk of developing endometritis than women undergoing a vaginal delivery. Endometritis that is unrelated to pregnancy usually occurs due to infection travelling upwards from the lower genital tract. This is common after any procedure involving the vagina like a hysteroscopy or a dilatation and curettage being done for various reasons. Endometritis may also involve the fallopian tubes and the ovaries resulting in salpingitis and oophoritis. Pelvic peritonitis may also be a part of endometritis and is commonly referred to as pelvic inflammatory disease (PID). Pelvic inflammatory disease may be acute or chronic. Acute and chronic infections both are usually caused by organisms like gonorrhea or chlamydia.

The primary presenting symptoms of endometritis are fever and lower abdominal pain. It is treated either in an inpatient set up with IV antibiotics or a mild infection can be treated with oral antibiotics in an outpatient set up. When identified and treated adequately, endometritis is completely curable.

Patient Information

Endometritis is defined as the irritation or infection of the inner lining of the uterus commonly seen in women after childbirth. It is most common after a delivery through an abdominal operation or a cesarean delivery and less common following a vaginal delivery. Endometritis also occurs in non-pregnant women following any procedure of the vagina or the uterus. Some examples of such procedures are the placement of a contraceptive device, hysteroscopy done to visualize the inside of the uterus for various reasons. These procedures facilitate the travel of bacteria in the vagina to the uterus resulting in infection.

Endometritis is caused by various types of organisms including those responsible for sexually transmitted diseases. The important symptoms of endometritis are fever, abdominal pain, abnormal vaginal bleeding or discharge, discomfort during a bowel movement, and a general feeling of being unwell. Endometritis especially occurring after a cesarean delivery presents with foul smelling lochia, the post delivery vaginal discharge.

The diagnosis is done based on the presenting features but blood tests like complete blood count (CBC), blood culture, testing of the vaginal discharge and sometimes a biopsy of the uterus may be required to confirm the diagnosis or identify the causative organism for therapeutic purpose. Endometritis is best treated with early and adequate use of antibiotics and most of the times may require hospitalization. Prevention of endometritis is best done by using proper sterile methods during procedures and prophylactic doses of antibiotics before a cesarean delivery. The outcome of treatment is almost always very good and patients with endometritis 90% of the times respond to therapy within 48 hours.

References

Article

  1. Olsen MA, Butler AM, Willers DM, et al. Risk factors for endometritis after low transverse cesarean delivery. Infect Control Hosp Epidemiol. 2010 Jan;31(1):69-77. doi: 10.1086/649018. Erratum in: Infect Control Hosp Epidemiol. 2013 Jul;34(7):767.
  2. Sokolova IE, Voropaeva SD, Pashkov EP. The role of nonsporulating anaerobic bacteria in the etiology of postabortion and postpartal endometritis. Mikrobiol Epidemiol Immunobiol. 1989 May;(5):29-35. Russian.
  3. Kogan EA, Demura TA, Vodianoĭ VIa, et al. Molecular and morphological aspects of endometrial receptivity disorders at chronic endometritis. Arkh Patol. 2012 May-Jun;74(3):15-7. Russian.
  4. Jaiyeoba O. Postoperative infections in obstetrics and gynecology. Clin Obstet Gynecol. 2012 Dec;55(4):904-13.
  5. Cicinelli E, Tinelli R, Lepera A, et al. Correspondence between hysteroscopic and histologic findings in women with chronic endometritis. Acta Obstet Gynecol Scand. 2010 Aug;89(8):1061-5.
  6. Johnston-MacAnanny EB, Hartnett J, Engmann LL,et al. Chronic endometritis is a frequent finding in women with recurrent implantation failure after in vitro fertilization. Fertil Steril. 2010 Feb;93(2):437-41.
  7. Ely JW, Dawson JD, Townsend AS, et al. Benign fever following vaginal delivery. J Fam Pract. 1996 Aug;43(2):146-51.
  8. Pitsos M, Skurnick J, et al. Association of pathologic diagnoses with clinical findings in chronic endometritis. J Reprod Med. 2009 Jun;54(6):373-7.
  9. Spandorfer SD, Graham E, Forouzan I. Postcesarean endometritis. Clinical risk factors predictive of positive blood cultures. J Reprod Med. 1996 Nov;41(11):797-800
  10. Guo GL, Chen SY, Zhang W, et al. Diagnosis value of hysteroscopy for chronic endometritis. Clin Exp Obstet Gynecol. 2013;40(2):250-2.
  11. Lamy C, Zuily S, Perdriolle E et al. Management of post-partum infections. J Gynecol Obstet Biol Reprod (Paris). 2012 Dec;41(8):886-903.
  12. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014 Dec 21;12:CD007892. 

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Last updated: 2017-08-09 17:24