Postpartum Endometritis
Summary
Postpartum endometritis is an infection of the uterine lining (decidua and myometrium) occurring after delivery. It is a major cause of maternal morbidity and mortality if not promptly treated. The most significant risk factor is Caesarean section (5-10x higher risk than vaginal delivery). Other risk factors include prolonged rupture of membranes, multiple vaginal examinations, and manual removal of placenta. Patients present with fever, uterine tenderness, offensive lochia, and tachycardia. The infection is typically polymicrobial, and organisms include Group A and B Streptococci, E. coli, and anaerobes. Treatment requires IV broad-spectrum antibiotics covering Gram-positives, Gram-negatives, and anaerobes. Sepsis 6 should be initiated within 1 hour if sepsis is suspected.
Key Facts
- Definition: Infection of the uterine lining after delivery
- Major Risk Factor: Caesarean section (5-10x risk)
- Presentation: Fever >38°C, Tender uterus, Offensive lochia, Tachycardia
- Organisms: Polymicrobial (GAS, GBS, E. coli, Anaerobes)
- Treatment: IV Clindamycin + Gentamicin (or Co-amoxiclav)
- Emergency: Suspect sepsis and act early
Clinical Pearls
"Sepsis Kills Mothers": Maternal sepsis is a leading cause of direct maternal death in the UK. Act fast.
"The 5 T's of Postpartum Fever": Think Temperature (endometritis), Thrombophlebitis, Trauma, Tissue (retained), Teat (mastitis).
"GAS = Danger": Group A Streptococcus (GAS) can cause fulminant sepsis — very high mortality if delayed treatment.
"Caesarean = Highest Risk": Always consider endometritis if fever occurs after C-section.
Incidence
- 1-3% after vaginal delivery
- 5-15% after Caesarean section (without prophylaxis)
- Reduced with prophylactic antibiotics at C-section
Risk Factors
| Factor | Notes |
|---|---|
| Caesarean section | Single biggest risk factor (5-10x) |
| Prolonged rupture of membranes (>8h) | Ascending infection |
| Multiple vaginal examinations | |
| Prolonged labour | |
| Manual removal of placenta | |
| Retained products of conception | |
| Internal fetal monitoring | |
| Obesity | |
| Diabetes |
Mechanism
- Ascending infection from lower genital tract
- Colonisation of decidua and myometrium
- Spread to parametrium and beyond if untreated
Organisms (Polymicrobial)
| Organism | Notes |
|---|---|
| Group A Streptococcus (GAS) | Highly virulent; Rapid sepsis |
| Group B Streptococcus (GBS) | Common coloniser |
| E. coli | Gram-negative |
| Anaerobes | Bacteroides, Peptostreptococcus |
| Enterococcus |
Symptoms and Signs
| Feature | Description |
|---|---|
| Fever | >38°C; Often >8.5°C |
| Uterine tenderness | On palpation |
| Offensive lochia | Foul-smelling vaginal discharge |
| Tachycardia | >00 bpm |
| Malaise | General unwellness |
| Lower abdominal pain |
Timing
Red Flags (Sepsis)
General
- Fever
- Tachycardia
- Signs of sepsis (hypotension, confusion, poor perfusion)
Abdominal
- Tender uterus (suprapubic)
- Peritonism (if spread)
Vaginal
- Offensive lochia
- Open cervical os (allows ascending infection)
Blood Tests
| Test | Expected |
|---|---|
| FBC | Raised WCC (may be normal in sepsis) |
| CRP | Raised |
| Lactate | Raised if sepsis |
| Blood cultures | Before antibiotics if possible |
| U&Es, LFTs | Assess organ function |
Microbiology
- High vaginal swab
- Endocervical swab
- Blood cultures
Imaging
- USS pelvis: Exclude retained products
- CT if concern for abscess or necrotising fasciitis
Management Approach
┌──────────────────────────────────────────────────────────┐
│ POSTPARTUM ENDOMETRITIS MANAGEMENT │
├──────────────────────────────────────────────────────────┤
│ │
│ SUSPECT SEPSIS? → SEPSIS 6 (Within 1 hour): │
│ 1. Give high-flow oxygen │
│ 2. Take blood cultures │
│ 3. Give IV antibiotics │
│ 4. Give IV fluids │
│ 5. Measure lactate │
│ 6. Measure urine output │
│ │
│ ANTIBIOTICS: │
│ • First-line: IV Clindamycin + Gentamicin │
│ (Covers Gram+, Gram-, Anaerobes) │
│ • OR IV Co-amoxiclav (+ Gentamicin if severe) │
│ • Duration: IV until afebrile 24-48h, then oral │
│ │
│ SUPPORTIVE: │
│ • IV fluids │
│ • Analgesia │
│ • VTE prophylaxis │
│ │
│ IF NOT RESPONDING: │
│ • Review antibiotics (microbiology advice) │
│ • USS: Retained products? Abscess? │
│ • CT if necrotising fasciitis suspected │
│ • Surgical evacuation if retained products │
│ • Laparotomy if abscess or necrosis │
│ │
│ PREVENTION: │
│ • Prophylactic antibiotics at Caesarean section │
│ • Limit vaginal examinations │
│ │
└──────────────────────────────────────────────────────────┘
Early
- Septic shock
- Pelvic abscess
- Peritonitis
- Necrotising fasciitis (rare but devastating)
Late
- Infertility (tubal damage)
- Asherman syndrome (intrauterine adhesions)
- Chronic pelvic pain
Maternal Death
- Postpartum sepsis remains a leading cause of maternal death
With Prompt Treatment
- Most women recover fully
- Response expected within 48-72 hours
Delayed Treatment
- Risk of septic shock, multi-organ failure
- Increased mortality
Key Guidelines
- RCOG Green-top Guideline 64a: Bacterial Sepsis in Pregnancy
- MBRRACE-UK: Maternal Mortality Reports
Key Evidence
Antibiotic Prophylaxis
- Reduces endometritis risk after C-section by >50%
What is Postpartum Endometritis?
Postpartum endometritis is an infection of the womb lining that can happen after giving birth. It's more common after Caesarean section.
What Are the Symptoms?
- High temperature (fever)
- Pain and tenderness in your lower tummy
- Smelly discharge from the vagina
- Feeling generally unwell
Is It Serious?
Yes, if not treated quickly, it can lead to serious infection (sepsis). It's important to seek help immediately if you have these symptoms after giving birth.
How is It Treated?
You will need antibiotics given through a drip (IV) in hospital. Most women recover fully with prompt treatment.
How Can It Be Prevented?
Antibiotics are given at the time of Caesarean section to reduce the risk.
Primary Guidelines
- Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 64a: Bacterial Sepsis in Pregnancy. 2012.
Key Studies
- MBRRACE-UK. Saving Lives, Improving Mothers' Care. 2023.