Reproductive · Year 2 · from Reproductive
Case 2: Postpartum Endometritis
Clinical Image
Source: Wikipedia - Endometritis - CC BY-SA 3.0
Case Presentation
A 28-year-old G1P1 woman is postoperative day 2 following cesarean delivery for arrest of dilation. Her labor had been prolonged, with rupture of membranes 28 hours before delivery, multiple cervical examinations, and internal fetal monitoring. She develops fever to 38.8°C with chills. She reports lower abdominal pain and foul-smelling lochia. Physical examination reveals uterine tenderness on palpation and purulent cervical discharge. Laboratory studies show WBC 18,000/μL with left shift. The diagnosis is postpartum endometritis. Blood and endometrial cultures are obtained. Empiric IV antibiotic therapy with clindamycin 900 mg IV every 8 hours plus gentamicin 5 mg/kg IV daily is initiated. By 48 hours, she remains febrile. Ampicillin 2 g IV every 6 hours is added to the regimen to cover enterococcus. Within 24 hours of adding ampicillin, she becomes afebrile. Antibiotics are continued until she has been afebrile for 24-48 hours. She is discharged on hospital day 5 without need for oral antibiotics and recovers fully.
Key Learning Points
- Endometritis is the most common cause of puerperal fever; cesarean delivery is the strongest risk factor (5-10x higher risk than vaginal delivery), especially with labor and ruptured membranes
- Other risk factors include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal monitoring, and chorioamnionitis
- The classic antibiotic regimen is clindamycin plus gentamicin; if no improvement in 48 hours, ampicillin is added to cover enterococcus
- Endometritis is a polymicrobial infection involving vaginal flora including anaerobes, gram-positive cocci, and gram-negative rods