Endometritis

Endometritis is inflammation of the endometrial lining of the uterus. In

addition to the endometrium, inflammation may involve the myometrium and,
occasionally, the parametrium.
Endometritis can be divided into pregnancy-related endometritis and
endometritis unrelated to pregnancy. When the condition is unrelated to
pregnancy, it is referred to as pelvic inflammatory disease (PID). Endometritis
is often associated with inflammation of the fallopian tubes (salpingitis),
ovaries (oophoritis), and pelvic peritoneum (pelvic peritonitis). The Centers for
Disease Control and Prevention (CDC) 2015 sexually transmitted diseases
treatment guideline defines PID as any combination of endometritis,
salpingitis, tubo-ovarian abscess, and pelvic peritonitis.
The diagnosis of endometritis is usually based on clinical findings, such as
fever and lower abdominal pain (see Clinical Presentation).
Most cases of endometritis, including those following cesarean delivery,
should be treated in an inpatient setting. For mild cases following vaginal
delivery, oral antibiotics in an outpatient setting may be adequate (see
Treatment and Management, as well as Medication).

Pathophysiology
Infection of the endometrium, or decidua, usually results from an ascending
infection from the lower genital tract. From a pathologic perspective,
endometritis can be classified as acute versus chronic. Acute endometritis is
characterized by the presence of neutrophils within the endometrial glands.
Chronic endometritis is characterized by the presence of plasma cells and
lymphocytes within the endometrial stroma.
In the nonobstetric population, pelvic inflammatory disease and invasive
gynecologic procedures are the most common precursors to acute
endometritis. In the obstetric population, postpartum infection is the most
common predecessor.
Chronic endometritis in the obstetric population is usually associated with
retained products of conception after delivery or elective abortion. In the
nonobstetric population, chronic endometritis has been seen with infections
(eg, chlamydia, tuberculosis, bacterial vaginosis) and the presence of an
intrauterine device.
The intrauterine device as a factor in the etiology of pelvic inflammatory
disease was associated with early forms of the device, in particular, the Dalkon
Shield. The incidence of pelvic inflammatory disease is not higher in users of
modern intrauterine devices than in non-users.

Etiology
Endometritis is a polymicrobial disease involving, on average, 2-3 organisms.
In most cases, it arises from an ascending infection from organisms found in
the normal indigenous vaginal flora.
Commonly isolated organisms include Ureaplasma
urealyticum, Peptostreptococcus, Gardnerella vaginalis, Bacteroides
bivius, and group B Streptococcus. Chlamydia has been associated with late-
onset postpartum endometritis. Enterococcus is identified in up to 25% of
women who have received cephalosporin prophylaxis.
Herpes and tuberculosis are rare causes, although in some countries
tuberculosis is not an uncommon etiologic agent.

Epidemiology
The incidence of postpartum endometritis in the United States varies
depending on the route of delivery and the patient population. After a vaginal
delivery, incidence is 1-3%. Following cesarean delivery, the incidence ranges
from 13-90%, depending on the risk factors present and whether
perioperative antibiotic prophylaxis had been given. In the nonobstetric
population, concomitant endometritis may occur in up to 70-90% of
documented cases of salpingitis.

Prognosis
Nearly 90% of women treated with an approved regimen note improvement in
48-72 hours. Delay in initiation of antibiotic therapy can result in systemic
toxicity.
Endometritis is associated with increased maternal mortality due to septic
shock. However, mortality is rare in the United States because of aggressive
antimicrobial management.
In the PID Evaluation and Clinical Health (PEACH) study, endometritis was not
found to be associated with subsequent pregnancy-related complications,
chronic pelvic pain, or infertility.

Diagnosis
When diagnosing endometritis, a doctor will start by taking a medical history
and performing a physical exam. The latter will probably include the doctor
performing a pelvic exam to evaluate the internal reproductive organs. The
doctor is looking for tenderness in the uterus and possible discharge from the
cervix.
A doctor will often want to rule out other causes for the symptoms. This
process may include:
Blood testing. A complete blood count, or CBC, can be used to monitor for
possible infection or assess inflammatory conditions.
Cervical cultures. The doctor may take a swab from the cervix to look for
chlamydia, gonorrhea, or other bacteria.
Wet mount. Discharge from the cervix may be collected and looked at under a
microscope. This can help to identify other causes of an infection or
inflammation.
Endometrial biopsy. This is a brief procedure performed in the doctor's office,
where the cervix is dilated to allow a small instrument into the uterus. The
instrument takes a small sample of the endometrial lining, which is then sent
to the lab for analysis.
Laparoscopy or hysteroscopy. These surgical procedures allow the doctor to
look directly at the uterus.

Treatment
When doctors treat endometritis, they aim to remove the infection and
inflammation from the uterus. This may involve:
Antibiotics. These are used to fight the bacteria causing the uterus lining
inflammation. If the infection is very severe, a person may need intravenous
antibiotics in the hospital.
Further tests. Cervical cultures or an endometrial biopsy to ensure that the
infection is completely gone after finishing the course of antibiotics. If not, a
different antibiotic may be needed.
Removing tissue. If there is any tissue left in the uterus after childbirth or a
miscarriage, the surgeon may need to remove it.
Treating any abscesses. If an abscess forms in the abdomen from the infection,
surgery or a needle aspiration will be needed to remove the infected fluid
or pus.
If the infection is sexually transmitted, a woman's sexual partner may need to
be treated also.

Complications
 Endometritis, if it is left untreated, may cause the following
complications:
 infertility
 pelvic peritonitis (general pelvic infection)
 abscess in the pelvis or uterus
 septicemia (bacteria in the bloodstream)
 septic shock