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Puerperal Endometritis

by Julie S. Moldenhauer, MD

Puerperal endometritis is uterine infection, typically caused by bacteria ascending from the lower genital or GI tract. Symptoms are uterine tenderness, abdominal or pelvic pain, fever, malaise, and sometimes discharge. Diagnosis is clinical, rarely aided by culture. Treatment is with broad-spectrum antibiotics (eg, clindamycin plus gentamicin).

Incidence of postpartum endometritis is affected mainly by the mode of delivery:

  • Vaginal deliveries: 1 to 3%

  • Scheduled caesarean deliveries (done before labor starts): 5 to 15%

  • Unscheduled caesarean deliveries (done after labor starts): 15 to 20%

Patient characteristics also affect incidence.


Endometritis may develop after chorioamnionitis during labor or postpartum. Predisposing conditions include

  • Prolonged rupture of the membranes

  • Internal fetal monitoring

  • Prolonged labor

  • Cesarean delivery

  • Repeated digital examination

  • Retention of placental fragments in the uterus

  • Postpartum hemorrhage

  • Colonization of the lower genital tract

  • Anemia

  • Bacterial vaginosis

  • Young maternal age

  • Low socioeconomic status

Infection tends to be polymicrobial; the most common pathogens include

  • Gram-positive cocci (predominantly group B streptococci, Staphylococcus epidermidis, and Enterococcus sp)

  • Anaerobes (predominantly peptostreptococci, Bacteroides sp, and Prevotella sp)

  • Gram-negative bacteria (predominantly Gardnerella vaginalis, Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis).

Uncommonly, peritonitis, pelvic abscess, pelvic thrombophlebitis (with risk of pulmonary embolism), or a combination develops. Rarely, septic shock and its sequelae, including death, occur.

Symptoms and Signs

Typically, the first symptoms are lower abdominal pain and uterine tenderness, followed by fever—most commonly within the first 24 to 72 h postpartum. Chills, headache, malaise, and anorexia are common. Sometimes the only symptom is a low-grade fever.

Pallor, tachycardia, and leukocytosis usually occur, and the uterus is soft, large, and tender. Discharge may be decreased or profuse and malodorous, with or without blood. When parametria are affected, pain and fever are severe; the large, tender uterus is indurated at the base of the broad ligaments, extending to the pelvic walls or posterior cul-de-sac. Pelvic abscess may manifest as a palpable mass separate from and adjacent to the uterus.


  • Clinical evaluation

  • Usually tests to exclude other causes (eg, urinalysis and urine culture)

Diagnosis within 24 h of delivery is based on clinical findings of pain, tenderness, and temperature > 38° C after delivery. After the first 24 h, puerperal endometritis is presumed present if no other cause is apparent in patients with temperature 38° C on 2 successive days. Other causes of fever and lower abdominal symptoms include UTI, wound infection, septic pelvic thrombophlebitis, and perineal infection. Uterine tenderness is often difficult to distinguish from incisional tenderness in patients who have had a cesarean delivery.

Patients with low-grade fever and no abdominal pain are evaluated for other occult causes, such as atelectasis, breast engorgement or infection, UTI, and leg thrombophlebitis. Fever due to breast engorgement tends to remain 39° C. If temperature abruptly rises after 2 or 3 days of low-grade fever, the cause is probably an infection rather than breast engorgement.

Urinalysis and urine culture are usually done.

Endometrial cultures are rarely indicated because specimens collected through the cervix are almost always contaminated by vaginal and cervical flora. Endometrial cultures should be done only when endometritis is refractory to routine antibiotic regimens and no other cause of infection is obvious; sterile technique with a speculum is used to avoid vaginal contamination, and the sample is sent for aerobic and anaerobic cultures.

Blood cultures are rarely indicated and should be done only when endometritis is refractory to routine antibiotic regimens or clinical findings suggest septicemia.

If despite adequate treatment of endometritis, fever persists for > 48 h (some clinicians use a 72-h cutoff) without a downward trend in peak temperature, other causes such as pelvic abscess and pelvic thrombophlebitis should be considered. Abdominal and pelvic imaging, usually by CT, is sensitive for abscess but detects pelvic thrombophlebitis only if the clots are large. If imaging shows neither abnormality, a trial of heparin is typically begun to treat presumed pelvic thrombophlebitis, usually a diagnosis of exclusion. A therapeutic response confirms the diagnosis.

Pearls & Pitfalls

  • If adequate treatment of puerperal endometritis does not result in a downward trend in peak temperature after 48 to 72 h, consider pelvic abscess and, particularly if no abscess is evident on scans, septic pelvic thrombophlebitis.


  • Clindamycin plus gentamicin, with or without ampicillin

Treatment is a broad-spectrum antibiotic regimen given IV until women are afebrile for 48 h. The first-line choice is clindamycin 900 mg q 8 h plus gentamicin 1.5 mg/kg q 8 h or 5 mg/kg once/day; ampicillin 1 g q 6 h is added if enterococcal infection is suspected or if no improvement occurs by 48 h. Continuing treatment with oral antibiotics is not necessary.


Preventing or minimizing predisposing factors is essential. Appropriate hand washing should be encouraged. Vaginal delivery cannot be sterile, but aseptic techniques are used. When delivery is cesarean, prophylactic antibiotics given within 60 min before surgery can reduce risk of endometritis by up to 75%.

Key Points

  • Puerperal endometritis is more common after cesarean delivery, particularly if unscheduled.

  • The infection is usually polymicrobial.

  • Treat based on clinical findings (eg, postpartum pain, fundal tenderness, or unexplained fever), using broad-spectrum antibiotics.

  • Endometrial and blood cultures are not routinely done.

  • For cesarean delivery, give prophylactic antibiotics within 60 min before surgery.

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