Endomyometritis and puerperal fever

Definition

• Puerperal fever means a temperature of 38.0 °C or more on two days after the first 24 hours.
• A single rise on the first day is often due to exertion, dehydration or the milk coming in.
• The approach begins with history, examination from head to toe, bloods and targeted imaging.

Lochia

• The sequence is lochia rubra, fusca, flava, alba.
• Altogether the lochia last about four to six weeks.
• A sudden stop with a high fundus suggests retained lochia.
• Offensive lochia with fever suggest endomyometritis.

• Postpartum endo(myo)metritis is an infection of the uterus, usually caused by bacteria ascending from the lower genital or gastrointestinal tract; the endometrium, myometrium and parametria may be involved.
• Postpartum endometritis is the most common cause of postpartum infection.

Occurrence & epidemiology

Epidemiology

• Frequency depends mainly on the mode of birth: in a large study it was 1% after vaginal birth, 3% after planned caesarean section and 5–10% after caesarean section in labour; overall, endometritis is 5 to 20 times more common after caesarean section.
• Postpartum infections as a whole affect about 5–7% of women in the first 6 weeks after birth.

Aetiopathogenesis

Aetiology and risk factors

• The infection is usually polymicrobial: gram-positive cocci (mainly group B streptococci, Staphylococcus epidermidis, enterococci), anaerobes (peptostreptococci, Bacteroides, Prevotella) and gram-negative organisms (including Gardnerella vaginalis, Escherichia coli, Klebsiella, Proteus).

Clinical features

Findings

• The typical examination finding is tenderness at the uterine angles on bimanual examination.
• Transvaginally you see a distended cavity with fluid or retained clot.

Clinical features and complications

• Usually lower abdominal pain and uterine tenderness come first, followed by fever, most often within the first 24–72 hours; chills, headache and malaise are common, and sometimes there is only a low-grade fever.
• The uterus is soft, large and tender; lochia may be reduced or profuse and malodorous, and tachycardia and leucocytosis are common.
• Complications are parametritis, peritonitis, pelvic abscess, septic pelvic thrombophlebitis and rarely septic shock; infections with group A streptococci or Clostridium species are associated with sepsis, and toxic shock syndrome may occur.

Diagnosis

Work-up

• Bloods include full blood count, CRP, urine dipstick and culture, and blood cultures with a high fever.
• Ultrasound assesses the uterine cavity, adnexa, kidneys, wound and breasts as appropriate.
• With suspected pelvic vein thrombosis, cross-sectional imaging helps, as ultrasound is often not enough.
• What matters is looking at the whole patient including her legs — postpartum thrombosis is otherwise missed.

• The diagnosis is clinical: within 24 hours of birth it is based on pain, tenderness and a temperature above 38 °C; thereafter it is presumed with temperatures of 38 °C or more on two successive days without another cause.
• Urinalysis and urine culture serve to exclude other causes; endometrial cultures are rarely useful because they are almost always contaminated by vaginal and cervical flora.

Keep learning in the app

Further reading (selection)

1. StatPearls: Endometritis (NCBI Bookshelf)
2. StatPearls: Postpartum Infection (NCBI Bookshelf)
3. MSD Manual Professional Edition: Postpartum Endometritis
4. DocCheck Flexikon, Lochialstau
5. DocCheck Flexikon, Puerperalfieber
6. DocCheck Flexikon, Wochenbett

Cross-references