What is the management of endometritis puerperal?

Management of Postpartum Endometritis

The gold standard treatment for postpartum endometritis is intravenous clindamycin 900 mg every 8 hours plus gentamicin (2 mg/kg loading dose, then 1.5 mg/kg every 8 hours), continued for at least 48 hours after clinical improvement, followed by oral doxycycline 100 mg twice daily to complete 10-14 days of total therapy. 1, 2, 3

Clinical Diagnosis

Postpartum endometritis should be suspected when fever ≥38.3°C (101°F) develops after the first 24 hours post-delivery and up to 10 days postpartum, accompanied by: 4, 1

• Lower abdominal pain and uterine tenderness 1
• Foul-smelling lochia 4
• Uterine subinvolution 5
• Elevated inflammatory markers (ESR or CRP) 1

The infection is polymicrobial, most commonly involving vaginal flora including E. coli, Streptococcus agalactiae, Bacteroides species, and anaerobes. 4, 5 Endometrial cultures can guide therapy but should not delay treatment initiation. 5

First-Line Treatment Regimen

Clindamycin plus gentamicin is superior to other regimens, with significantly fewer treatment failures compared to penicillins (RR 0.65) or cephalosporins (RR 0.60 when comparing cephalosporins to clindamycin/gentamicin). 2, 6

Dosing:

• Clindamycin 900 mg IV every 8 hours 1, 3
• Gentamicin: 2 mg/kg IV/IM loading dose, then 1.5 mg/kg every 8 hours 1
• Once-daily gentamicin dosing shows fewer treatment failures than thrice-daily dosing 2

Continue IV antibiotics for at least 48 hours after the patient becomes afebrile and shows clinical improvement (resolution of tachycardia, decreased uterine tenderness). 1, 3

After clinical improvement, transition to oral doxycycline 100 mg twice daily to complete 10-14 days total therapy. 1

Alternative Regimen

If clindamycin/gentamicin is contraindicated: 1

• Cefoxitin 2 g IV every 6 hours OR cefotetan 2 g IV every 12 hours
• PLUS doxycycline 100 mg orally or IV every 12 hours
• Continue for 48 hours after clinical improvement, then oral doxycycline to complete 10-14 days

Important caveat: Regimens with poor activity against penicillin-resistant anaerobic bacteria (like Bacteroides fragilis) have significantly higher failure rates (RR 1.94) and more wound infections (RR 1.88). 2 This is why clindamycin's superior anaerobic coverage makes it preferable to doxycycline alone. 4, 1

When to Hospitalize for IV Therapy

Admit for parenteral antibiotics if: 1

• Surgical emergencies (appendicitis, ectopic pregnancy) cannot be excluded
• Patient is pregnant
• Pelvic abscess is suspected
• Severe illness, nausea/vomiting preclude oral intake
• Patient is an adolescent
• Failed outpatient therapy
• Unable to arrange 72-hour follow-up

Treatment Failure Management

Approximately 10% of patients fail initial therapy. 3 If fever persists beyond 48-72 hours of appropriate antibiotics: 3, 7

• Investigate for retained placental tissue - requires uterine curettage 7
• Evaluate for pelvic abscess - may need imaging (ultrasound/CT) 7
• Consider wound infection or septic pelvic thrombophlebitis 3
• Rule out hematometra or lochiometra - requires vacuum aspiration 7

Post-Treatment Considerations

Oral antibiotics after completing IV therapy are NOT necessary once uncomplicated endometritis has clinically improved - three studies found no benefit in preventing recurrent endometritis. 2, 6 However, the CDC guideline recommends completing 10-14 days total therapy with oral doxycycline, which represents the current standard of care. 1

Prevention Strategies

• Prophylactic antibiotics within 60 minutes before cesarean section reduce postpartum endometritis by approximately 60% 8, 3
• Vaginal preparation with povidone-iodine before cesarean delivery reduces endometritis from 8.3% to 4.3% 8
• Screen and treat bacterial vaginosis in late pregnancy to reduce risk 4

Common Pitfalls to Avoid

• Do not discontinue IV therapy before 48 hours of clinical improvement - premature discontinuation increases failure rates 1
• Do not use regimens with poor anaerobic coverage (second/third generation cephalosporins without cephamycins) as monotherapy - these have nearly double the failure rate 2
• Do not forget to screen for underlying STIs (Chlamydia, Gonorrhea) that may have contributed to the infection 4, 1