Acute Endometritis

Acute endometritis is bacterial infection of the endometrium, usually after childbirth (especially caesarean delivery), miscarriage, abortion or uterine instrumentation, or from ascending pelvic infection.

• It is polymicrobial with aerobic streptococci, Escherichia coli, anaerobes, Staphylococcus aureus, and chlamydia or gonorrhoea in non-puerperal cases.
• Risk factors are caesarean delivery, prolonged labour, prolonged rupture of membranes, retained placenta, and many vaginal examinations.
• Early antibiotics prevent sepsis.

Fever above 38 degrees Celsius, lower abdominal pain, uterine tenderness, foul-smelling lochia or discharge, and sometimes heavy bleeding or subinvolution.

• Tachycardia, rigors, tender enlarged uterus.
• Differential diagnosis: wound infection, urinary tract infection, mastitis, pneumonia, retained products of conception, pelvic abscess, septic pelvic thrombophlebitis, malaria.
• Complications: pelvic abscess, peritonitis, septic shock, septic pelvic thrombophlebitis, Asherman syndrome and infertility.

Diagnosis is clinical, with cultures and ultrasound to find the organism and any retained tissue.

• Clinical diagnosis: fever, uterine tenderness and foul lochia after delivery or abortion.
• Full blood count, C-reactive protein, blood cultures, high vaginal and endocervical swabs, urine culture.
• Malaria rapid test or microscopy in endemic areas.
• Pelvic ultrasound for retained tissue or abscess.
• HIV test; lactate and renal function in severe illness.

Start broad-spectrum IV antibiotics early, evacuate retained tissue, and treat sepsis.

• Supportive: IV access and fluids; paracetamol; continue breastfeeding; monitor temperature, pulse, blood pressure and urine output; sepsis bundle if shock.
• Pharmacological: clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily (maximum 480 mg), continued until afebrile for 24 to 48 hours. Alternative: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly, or ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV daily plus metronidazole 500 mg IV 8-hourly. Oral step-down is not needed once afebrile for 24 to 48 hours. In non-puerperal cases: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly plus metronidazole 400 mg oral 12-hourly for 14 days. Analgesia with paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours). Septic shock: 30 mL/kg crystalloid, then noradrenaline if blood pressure stays low.
• Procedures: evacuation of retained products of conception under antibiotic cover; drainage of pelvic abscess; laparotomy for peritonitis or necrotising infection; hysterectomy for uncontrolled sepsis.
• Special groups: in renal impairment adjust gentamicin by creatinine clearance and monitor levels, or use ceftriaxone plus metronidazole. In breastfeeding women these drugs are compatible with feeding. When septic pelvic thrombophlebitis is suspected, add enoxaparin 1 mg/kg subcutaneous 12-hourly.
• Red flags: hypotension, respiratory rate above 22 per minute, confusion, lactate above 2 mmol/L, persistent fever after 72 hours, peritonism.
• Follow-up: review at 1 week and at 6 weeks postpartum; repeat ultrasound if fever persists.