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Endometritis and Other Postpartum Infections
Justin P. Lavin Jr., MD, FACOG
Ayesha Hasan, MD
Danielle Taylor, DO, MS
image BASICS
  • Endometritis (infection of the endometrium) is the most common postpartum infection.
  • Bacterial infection of genital tract, usually within the 1st week after delivery, can occur as late as 1 to 6 weeks postpartum.
  • Less common are postpartum infections of the myometrium and parametrial tissues. Vaginal and cervical infections, perineal cellulitis, pelvic cellulitis, septic pelvic vein thrombophlebitis, and parametrial phlegmon are other less-common postpartum infections of the pelvic region.
  • System(s) affected: reproductive
  • Synonym(s): postpartum infection; endometritis; endoparametritis; endomyometritis; myometritis; endomyoparametritis; metritis; metritis with pelvic cellulitis
Predominant age and gender: women of childbearing years
  • Occurs after 1-3% of all births
  • Infection is 10 times more likely after cesarean section
    • 2-15% of infections occur prior to labor
    • 30-35% occur after labor in absence of appropriate antibiotic prophylaxis; 2-15% occur after labor with appropriate prophylaxis
    • Fifth leading cause of maternal mortality, accounting for 11% of maternal deaths
  • Endometritis is more common in labors complicated by chorioamnionitis.
  • Other infections follow trauma to the perineum, vagina, cervix, and uterus.
  • Postpartum infections are typically polymicrobial, involving organisms ascending from the lower genital tract:
    • Aerobic isolates (70%): Streptococcus faecalis, Streptococcus agalactiae, Streptococcus viridans, Staphylococcus aureus, Escherichia coli
    • Anaerobic isolates (80%): Peptococcus sp., Peptostreptococcus sp., Clostridium sp., Bacteroides bivius, Bacteroides fragilis, Fusobacterium sp.
  • Other genital mycoplasmata
  • Consider herpes simplex virus and cytomegalovirus, particularly in immunocompromised patients failing to improve on appropriate antibiotics.
  • Thrombosis of any pelvic vein, including vena cava
  • Phlegmon on leaves of the broad ligament
  • Cesarean delivery is the primary risk factor.
  • Chorioamnionitis
  • Bacterial vaginosis
  • Group B streptococcal colonization of genital tract
  • HIV infection
  • Prolonged labor
  • Prolonged rupture of membranes
  • Multiple vaginal examinations
  • Internal fetal monitoring during labor
  • Operative vaginal delivery
  • Manual extraction of the placenta
  • Low socioeconomic status
  • Obesity
  • Anemia
  • Care in a teaching hospital
  • Vaginal delivery
    • Avoid unnecessary vaginal examinations.
    • Treat chorioamnionitis during labor.
    • Avoid manual placental extraction and retained placental products.
    • Consider antibiotic prophylaxis for third- and fourth-degree laceration (1)[B].
    • Use aseptic technique for operative vaginal delivery.
    • Antibiotic prophylaxis for operative vaginal delivery is not necessary (2)[A].
  • Cesarean delivery
    • Preoperative preparation using a paint and scrub technique with a 10% povidone iodine scrub and topical solution decreases puerperal infection by up to 38% (3)[B].
    • Prophylactic antibiotics before both emergency and scheduled cesarean deliveries prior to skin incision reduces the prevalence of postpartum infection (4)[A],(5,6)[B].
      • Antibiotics should be administered within 1 hour of the surgery start time (6)[B].
      • Appropriate administration of antibiotics results in a 40% reduction in postpartum maternal infections without any increase in neonatal infectious outcomes (6)[B].
    • Extending the spectrum of coverage to include both a cephalosporin and a macrolide may further decrease infection risk (7)[A],(8)[B].
    • Vaginal preparation with povidone iodine solution immediately before cesarean delivery reduces the risk of postoperative endometritis (9)[A].
    • Weight-based antibiotic dosage helps ensure appropriate tissue concentrations prior to skin incision (10).
  • Chorioamnionitis
  • Wound infection
  • Oral temperature >38°C (100.4°F)
  • Tachycardia
  • Uterine tenderness on exam
  • Other localized abdominopelvic tenderness on exam
  • Purulent or malodorous lochia
  • Heavy vaginal bleeding
  • Ileus
  • Group A or B streptococcal bacteremia may have no localizing signs.
  • “5 Ws”: Wind (pneumonia); Water (UTI); Wound infection; Wow (mastitis); Wonder drug (medication-related fever)
  • Viral syndrome; dehydration
  • Thrombophlebitis
  • Thyroid storm
  • Appendicitis
Initial Tests (lab, imaging)
  • CBC: Interpret with care (Physiologic leukocytosis may be as high as 20,000 WBCs.).
  • Two sets of blood cultures (especially with suspected sepsis)
  • Note: Diagnosis often made on clinical grounds. Potential testing includes:
    • Genital tract cultures and rapid test for group B streptococci (may be done during labor)
    • Amniotic fluid Gram stain: usually polymicrobial
    • Uterine tissue cultures: Prep the cervix with Betadine and use a shielded specimen collector or Pipelle; difficult to obtain without contamination
  • If patient is not responsive to antibiotics in 24 to 48 hours:
    • Ultrasound for retained products of conception, pelvic abscess, or mass
    • CT or MRI looking for pelvic vein thrombophlebitis, abscess, or deep-seated wound infection
Diagnostic Procedures/Other
Paracentesis/culdocentesis with culture rarely necessary
Test Interpretation
  • Superficial layer of infected necrotic tissue in microscopic sections of uterine lining
  • >5 NEUTROPHILS per high-power field in superficial endometrium; ≥1 plasma cell in endometrial stroma
First Line
  • Clindamycin 900 mg IV q8h + gentamicin 5 mg/kg IV q24h (11)[A]
  • Potential side effects include nephrotoxicity, ototoxicity, pseudomembranous colitis, or diarrhea (in up to 6%).
Second Line
  • Ampicillin-sulbactam 3 g IV q6h
  • Metronidazole 500 mg q8-12h + penicillin 5,000,000 U q6h, or
  • Ampicillin 2 g q6h + gentamicin 5 mg/kg q24h (11)[A]
  • Cefoxitin 2 g IV q6h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours
  • Cefotetan 2 g IV q12h. Add ampicillin 2 g IV q6h, if clinical failure after 48 hours (11)[A]
  • P.343

  • Note: Base therapy on cultures, sensitivities, and clinical response.
  • Contraindications
    • Drug allergy
    • Renal failure (aminoglycosides)
    • Avoid sulfa, tetracyclines, and fluoroquinolones before delivery and if breastfeeding. Metronidazole is relatively contraindicated if breastfeeding.
  • Precautions:
    • Clindamycin and other antibiotics occasionally cause pseudomembranous colitis.
    • Antibiotic-associated diarrhea (Clostridium difficile)
  • Note: Consider adding a macrolide antibiotic (for chlamydia coverage) for infections occurring after 48 hours.
  • Note: Heparin typically indicated for septic pelvic vein thrombophlebitis; requires 10 days of full anticoagulation
  • Curettage for retained products of conception
  • Surgery to drain abscess
  • Surgery to decompress the bowel
  • Surgical drainage of a phlegmon is not advised unless it is suppurative. Surgical removal of other inflamed tissue is usually not required.
Admission Criteria/Initial Stabilization
  • Inpatient care is recommended for postpartum infections.
  • Many infections occur after hospital discharge.
  • IV antibiotics and close observation for severe infections
  • Open and drain infected wounds.
  • Optimize fluid status.
Patient Monitoring
  • Individualize according to severity
  • IV antibiotics can be stopped when the patient is afebrile for 24 to 48 hours.
  • Oral antibiotics on discharge are not necessary, unless patient was bacteremic; then continue oral antibiotics to complete a 7-day course.
As tolerated, although may be limited by ileus
  • Advise patient to contact physician with fever >38°C (100.4°F) postpartum, heavy vaginal bleeding, foul-smelling lochia, or other symptoms of infection.
  • Information available at http://www.healthline.com/health/pregnancy/complications-postpartum-endometritis
With supportive therapy and appropriate antibiotics, most patients improve quickly and recover without complication.
1. Duggal N, Mercado C, Daniels K, et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol. 2008;111(6):1268-1273.
2. Liabsuetrakul T, Choobun T, Peeyananjarassri K, et al. Antibiotic prophylaxis for operative vaginal delivery. Cochrane Database Syst Rev. 2014;(10): CD004455.
3. Weed S, Bastek JA, Sammel MD, et al. Comparing postcesarean infectious complication rates using two different skin preparations. Obstet Gynecol. 2011;117(5):1123-1129.
4. Smaill FM, Grivell GM. Antibiotic prophylaxis versus no prophylaxis for preventing infection after cesarean section. Cochrane Database Sys Rev. 2014;(10):CD007482.
5. Dinsmoor MJ, Gilbert S, Landon MB, et al. Perioperative antibiotic prophylaxis for nonlaboring cesarean delivery. Obstet Gynecol. 2009;114(4):752-756.
6. American College of Obstetricians and Gynecologist. ACOG practice bulletin No. 120: use of prophylactic antibiotics in labor and delivery. Obstet Gynecol. 2011;117(6):1472-1483.
7. Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol. 2008;199(3):301.e1-301.e6.
8. Tita AT, Owen J, Stamm AM, et al. Impact of extended-spectrum antibiotic prophylaxis on incidence of postcesarean surgical wound infection. Am J Obstet Gynecol. 2008;199(3):303. e1-303.e3.
9. Haas DM, Morgan S, Contreras K. Vaginal preparation with antiseptic solution before cesarean section for preventing postoperative infections. Cochrane Database Syst Rev. 2014;(12): CD007892.
10. Pevzner L, Swank M, Krepel C, et al. Effects of maternal obesity on tissue concentrations of prophylactic cefazolin during cesarean delivery. Obstet Gynecol. 2011;117(4):877-882.
11. French LM, Smaill FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev. 2015;(2):CD001067.
Additional Reading
  • Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis. BJOG. 2013; 120(6):661-669.
  • Bianco A, Roccia S, Nobile CG, et al. Postdischarge surveillance following delivery: the incidence of infections and associated factors. Am J Infect Control. 2013;41(6):549-553.
  • Maharaj D. Puerperal pyrexia: a review. Part I. Obstet Gynecol Surv. 2007;62(6):393-399.
  • Maharaj D. Puerperal pyrexia: a review. Part II. Obstet Gynecol Surv. 2007;62(6):400-406.
  • Srinivas SK, Fager C, Lorch SA. Variations in postdelivery infection and thrombosis by hospital teaching status. Am J Obstet Gynecol. 2013;209(6):567. e1-567.e7.
  • Sun J, Ding M, Liu J, et al. Prophylactic administration of cefazolin prior to skin incision versus antibiotics at cord clamping in preventing postcesarean infectious morbidity: a systematic review and meta-analysis of randomized controlled trials. Gynecol Obstet Invest. 2013;75(3):175-178.
See Also
Algorithm: Pelvic Pain
  • O86.12 Endometritis following delivery
  • O86.4 Pyrexia of unknown origin following delivery
  • O86.13 Vaginitis following delivery
Clinical Pearls
  • Postpartum endometritis follows 1-3% of all births.
  • Infections are typically polymicrobial and involve organisms ascending from the lower genital tract.
  • Evidence supports antibiotic prophylaxis prior to skin incision for all cesarean deliveries but not for operative vaginal deliveries.
  • clindamycin 900 mg IV q8h and gentamicin 5 mg/kg q24h are recommended as first-line therapy for endometritis. Treat until the patient is afebrile for 24 to 48 hours, at which point antibiotics can be stopped completely (except in cases of documented bacteremia, which require a 7-day course of therapy).
  • If no improvement occurs on antibiotics, consider retained placental products, abscess, wound infection, hematoma, cellulitis, phlegmon, or septic pelvic vein thrombosis.