Obgyn · Year 3 · from Obgyn
Case 2: Postpartum Endometritis
Patient Demographics
- Age: 25 years
- Sex: Female
- Occupation: Retail sales associate
Chief Complaint
"I have a fever and my stomach hurts since I came home from the hospital."
History of Present Illness
The patient is postpartum day 4 following cesarean delivery for arrest of dilation. She was discharged on postpartum day 2 feeling well. She now presents with fever, lower abdominal pain, and foul-smelling vaginal discharge that began yesterday. She has been breastfeeding but notes decreased milk supply. She denies urinary symptoms, leg swelling, or shortness of breath.
Delivery History
- Cesarean delivery at 40 weeks for arrest of dilation at 7 cm
- Membranes ruptured for 18 hours prior to delivery
- Multiple cervical examinations during labor (6 total)
- Received prophylactic antibiotics (cefazolin) prior to incision
- Operative time 45 minutes, uncomplicated
Risk Factors for Endometritis
- Cesarean delivery (strongest risk factor)
- Prolonged rupture of membranes (>18 hours)
- Multiple vaginal examinations
- Prolonged labor
Physical Examination Findings
- Vital Signs: Temperature 39.2C (102.6F), BP 110/68 mmHg, HR 108 bpm
- General: Appears uncomfortable, flushed
- Abdomen: Soft, diffuse lower abdominal tenderness, fundus at umbilicus and tender to palpation
- Incision: Clean, dry, intact, no erythema or drainage
- Pelvic: Foul-smelling lochia, uterine tenderness on bimanual exam, no adnexal masses, cervical motion tenderness present
Diagnostic Workup
- CBC: WBC 18,500/mm3 with left shift (85% neutrophils)
- Urinalysis: Normal, no pyuria
- Blood Cultures: Obtained prior to antibiotics
- Urine Culture: Pending
- Pelvic Ultrasound: No fluid collection or abscess, normal postoperative appearance
Diagnosis
Postpartum Endometritis (post-cesarean)
- Fever >38C within 10 days of delivery
- Uterine tenderness
- Foul-smelling lochia
- Leukocytosis with left shift
Management Plan
Antibiotic Therapy (Standard Regimen):
- Clindamycin 900 mg IV every 8 hours
- Gentamicin 5 mg/kg IV every 24 hours (or divided dosing)
Rationale for Drug Selection:
- Polymicrobial infection (aerobic and anaerobic bacteria)
- Clindamycin provides excellent anaerobic coverage
- Gentamicin covers gram-negative organisms
- Alternative: Ampicillin-sulbactam or piperacillin-tazobactam
Supportive Care:
- IV fluids
- Acetaminophen for fever and comfort
- Continue breastfeeding (medications compatible)
Monitoring:
- Temperature curve every 4 hours
- Daily CBC
- Clinical assessment for improvement
Clinical Course
Day 1 of Treatment:
- Temperature 38.4C (improved from 39.2C)
- Still having some uterine tenderness
Day 2 of Treatment:
- Afebrile for 24 hours
- Uterine tenderness improved
- Lochia less malodorous
- WBC decreasing to 12,000
Day 3 of Treatment:
- Afebrile for 48 hours
- Minimal tenderness
- Ready for discharge
Discharge Plan
- Discontinue IV antibiotics after 24-48 hours afebrile
- NO oral antibiotics needed upon discharge (this is unique to postpartum endometritis)
- Return precautions: recurrent fever, worsening pain, wound issues
- Follow-up at postpartum visit
Teaching Points
- Post-cesarean endometritis is more common than post-vaginal delivery
- Triple antibiotic regimen (add ampicillin) may be needed if no improvement in 48-72 hours to cover enterococcus
- Septic pelvic thrombophlebitis should be considered if fever persists despite antibiotics ("picket fence" fever pattern)
- Wound infection should be evaluated separately if incision shows concerning signs
Clinical Image
Image Description: Clinical illustration showing the pathophysiology of postpartum endometritis with bacterial ascent from the lower genital tract to the uterine cavity, highlighting risk factors and typical microbiology.
Attribution: Educational illustration. Used for medical education purposes.