Which of the following would be a risk factor for developing a postpartum infection?

Postpartum endometritis is uterine infection, typically caused by bacteria ascending from the lower genital or gastrointestinal 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

• Repeated digital cervical examination

• Retention or manual removal of placental fragments in the uterus

• Bacterial colonization of the lower genital tract

• Diabetes

• Young maternal age

• Low socioeconomic status

Infection tends to be polymicrobial; the most common pathogens include the following:

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

Infection may occur in the endometrium (endometritis), parametrium (parametritis), and/or myometrium (myometritis).

• Clinical evaluation

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

Diagnosis within 24 hours of delivery is based on clinical findings of pain, tenderness, and temperature > 38° C after delivery.

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 hours (some clinicians use a 72-hour cutoff) without a downward trend in peak temperature, other causes, such as pelvic abscess and pelvic thrombophlebitis (particularly if no abscess is evident on scans), 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.

• Clindamycin plus gentamicin, with or without ampicillin

Treatment of postpartum endometritis is a broad-spectrum antibiotic regimen given IV until women are afebrile for 48 hours.

Preventing or minimizing predisposing factors is essential. Vaginal delivery cannot be sterile, but aseptic techniques are used.

When delivery is cesarean, prophylactic antibiotics given within 60 minutes before surgery can reduce risk of endometritis by up to 75%.

• Postpartum 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 minutes before surgery.

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