History

Fact Explanation
Lower Abdominal Pain This is typically experienced in the suprapubic region, and is due to referral of pain secondary to inflammation of the uterine cavity lining. [1]
Dyspareunia This classically manifests as a deep seated pain during sexual intercourse (i.e. deep dyspareunia), and is due to inflammation of the pelvic structures. [2]
Vaginal Bleeding This includes intermenstrual bleeding, menorrhagia, abnormal spotting, and postpartum hemorrhage. It is a consequence of involvement of the endometrial layer; lymphocytic infiltration of the arterioles contained therein increases vascular permeability, predisposing to bleeding. [1] [6]
Vaginal Discharge Where present, this may be purulent, offensive, and/or blood stained; it is a consequence of the endometrial inflammation. [1]
Purulent Lochia This is a characteristic feature of postpartum endometritis; it is due to the endometrial inflammation. [5]
Urinary Symptoms Key urinary symptoms include dysuria, frequency and urgency; these occur when the mucosa of the adjacent urinary tract becomes involved. [1]
Fever This may be associated with chills and rigors; it is a result of the underlying inflammatory process. [1]
Risk Factors: Vaginal or Caesarean Delivery Endometritis may occur in the postpartum period, following both vaginal and Caesarean delivery. In patients who have undergone a low transverse Cesarean section, factors associated with an increased risk for endometritis include younger age, anemia, and amniotomy. [5]
Risk factors: Other Obstetric Factors These include therapeutic evacuation of retained products of conception, and septic abortion. [3][4]
Risk factors: Gynecological Factors Endometritis is often encountered in association with pelvic inflammatory disease (PID). Certain sexual behaviors also increase the risk of the condition; these include having multiple sexual partners, a partner with multiple sexual partners, or engaging in intercourse with commercial sex workers. The use of intrauterine contraceptive devices (IUCD) may also predispose to endometritis, particularly if there is failure to adhere to aseptic techniques during the insertion, or if the device is left in-situ for prolonged periods of time. [3][4]
Complication: Systemic Infection This is a complication of severe endometritis. Affected patients may demonstrate features of systemic inflammatory response syndrome (SIRS); altered mentation and shock may also be present. [4]
Complication: Pelvic Abscess formation Severe endometritis may result in abscess formation within the pelvis. Suggestive clinical features include swinging pyrexia, and pronounced abdominal pain which fails to respond to conventional therapy. Note that features of peritonitis are usually not present, as involvement of the parietal peritoneum is rare. [4]
Complication: Secondary Postpartum Hemorrhage This is an important complication of postpartum endometritis, and is due to the increase in endometrial vascular permeability encountered in the disease. [4]
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. British Association for Sexual Health and HIV, 2011 [Viewed on 07 September 2014]. Available from : http://www.bashh.org/documents/3572.pdf
  2. FERRERO S, RAGNI N, REMORGIDA V. Deep dyspareunia: causes, treatments, and results. Curr Opin Obstet Gynecol [online] 2008 Aug, 20(4):394-9 [viewed 09 September 2014] Available from: doi:10.1097/GCO.0b013e328305b9ca
  3. BOWIE WR, JONES H. Acute pelvic inflammatory disease in outpatients: association with Chlamydia trachomatis and Neisseria gonorrhoeae. Ann Intern Med [online] 1981 Dec, 95(6):685-8 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7305145
  4. EZRA Y, BIRKENFELD A, LEVIJ IS. Endometrial reaction to intrauterine device in pregnancy. Gynecol Obstet Invest [online] 1989, 28(1):5-7 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/2777135
  5. OLSEN MA, BUTLER AM, WILLERS DM, GROSS GA, DEVKOTA P, FRASER VJ. Risk Factors for Endometritis Following Low Transverse Cesarean Section Infect Control Hosp Epidemiol [online] 2010 Jan, 31(1):69-77 [viewed 07 September 2014] Available from: doi:10.1086/649018
  6. KIVIAT, NANCY B.,WØLNER-HANSSEN, PÅL .; ESCHENBACH, DAVID A. ; WASSERHEIT, JUDITH N. .; PAAVONEN, JORMA A..; BELL, THOMAS A. .; CRITCHLOW, CATHY W. M.S.; STAMM, WALTER E..; MOORE, DONALD E..; HOLMES, KING K.Endometrial Histopathology in Patients with Culture-proved Upper Genital Tract Infection and Laparoscopically Diagnosed Acute Salpingitis.American Journal of Surgical Pathology:February 1990 14(2);167-175. [viewed 07 December 2014] Available from http://journals.lww.com/ajsp/1990/02000/Endometrial_Histopathology_in_Patients_with.8.aspx

Examination

Fact Explanation
Lower Abdominal Tenderness Tenderness and guarding of the suprapubic region may be present; in postpartum patients, the palpable uterus may be tender. These features are due to inflammation of the uterus. [1]
Vaginal discharge Speculum examination may reveal a purulent, offensive, and blood stained vaginal discharge. This is a result of inflammation of the uterine cavity lining. [1]
Purulent Lochia This is specific to postpartum endometritis, and is due to inflammation of the endometrium. [1]
Pelvic Tenderness Pelvic examination may reveal uterine tenderness, which is highly specific for endometritis. [2]
Fever, Tachypnea, and Tachycardia These signs are due to the systemic response to the inflammation; the criteria for the systemic inflammatory response syndrome (SIRS) may also be met.[1]
Signs of Pelvic Inflammatory Disease Signs suggestive of associated pelvic inflammatory disease (PID) include cervical motion tenderness, and adnexal tenderness. [2]
Signs of Salpingitis Where endometritis is associated with salpingitis and/or a tubo-ovarian abscess, tenderness of- and the presence of a mass in the lateral fornices may be detected. [3]
Signs of a Pelvic Abscess Tenderness and fullness in the pouch of Douglas may indicate that a pelvic abscess has developed.
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. British Association for Sexual Health and HIV, 2011 [Viewed on 07 September 2014]. Available from : http://www.bashh.org/documents/3572.pdf
  2. WEBSTER DP, SCHNEIDER CN, CHECHE S, DAAR AA, MILLER G. Differentiating acute appendicitis from pelvic inflammatory disease in women of childbearing age. Am J Emerg Med [online] 1993 Nov, 11(6):569-72 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/8240553
  3. LAREAU SM, BEIGI RH. Pelvic inflammatory disease and tubo-ovarian abscess. Infect Dis Clin North Am [online] 2008 Dec, 22(4):693-708, vii [viewed 09 September 2014] Available from: doi:10.1016/j.idc.2008.05.008
  4. DINARELLO CA.Cytokines as endogenous pyrogens.J Infect Dis. 1999 Mar;179 Suppl 2:S294-304. [Viewed 07.December 2014] Available from http://jid.oxfordjournals.org/content/179/Supplement_2/S294.long

Differential Diagnoses

Fact Explanation
Pelvic Inflammatory Disease Pelvic Inflammatory Disease (PID) itself can give rise to endometritis; thus, these patients may manifest essentially the same symptoms as women with endometritis due to other conditions. If associated salpingitis, oophoritis, pelvic peritonitis, or a tubo-ovarian abscess are present, clinical findings suggestive of these entities may also be noted. [3]
Ectopic preganancy This is the most important differential diagnosis, as these women can also present with abdominal pain, and a vaginal discharge with bleeding, along with pelvic tenderness, and cervical motion tenderness. A urine hCG test is a good differentiator; a positive result favors ectopic pregnancy, while a transvaginal scan will subsequently confirm the diagnosis. [4]
Acute appendicitis This is a common cause of lower abdominal pain in women of reproductive age, but can usually be differentiated from Endometritis via clinical findings alone. Key differentiating factors include a history of migration of pain from the periumbilical region, localization of the pain to the right iliac fossa, and the presence of tenderness and rebound tenderness in the same region. Where deemed necessary, ultrasound studies or computed tomography (CT) can be used to rule to this diagnosis; the latter is far more specific and sensitive, but at the cost of exposing the patient to ionizing radiation. [2]
Urinary Tract Infection This can also give rise to lower abdominal pain and urinary symptoms; suprapubic tenderness may also be present, due to inflammation of the bladder. However, the absence of vaginal discharge and/or abnormal vaginal bleeding is a key differentiating factor. A urinalysis, and microscopy and culture of the urine will help definitively rule out this diagnosis. [1]
References
  1. HOOTON THOMAS M.. Uncomplicated Urinary Tract Infection. N Engl J Med [online] 2012 March, 366(11):1028-1037 [viewed 07 September 2014] Available from: doi:10.1056/NEJMcp1104429
  2. HUMES D J. Acute appendicitis. BMJ [online] 2006 September, 333(7567):530-534 [viewed 07 September 2014] Available from: doi:10.1136/bmj.38940.664363.AE
  3. SOPER DAVID E.. Pelvic Inflammatory Disease. Obstetrics & Gynecology [online] 2010 August, 116(2, Part 1):419-428 [viewed 07 September 2014] Available from: doi:10.1097/AOG.0b013e3181e92c54
  4. Ectopic pregnancy and miscarriage: Diagnosis and initial management in early pregnancy of ectopic pregnancy and miscarriage.NICE guidelines [CG154] Published date: December 2012.[viewed 2014 November]Available fromhttp://www.nice.org.uk/guidance/cg154/chapter/1-recommendations#symptoms-and-signs-of-ectopic-pregnancy-and-initial-assessment-2

Investigations - for Diagnosis

Fact Explanation
Basic Test: Complete Blood Count This is usually the first basic investigation performed in these patients. Results may be completely normal; where abnormalities are present, a neutrophil leukocytosis is the most common finding. Note that in severe infections, neutropenia may occur.[1]
Specific Test: High Vaginal Swab This is one of the most important diagnostic investigations. Microscopy of a wet smear of vaginal fluid usually shows abundant leukocytes; absence of this should prompt consideration of an alternate diagnosis. Cultures of an endocervical may help in identifying the etiological agent; they are essential if infection with N. gonorrhoeae or C. trachomatis is suspected. [3]
Endometrial Biopsy This invasive procedure should not be routinely performed in women with acute endometritis; where done so, histopathology typically reveals nonspecific inflammatory changes. This is as opposed to chronic endometritis, where the presence of characteristic histological features is often useful in confirming the diagnosis. [3][6]
References
  1. UK National Guideline for the Management of Pelvic Inflammatory Disease. British Association for Sexual Health and HIV, 2011 [Viewed on 07 September 2014]. Available from : http://www.bashh.org/documents/3572.pdf
  2. APUZZIO JJ, HESSAMI S, RODRIGUEZ P. Blood cultures for women hospitalized with acute pelvic inflammatory disease. Are they necessary? J Reprod Med [online] 2001 Sep, 46(9):815-8 [viewed 09 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11584483
  3. CDC:Sexually Transmitted Diseases Treatment Guidelines, 2010.December 17, 2010 / Vol. 59 / No. RR-12. [Viewed 06 December 2014] Available from:http://www.cdc.gov/std/treatment/2010/std-treatment-2010-rr5912.pdf
  4. OSBORNE NG. Tubo-Ovarian Abscess: Pathogenesis and Management J Natl Med Assoc [online] 1986 Oct, 78(10):937-951 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2571486
  5. JOO SH, KIM MJ, LIM JS, KIM JH, KIM KW. CT Diagnosis of Fitz-Hugh and Curtis Syndrome: Value of the Arterial Phase Scan Korean J Radiol [online] 2007, 8(1):40-47 [viewed 09 September 2014] Available from: doi:10.3348/kjr.2007.8.1.40
  6. GREENWOOD SM, MORAN JJ.Chronic endometritis: morphologic and clinical observations.Obstet Gynecol. 1981 Aug;58(2):176-84.[viewed December 06 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/7254729

Investigations - for Management

Fact Explanation
Ultrasound Abdomen + Pelvis Ultrasonography has multiple uses in the evaluation of these patients. In women with postpartum endometritis, this may reveal if retained products of conception are present. It is also of use in screening patients for abscess formation within the pelvic cavity (particularly those the pouch of Douglas, and tubo-ovarian abscesses). Note that in uncomplicated endometritis, sonography is usually normal. [4]
CT Abdomen This test can be used to screen patients for complications of endometritis and/or pelvic inflammatory disease (where both co-exist); particularly if there is a poor initial response to antibiotic therapy. [5]
Blood Cultures These are not routinely performed, but may be considered in severe infections; a positive result will help identify the causative organism. [2]
Inflammatory Markers These include erythrocyte sedimentation rate (ESR), and C-reactive Protein (CRP) levels. Regular assessment of inflammatory markers helps evaluate the patient response to therapy; note that CRP is preferred over ESR, as this changes more rapidly, and thus better reflects improvement of the disease.
References

Management - General Measures

Fact Explanation
Management Setting Mild endometritis and endometritis following vaginal delivery can usually be managed at home, with oral antibiotics. Severe endometritis, endometritis following Caesarean section, and endometritis associated with surgical treatment for miscarriage require admission to a hospital, to allow parenteral antibiotic therapy.[2]
Treatment of Fever Oral Acetaminophen is usually used for this purpose, as it has combined antipyretic and analgesic effects. [3]
Treatment of Pain Oral Acetaminophen is usually used as a first-line analgesic agent, as it has combined analgesic and antipyretic effects. More severe grades of pain may require nonsteroidal anti-inflammatory drugs (NSAIDS) such as mefenamic acid or diclofenac sodium; these can be administered via the oral or rectal routes. Tramadol can be considered in women with severe pain. [3]
Hydration Patient intake of fluids may be low due to the illness. Adequate hydration should be maintained via administration of oral and/or intravenous fluids. [3]
Monitoring In women receiving outpatient therapy, assessment of the clinical response to antibiotic therapy should occur after 48 to 72 hours, as most patients respond by this time. Where the endometritis is severe enough to require hospitalization, the patient's vital parameters, fluid intake/output, leukocyte count, and C-reactive protein level should be monitors. [3]
Patient Advice Adequate information should be provided about the disease - especially the potential long-term complications, e.g. infertility, and ectopic pregnancy. The patient should also be advised to avoid sexual intercourse during the initial period of treatment; barrier contraception should be subsequently encouraged. Note also that women diagnosed with pelvic inflammatory disease should receive appropriate counseling, particularly about avoiding risky sexual behavior. [1]
References
  1. SAFRIN S, SCHACHTER J, DAHROUGE D, SWEET RL. Long-term sequelae of acute pelvic inflammatory disease. A retrospective cohort study. Am J Obstet Gynecol [online] 1992 Apr, 166(4):1300-5 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/1566789
  2. CHAIM W, BURSTEIN E. Postpartum infection treatments: a review. Expert Opin Pharmacother [online] 2003 Aug, 4(8):1297-313 [viewed 07 September 2014] Available from: doi:10.1517/14656566.4.8.1297
  3. UK National Guideline for the Management of Pelvic Inflammatory Disease. British Association for Sexual Health and HIV, 2011 [Viewed on 07 September 2014]. Available from : http://www.bashh.org/documents/3572.pdf

Management - Specific Treatments

Fact Explanation
Antibiotics: Choice of Regime As polymicrobial infections are common, broad spectrum cover is essential. Commonly used regimes include a second or third generation cephalosporin in combination with Metronidazole; a third generation cephalosporin with doxycycline; Gentamicin along with a macrolide; or Clindamycin. Potent intravenous monotherapy can also be used, e.g. a newer generation fluroquinolone, or a third generation cephalosporin. The treatment duration is usually 14 days; note however that abbreviated antibiotic therapy, with only a short course of intravenous drugs has been shown to be safe and cost effective. [1] [2]
Antibiotics: Choice of Route Antibiotic therapy is the mainstay of management, and should be commenced as soon as samples have been collected for cultures. Oral antibiotics are adequate for mild illness. Intravenous antibiotics are required for severe disease, and can be converted to an oral formulation following an adequate response.[1]
Surgical Management: ERPC Women who develop endometritis following vaginal delivery or a miscarriage may have retained products within the uterine cavity. Where this has been established, evacuation of retained products of conception (ERPC) should be performed under general anesthesia. Note that if performed in the immediate postpartum period, this procedure carries a risk of uterine perforation.[3]
References
  1. SOPER DE, KEMMER CT, CONOVER WB. Abbreviated antibiotic therapy for the treatment of postpartum endometritis. Obstet Gynecol [online] 1987 Jan, 69(1):127-30 [viewed 07 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/3796913
  2. FRENCH LM, SMAILL FM. Antibiotic regimens for endometritis after delivery. Cochrane Database Syst Rev [online] 2004 Oct 18:CD001067 [viewed 07 September 2014] Available from: doi:10.1002/14651858.CD001067.pub2
  3. VARAKLIS K, STUBBLEFIELD PG.Evaluating the role of incidental diagnostic dilation and curettage in young women undergoing elective laparoscopic sterilization.J Reprod Med. 1995 Jun;40(6):415-7. [Viewed 07 December 2014] Available from:http://www.ncbi.nlm.nih.gov/pubmed/7650651