Endometritis with severe symptoms requires i.v. antimicrobials.
Normal lochia
Postpartum discharge typically lasts for 4-6(-8) weeks. The initial blood-stained discharge (lochia rubra) lasts for 3-4 days after which it becomes reddish brown (lochia serosa) for about one week. This is followed by whitish discharge (lochia alba) for 3-4 weeks.
About 25% of women have lochia for more than six weeks, particularly when breast feeding.
The amount of lochia will vary from day to day. Vaginal or cervical lacerations sustained during delivery will increase the amount of lochia, as will breast feeding.
Bleeding complications
The majority of cases involve primary postpartum haemorrhage (< 24 hours after delivery); these cases are not discussed in the present article.
The frequency of secondary postpartum haemorrhage (> 24 hours and up to 6 weeks after delivery) is about 1%.
Primary postpartum haemorrhage and manual extraction of the placenta are the principal factors responsible for secondary haemorrhage.
The majority of cases occur during the second postpartum week.
Clinical examination must aim to determine the site of bleeding.
Causes of excessive bleeding
Retained placental products or foetal membranes
Endometritis
Episiotomy dehiscence
Vaginal or cervical laceration
Choriocarcinoma following term pregnancy is rare and its presenting symptoms vary. However, it must be suspected where vaginal bleeding increases progressively and/or the patient presents with chest pain, dyspnoea, haemoptysis, headache or an episode of unconsciousness Gestational Trophoblastic Disease.
Recent obstetric history
Course of pregnancy
Delivery and recovery
Check essential information concerning delivery from locally relevant source(s) (e.g. health record).
The risk of vaginal and cervical lacerations is increased by the following: vacuum extraction, forceps delivery, breech delivery, precipitate delivery, shoulder dystocia and delivery of a macrosomic infant.
If caesarean section was performed, what were the indications, possible complications and recovery. The risk of endometritis after caesarean section is 4-10%.
The patient's records will indicate whether the placenta and foetal membranes were delivered complete or whether some parts were retained in the uterus.
Establish the amount of blood loss.
Ask the patient about her general health status and symptoms suggestive of an infection.
Gynaecological examination
Establish the site of bleeding!
Inspect the episiotomy. Have the sutures given way and the wound reopened? Is there a palpable haematoma? Is wound infection evident?
Inspect and palpate the vaginal walls
Inspect the cervix. Is the blood flowing from the uterus? Is the blood bright red? Anything suggestive of an infection?
Internal examination: the size and tenderness of the uterus.
Empirical antimicrobial therapy is usually used in the treatment of slight bleeding from an episiotomy wound or from a laceration on the vaginal or cervical mucous membranes, even though infection is the cause of bleeding only in the minority of cases. The antimicrobial treatment of choice is either a first-generation cephalosporin combined with metronidazole or amoxicillin 500 mg combined with clavulanic acid thrice daily for 7 days.
Early surgical intervention is warranted in a haematoma of the episiotomy wound or vagina.
Symptomless haematoma initially only needs to be observed. Antimicrobial therapy should be initiated as soon as healing appears to be delayed or the haematoma becomes infected.
The cause of excessive blood flow from the uterus must be investigated with ultrasound examination.
Retained products of conception must be evacuated .
If the bleeding is scant and there are no signs of retained products, the treatment should consist of antimicrobials and monitoring.
Endometritis is an infection of the inner lining of the uterus (endometrium) and it often extends to involve the myometrium, leading to endomyometritis.
Risk factors
Prolonged delivery
Frequent procedures and internal examinations during delivery
Premature rupture of foetal membranes
Retained products of conception
Vacuum extraction and forceps delivery
Caesarean section - prolonged procedure, use of instruments and sutures, accumulation of blood or tissue fluid in the pelvis or tissues are predisposing factors.
Aetiology
Pathogenic bacteria ascend, via cervix, from the vagina to the uterus where the placental bed and gestational endometrium provide an ideal growth medium. As the infection progresses, local myometrium becomes involved. The bacteria will then spread, via circulation, to infect the rest of the myometrium.
The most common aerobic causative agents are beta-haemolytic streptococci, Escherichia coli, enterococci and chlamydia. Bacteroides species and B. fragilis are the most common anaerobic pathogens. The infection is usually polymicrobial.
Tissue viability, and the circulation within the tissues, is diminished after caesarean delivery, leading to reduced resistance particularly against anaerobic bacteria.
Clinical signs and symptoms
Symptoms usually start 4-10 days after delivery but they may also present later.
Fever
Lower abdominal pain, which may radiate to involve the entire abdomen
Tender lower abdomen, uterus and possibly adjacent tissues
Foul smelling lochia
Purulent discharge at the cervix
Laboratory investigations as appropriate
CRP, increased up to 100-150 mg/l
Midstream urine to exclude concurrent urinary tract infection, including as necessary bacterial culture
Blood cultures, if severe general symptoms occur
Samples for chlamydia infection and gonorrhoea if these are suspected
Severe endometritis (severe and generalised symptoms, high fever, CRP > 100 mg/l) requires hospitalisation and treatment with intravenous antimicrobials.
Initially, for example, cefuroxime 1.5 mg thrice daily combined with metronidazole 500 mg thrice daily. Subsequent treatment in accordance with the results of bacterial cultures.
If the disease is severe and the treatment response is poor to cephalosporin+metronidazole therapy before the bacterial culture is ready, or if the patient has endometritis together with a wound infection (section, episiotomy): alternatively the combination of clindamycin and the aminoglycoside gentamicin.
Endometritis after caesarean delivery warrants early treatment with i.v. antimicrobials which should continue for up to 2 weeks.
Breast feeding is allowed during the combination therapy of cephalosporin and metronidazole.
the infection may have spread to the tissues adjacent to the uterus, or there may be lumbar peritonitis, an abscess, septic thrombophlebitis in the lumbar region or an infected haematoma
the patient will need further investigations in a hospital (ultrasound examination, CT/MRI scan).