Postpartum endomyometritis is infection of the endometrium, myometrium, and parametrial tissues.

Incidence. About 5% of vaginal deliveries and 10% of cesarean deliveries are affected by postpartum uterine infection. Rates are significantly higher in women of lower socioeconomic status.

Etiology and diagnosis

• Risk factors include cesarean delivery, maternal diabetes mellitus, manual removal of the placenta, and all of the risks for chorioamnionitis.

• Endomyometritis, like chorioamnionitis, is an ascending polymicrobial infection often caused by normal vaginal flora.

• It may develop immediately to several days after delivery.

• Diagnosis is clinical: fever 38.0°C or greater on two separate occasions >2 to 4 hours apart or a single temperature >39.0°C, uterine tenderness, tachycardia, purulent vaginal discharge, and associated findings such as dynamic ileus, pelvic peritonitis, pelvic abscess, and bowel obstruction.

• Endometrial cultures are unnecessary; they are typically contaminated by normal flora and yield results much later than clinically required. Blood culture is indicated only for the most severe cases with concern for sepsis.

Management. Acceptable broad-spectrum antibiotic regimens include the following:

• Therapy with gentamicin and clindamycin ± ampicillin until 24 to 48 hours afebrile

• Alternate single-agent therapies include ertapenem, ceftriaxone, cefotetan, Unasyn, Zosyn, or Timentin. The aim is broad polymicrobial coverage.

• Gentamicin is administered every 8 hours before delivery. For postpartum treatment, however, several studies show 5 to 7 mg/kg daily dosing is safe, efficacious, and cost-effective. Drug levels are not monitored for daily dosing.

Endomyometritis typically resolves with 48 hours of antibiotic treatment. Oral antibiotics are not required after completion of IV course.

If fever persists or patient develops sepsis, additional workup should be considered. This may include urine and blood cultures; chest and abdominal radiographs; pelvic examination; and pelvic/abdominal ultrasound, CT, or magnetic resonance imaging.

Infections with clostridia, group A streptococci, and staphylococci should be suspected in patients presenting with sepsis. Group A streptococcal septicemia is the leading cause of peripartum sepsis worldwide but is relatively rare in the United States (for management, see chapter 8). Toxic shock syndrome may be suspected when there is high fever, desquamation, diffuse macular rash, or multisystem organ failure. In rare cases, postpartum hysterectomy has been reported for uterine myonecrosis.