Endometritis is a condition where the lining of the uterus, known as the endometrium, becomes inflamed. It most commonly occurs after childbirth, abortion, miscarriage or other gynecologic procedures. Endometritis can be a serious condition that requires prompt treatment with antibiotics to prevent complications like infertility, abscess formation or sepsis. Certain factors can increase a woman’s risk of developing endometritis.
Risk Factors
Some of the main risk factors that can increase a woman’s chance of getting endometritis include:
Prolonged labor
Labor that lasts more than 24 hours significantly increases the risk of infection in the uterus. During prolonged labor, the amniotic sac can rupture prematurely and allow bacteria to enter the uterus. The cervix also remains dilated for longer, which provides an entry point for bacteria.
Multiple vaginal exams during labor
Each time a vaginal exam is performed during labor to check cervical dilation, bacteria can be introduced into the uterus. Therefore, the more vaginal exams done, the higher the risk of infectious organisms making their way into the uterine cavity.
Difficult delivery
Deliveries requiring use of forceps or vacuum extraction put women at increased risk for endometritis. The physical trauma to the genital tract during an assisted vaginal delivery can cause inflammation and create an entry point for bacteria. Cesarean sections, especially those done after prolonged labor, also raise endometritis risk.
Manual removal of the placenta
If the placenta does not detach from the uterine wall spontaneously after childbirth, the doctor may need to reach inside the uterus and manually remove it. This disrupts the lining of the uterus and predisposes it to infection.
Rupture of amniotic membranes >18 hours before delivery
When the amniotic sac breaks more than 18 hours before the baby is born, the protective barrier of the amniotic fluid is lost. This allows bacteria to travel upwards into the uterus. The longer the time between membrane rupture and delivery, the higher the likelihood of infection setting in.
Retained products of conception
Any retained placental fragments or fetal membranes left in the uterus after delivery provide an environment for bacteria to grow. Pieces of placenta or amniotic tissue serve as a source of nutrition for microorganisms.
Bacterial vaginosis
This type of vaginal infection is caused by an imbalance of naturally occurring bacteria in the vagina. Having bacterial vaginosis during pregnancy or labor increases the chances of developing endometritis.
Group B streptococcus colonization
Group B strep is a bacterium that colonizes the vagina in some women. If group B strep is present during childbirth, the bacteria can make its way into the uterus and cause endometritis.
Multiple birth delivery
The risk of postpartum endometritis is greater in twin or triplet births compared to singleton births. The increased risk is likely related to prolonged labor, operative deliveries and excessive trauma to the uterine cavity.
Lack of prenatal care
Women who do not get adequate prenatal care are at increased risk for developing endometritis after childbirth. Without prenatal care, vaginal infections may go untreated and raise the likelihood of infections post-delivery.
First pregnancy
Women pregnant for the first time have a higher rate of endometritis compared to women who have had previous pregnancies. The reason may be that the uterus and vagina have less protective bacteria colonies during a first pregnancy.
Younger maternal age
Younger women under the age of 25 have an increased risk of endometritis after childbirth compared to older women. The cervix may not seal off as effectively after delivery in younger women, allowing bacteria to enter the uterus.
Obesity
Obese women with a body mass index (BMI) over 30 are more likely to develop endometritis. Obesity can be associated with undiagnosed diabetes and poor healing, both of which raise infection risk.
Anemia
Women with anemia or low iron levels have impaired healing and are more prone to developing infections after childbirth or gynecologic procedures. Anemia inhibits the body’s ability to fight off infectious organisms.
Immunosuppression
Any condition that suppresses the immune system, like HIV/AIDS, chronic illnesses or medications like steroids or chemotherapy, can increase susceptibility to endometritis. A weakened immune response makes it harder to fend off bacteria.
Low socioeconomic status
Women living in poverty are at greater risk for maternal infections including endometritis. This may be attributed to inadequate access to healthcare, untreated vaginal infections or poor nutrition.
Prevention
While some risk factors for endometritis like emergencies during delivery or cesarean sections can’t be avoided, some strategies can help reduce the risk of developing this condition:
Obtain regular prenatal care
Seeing a healthcare provider regularly during pregnancy allows for early diagnosis and treatment of any infections that could increase endometritis risk. It also helps ensure the mother is in optimal health before delivery.
Practice good genital hygiene
Cleaning the vaginal area daily with warm water prevents buildup of bacteria that could be pushed into the uterus during childbirth.
Get chronic conditions like diabetes under control
Having diabetes or other chronic diseases managed well can lower the chances of post-delivery infection complications.
Ask to limit vaginal exams during labor
Requesting that vaginal exams during labor are kept to a minimum can help avoid introducing unnecessary bacteria. Exams should only be done when medically indicated.
Consider probiotics
Taking probiotic supplements with lactobacillus bacteria strains may help prevent infectious complications by promoting growth of healthy vaginal flora.
Optimize nutrition status
Eating a balanced diet high in iron, vitamins and minerals allows for proper tissue healing and immune function. This enhances the body’s defenses against infection.
Stop smoking
Cigarette smoking impairs healing after childbirth. Quitting smoking for at least 2 months before delivery can decrease the risk of infections.
Diagnosis
Endometritis is diagnosed when a woman develops certain symptoms and signs of infection in the postpartum or post-procedural period. Diagnostic methods may include:
Physical exam
The physician visually inspects the vagina and cervix for redness, discharge or bleeding. The uterus may feel enlarged, tender and boggy on abdominal exam.
Patient history
Important clues are onset of fever, chills, foul-smelling vaginal discharge, abdominal pain, uterine tenderness and other symptoms in the days after delivery. Risk factors like prolonged labor are also noted.
Blood tests
A complete blood count may show elevated white blood cells in response to infection. Blood cultures may grow out the causative bacteria.
Endometrial biopsy
A sample of the endometrial lining can be taken and sent for microbiological testing. This helps identify the type of pathogens involved.
Ultrasound
Imaging showing thickened endometrium and fluid collections in the uterus supports a diagnosis of endometritis.
Hysteroscopy
This involves inserting a thin camera into the uterus to directly visualize inflammation, pus and retained products of conception that could indicate endometritis.
Treatment
Endometritis requires prompt antibiotic treatment for a rapid recovery. Treatment consists of:
Intravenous antibiotics
Hospitalized women are given broad spectrum IV antibiotics that cover common bacteria involved. Antibiotics are continued for 24-48 hours after fever resolves.
Oral antibiotics
Oral antibiotics like doxycycline, clindamycin or metronidazole may be prescribed for 7-10 days once the patient is discharged.
Uterine evacuation
If ultrasound or hysteroscopy reveals retained tissue in the uterus, suction curettage is done to remove it and stop ongoing infection.
IV fluids
Fluids and electrolytes are given through the IV to correct dehydration from fever and prevent kidney damage from sepsis.
Pain management
Medications like ibuprofen or acetaminophen help relieve abdominal, back and muscle pain.
Fever reduction
Fever is lowered with acetaminophen, cooling blankets and tepid sponge baths to avoid febrile seizures.
Complications
Endometritis has the potential to cause serious complications if not treated adequately including:
Severe sepsis
Untreated infection can spread to the bloodstream leading to sepsis, a life-threatening condition. Sepsis requires ICU monitoring and strong IV antibiotics.
Infertility
Chronic inflammation from endometritis can cause permanent scarring in the fallopian tubes, blocking the passage of eggs. This leads to infertility.
Chronic pelvic pain
Inflammation that persists in the uterus and pelvis after the acute infection has resolved can cause chronic pelvic pain.
Abscess formation
Pockets of pus can form in the uterus, fallopian tubes or other pelvic structures requiring drainage.
Adhesions
Bands of scar tissue called adhesions that develop after endometritis can impair fertility and cause chronic abdominal pain.
Hysterectomy
A severely damaged uterus may need to be surgically removed if infection causes irreversible scarring unresponsive to antibiotics.
Prevention
Proper prenatal care and safe delivery practices can help prevent many cases of postpartum endometritis:
Screen and treat vaginal infections during pregnancy
Identifying and curing issues like bacterial vaginosis or chlamydia before delivery prevents their spread to the uterus.
Administer antibiotics during C-sections
Giving IV antibiotics right before cesarean delivery provides protection against infection of the surgical site.
Provide antibiotic prophylaxis if GBS positive
Women who test positive for group B strep during pregnancy should get IV antibiotics during labor to prevent neonatal and maternal infections.
Optimize maternal health and nutrition
Controlling chronic diseases, stopping smoking and taking prenatal vitamins improves the mother’s infection resistance.
Promote vaginal delivery when possible
Choosing vaginal delivery instead of elective C-section when eligible lowers the risk of surgical site infections.
Follow sterile technique during delivery and exams
Using sterile drapes, gloves, instruments and proper hand hygiene protects the uterine cavity from bacteria.
Conclusion
Endometritis is a preventable condition in many cases with optimal prenatal care and intrapartum infection control. Risk factors like prolonged labor or poor vaginal flora should be minimized when possible. Early diagnosis and prompt intravenous and oral antibiotic therapy cures most cases of endometritis. However, delayed treatment raises the likelihood of severe complications like infertility, chronic pain and hysterectomy. Creating awareness of endometritis risk factors and preventive strategies is key to safeguarding maternal health after childbirth. With proper precautions, screening and management, the incidence of postpartum endometritis can be greatly reduced.