Postcaesarean Endometritis

Postcaesarean endometritis is infection of the uterine lining, decidua and sometimes the myometrium after caesarean section, with fever, uterine tenderness and foul lochia. It is the commonest cause of fever after caesarean section and is more frequent after labour with ruptured membranes. Organisms are polymicrobial, including streptococci, Escherichia coli, Bacteroides and genital mycoplasmas. It matters because it can lead to pelvic abscess, septic thrombophlebitis, sepsis and infertility.

• Risk factors: labour before surgery, ruptured membranes for 18 hours or more, chorioamnionitis, many vaginal examinations, obesity, diabetes, bacterial vaginosis, group B streptococcus carriage, HIV, retained products, long operation, no prophylactic antibiotics.
• Usually appears 24 hours to 5 days after surgery.
• Early treatment usually gives cure.

Women have fever of 38 degrees Celsius or more, lower abdominal pain, uterine tenderness, foul or purulent lochia, tachycardia and sometimes rigors. The uterus is subinvoluted and tender.

• Fever 24 to 72 hours after surgery.
• Foul-smelling lochia.
• Differential diagnosis: wound infection, urinary tract infection, pneumonia, mastitis, pelvic abscess, septic pelvic thrombophlebitis, malaria, deep vein thrombosis, atelectasis, drug fever.
• Complications: pelvic abscess, parametritis, peritonitis, septic pelvic thrombophlebitis, bacteraemia and septic shock, wound infection, subinvolution, tubal damage and infertility, hysterectomy, maternal death.

The diagnosis is clinical, with tests to find the organism and complications.

• Temperature, pulse, blood pressure, respiratory rate, uterine tenderness, lochia, wound and breasts, chest and calves.
• Full blood count, C-reactive protein, blood cultures (2 sets), high vaginal swab, urine culture, malaria test.
• Pelvic ultrasound for retained products, pelvic collection and haematoma; CT for a suspected abscess or septic thrombophlebitis.
• Lactate and creatinine for suspected sepsis.

The principle is broad-spectrum IV antibiotics until the woman has been afebrile for 24 to 48 hours, with search for complications.

• Supportive: admit; oral or IV fluids (Ringer's lactate 1 litre over 4 hours); hourly urine output in sepsis; breastfeeding continues; mobilise and give chest physiotherapy; paracetamol for fever.
• Pharmacological: clindamycin 900 mg IV 8-hourly plus gentamicin 5 mg/kg IV once daily until afebrile for 24 to 48 hours, or ampicillin 2 g IV 6-hourly plus gentamicin 5 mg/kg IV once daily plus metronidazole 500 mg IV 8-hourly; ceftriaxone 2 g IV once daily plus metronidazole 500 mg IV 8-hourly if gentamicin is unsuitable; add ampicillin 2 g IV 6-hourly if no response in 48 to 72 hours; no oral antibiotics are needed after discharge from IV therapy unless bacteraemia, when amoxicillin-clavulanate 625 mg oral 8-hourly completes 7 days; paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours); therapeutic enoxaparin 1 mg/kg subcutaneous 12-hourly for septic pelvic thrombophlebitis for at least 7 days after fever settles.
• Procedures: evacuation of retained products under antibiotic cover; drainage of a pelvic abscess by ultrasound guided or surgical drainage; laparotomy and hysterectomy for necrotising myometritis or uncontrolled sepsis.
• Special groups: renal impairment replaces gentamicin with ceftriaxone 2 g IV once daily; HIV positive women continue tenofovir 300 mg, lamivudine 300 mg and dolutegravir 50 mg oral once daily; penicillin allergy with a severe reaction uses clindamycin plus gentamicin.
• Red flags: fever persisting beyond 48 to 72 hours of treatment, systolic blood pressure below 90 mmHg, rigors, severe abdominal pain, rigid abdomen, oliguria, confusion.
• Follow-up: temperature 4-hourly; review at 1 week and 6 weeks; ultrasound if fever continues; counselling about antibiotic prophylaxis (cefazolin 2 g IV plus azithromycin 500 mg IV before skin incision) at the next caesarean section.