What is the best treatment for a postpartum woman with symptoms of endometritis, including fever, chills, back pain, pelvic spasms, and passing of clots?

Treatment of Postpartum Endometritis

The combination of intravenous clindamycin and gentamicin is the most effective treatment for postpartum endometritis and should be initiated immediately upon diagnosis. 1

Diagnosis

Postpartum endometritis should be suspected when a woman presents with:

• Fever (≥101°F or >100.4°F on more than two occasions >6 hours apart after the first 24 hours of delivery and up to 10 days post-delivery)
• Abdominal pain
• Uterine tenderness
• Foul-smelling lochia (vaginal discharge)
• Possible chills, back pain, pelvic spasms, and passing of clots 2

First-line Treatment

1. Intravenous antibiotic therapy:
   • Clindamycin (900 mg IV every 8 hours) plus
   • Gentamicin (5 mg/kg IV once daily) 1, 3

This combination has been shown to have fewer treatment failures compared to penicillins (RR 0.65,95% CI 0.46 to 0.90) and cephalosporins (RR 0.65,95% CI 0.46 to 0.90) 1.

Duration of Treatment

• Continue IV antibiotics until the patient is afebrile and clinically improved for at least 24-48 hours
• No additional oral antibiotic therapy is necessary after clinical improvement with IV therapy 1

Alternative Regimens

If clindamycin/gentamicin is contraindicated:

• For patients with penicillin allergy or during breastfeeding:
  • Alternative regimens with good activity against penicillin-resistant anaerobic bacteria should be used
  • Avoid regimens with poor activity against anaerobic bacteria as they have higher treatment failure rates (RR 1.94,95% CI 1.38 to 2.72) 1

Monitoring and Additional Management

• Most patients will respond to appropriate antibiotic treatment within 24-48 hours 4
• If fever persists beyond 48-72 hours despite appropriate antibiotics:
  1. Perform pelvic ultrasound to rule out retained products of conception or abscess
  2. Consider CT scan or MRI to evaluate for pelvic abscess requiring drainage or septic pelvic thrombophlebitis 3
  3. For septic pelvic thrombophlebitis: add anticoagulation with heparin for the duration of antibiotic therapy 3, 5

Special Considerations

• Cesarean delivery: Women who have had cesarean delivery are at higher risk for endometritis compared to those with vaginal delivery 6
• Diagnostic testing: Consider testing for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and HIV in patients with suspected endometritis 2
• Prevention: Antibiotic prophylaxis (typically cephalosporins) administered within 60 minutes before cesarean delivery skin incision can reduce the incidence of postpartum endometritis 2, 7

Common Pitfalls to Avoid

1. Delayed treatment: Initiate antibiotics immediately upon diagnosis as prevention of long-term sequelae is directly linked to prompt administration of appropriate antibiotics 2

2. Inadequate antibiotic coverage: Ensure the regimen has good activity against penicillin-resistant anaerobic bacteria 1

3. Failure to investigate persistent fever: If fever persists beyond 48-72 hours of appropriate antibiotic therapy, further investigation with imaging is warranted 3

4. Overlooking complications: Be vigilant for complications such as pelvic abscess or septic pelvic thrombophlebitis, especially in patients with persistent back pain 5