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Postpartum Endometritis

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261. Postterm Pregnancy (Overview)

’ gestation). [ ] Maternal risks and mode of delivery The maternal risks of postterm pregnancy are often underappreciated. These include an increase in (9-12% vs 2-7% at term), an increase in severe perineal injury (3 rd and 4 th degree perineal lacerations) related to macrosomia (3.3% vs 2.6% at term) and operative vaginal delivery, and a doubling in the rate of cesarean delivery (14% vs 7% at term). [ , , , ] The latter is associated with higher risks of complications such as endometritis, hemorrhage (...) in term pregnancies prior to 42 weeks of gestation. Such complications as chorioamnionitis, severe perineal lacerations, cesarean delivery rates, postpartum hemorrhage, and endomyometritis all increase progressively after 39 weeks of gestation. [ , , , , ] Next: Timing of Delivery The first decision that must be made when managing an impending postterm pregnancy is whether to deliver. In certain cases (eg, nonreassuring surveillance, oligohydramnios, growth restriction, certain maternal diseases

2014 eMedicine.com

262. Normal and Abnormal Puerperium (Overview)

that are effective for 12 weeks. Intrauterine devices can be placed immediately post partum (after delivery of the placenta) or after uterine involution occurs typically 4-6 weeks after delivery. Immediate postpartum insertion is associated with an increased risk of expulsion, approximately 24%. Immediate insertion is contraindicated in those with any postpartum infection including peripartum chorioamnionitis, endometritis or puerperal sepsis. [ ] Permanent methods of birth control (ie, tubal ligation, vasectomy (...) have a cesarean delivery have a five to 20-fold greater chance of a postpartum infection compared to those who delivery vaginally . [ ] Therefore ACOG recommends the routine administration of prophylactic antibiotics in women undergoing cesarean section. [ ] In a large Cochrane review of 95 studies including over 15,000 women who had cesarean deliveries, there was a 60-70% reduction in postpartum complications after the use of prophylactic antibiotics including wound infection and endometritis

2014 eMedicine.com

263. Oophoritis (Overview)

-related factors PID rarely occurs in pregnancy; however, chorioamnionitis can occur in the first 12 weeks of gestation, before the mucous plug solidifies and seals off the uterus from ascending bacteria. Fetal loss may result. Concurrent pregnancy influences the choice of antibiotic therapy for PID and demands that an alternative diagnosis of ectopic pregnancy be excluded. Uterine infection is usually limited to the endometrium but may be more invasive in a gravid or postpartum uterus. Genetic factors (...) infection with BV-associated organisms (eg, G vaginalis ). However evidence is unclear if detecting and treating BV reduces PID related infection. [ ] In some regions, PID may be from a granulomatous salpingitis caused by Mycobacterium tuberculosis or Schistosoma species. [ ] In a cross-sectional study of 736 women with PID, patients with Trichomonas infections demonstrated a 4-fold increase in the histologic evidence of acute endometritis. Coinfection with HSV-2, N gonorrhoeae , C trachomatis , and BV

2014 eMedicine.com

264. Fallopian Tube Reconstruction (Overview)

a tubal sterilization reversal procedure delivered live children. The menstrual history is essential to evaluate a possible ovulatory factor. The obstetrical history establishes whether the woman has ever been able to conceive and whether she has had any pregnancy complications, such as an ectopic pregnancy or postpartum endometritis, that may have compromised her reproductive tract. The gynecological history reveals possible problems with the reproductive organs that may affect fertility (...) possible causes of ovulatory dysfunction secondary to hypothalamic/pituitary disorders or intrinsic ovarian malfunction. A history of PID, endometritis, and other causes of pelvic inflammation, such as endometriosis or appendicitis, should be elicited. Correctible medical contraindications to pregnancy (and surgery), such as uncontrolled diabetes, hypertension, or cardiac or renal disease, should be excluded or corrected. The surgical history should focus on the pelvis because any surgery

2014 eMedicine.com

265. Ankylosing Spondylitis (Follow-up)

cytology and colposcopy at 6-month intervals is recommended. Biopsy is performed if a high-grade lesion or HSIL cytology is diagnosed. If the colposcopy study is inadequate, if CIN 2 or higher is found, or if CIN is identified in the endocervix sample, an excisional procedure is performed. Recommendations are similar for women younger than 21 years who have been screened inadvertently. For pregnant women with CIN 1, no treatment is recommended, but testing is repeated postpartum. CIN grades 2 and 3 (...) disease, postponing reevaluation until 6 weeks' or longer postpartum is acceptable. Algorithms for the management of genital dysplasias are available from the . Adenocarcinoma in situ The management of adenocarcinoma in situ is often difficult since this disease process frequently extends well into the endocervical canal and may be multifocal or possess "skip lesions." Invasion cannot be excluded without an excisional procedure, but negative margins performed after an excisional procedure do

2014 eMedicine.com

266. Bacterial Infections and Pregnancy (Follow-up)

both a high degree of clinical awareness and adequate screening. Group B Streptococcus Group B Streptococcus (GBS; Streptococcus agalactiae ) is the most common cause of life-threatening infections in newborns and can also affect the mother. Features of GBS infection are as follows: GBS can be found as part of normal vaginal, rectal, and oral flora Intrapartum transmission occurs via ascending spread or at the time of delivery In pregnant women, GBS causes cystitis, amnionitis, endometritis (...) , and stillbirth; occasionally, GBS bacteremia leads to endocarditis or meningitis In postpartum women, GBS can cause urinary tract infections (UTIs) and pelvic abscesses In newborns, early-onset GBS infection occurs before age 7 days (mean age at presentation is age 12 hours) and primarily manifests as nonfocal sepsis, pneumonia, or meningitis Late-onset disease in neonates occurs at age 7-89 days (mean age, 36 days), and nonfocal bacteremia and meningitis are the most common presentations Babies who survive

2014 eMedicine.com

267. Ureaplasma Infection (Diagnosis)

with salpingitis; M genitalium may also be involved in pelvic inflammatory disease and cervicitis. Whether Ureaplasma infection causes involuntary infertility remains speculative. Ureaplasma species can cause placental inflammation and may invade the amniotic sac early, causing persistent infection and adverse pregnancy outcomes, including premature birth. M hominis has been isolated from the blood of approximately 10% of women with postpartum or postabortal fever, but not from afebrile women who had abortions (...) to be more common in African Americans than in whites, but it is not clear whether this is a true racial difference as opposed to a socioeconomic factor. Sex No obvious sex predilection is reported for infections due to genital mycoplasmal species, except for the differences in urogenital diseases such as salpingitis and endometritis, which are gender-specific. The carriage rate of genital Mycoplasma species in the lower urogenital tract is somewhat greater for females than for males. Ureaplasma species

2014 eMedicine.com

268. Broad Ligament Disorders (Overview)

the lower edge of the uterine corpus to the anterior wall of the rectum posteriorly. Ligamentopexy of the uterosacral ligaments is performed using 3-4 separate absorbable stitches or stapling. Reapproximation of the free edges of the peritoneum is performed. In their series, one case was complicated by intraoperative bleeding necessitating conversion to laparotomy, one by retroperitoneal hematoma, and another by postoperative endometritis. They observed the patients for an average of 2.9 years and noted (...) in the vagina or the possibility of an expanding vaginal hematoma. Jain et al suggested that a pelvic MRI should be used to evaluate patients with persistent postpartum localized pelvic pain, fullness or discomfort, or a sudden drop in hematocrit level with no apparent source of bleeding. They reported 7 cases of patients having postpartum hemorrhage nonapparent to the clinical examination; in these cases, hematoma was successfully diagnosed by MRI. [ ] Broad ligament hematoma may be treated either

2014 eMedicine.com

269. Salpingitis (Diagnosis)

or postpartum uterus. Genetic factors Genetically mediated variation in immune response plays an important role in susceptibility to PID. [ ] Variants in the genes that regulate toll-like receptors (TLRs), an important component in the innate immune system, have been associated with an increased progression of C trachomatis infection to PID. [ ] Den Hartog et al found a possible contributing role of 5 single-nucleoside polymorphisms (SNPs) in 4 genes encoding pattern recognition receptors in local tubal (...) to vaginal inflammation, which could facilitate ascending infection with BV-associated organisms (eg, G vaginalis ). However evidence is unclear if detecting and treating BV reduces PID related infection. [ ] In some regions, PID may be from a granulomatous salpingitis caused by Mycobacterium tuberculosis or Schistosoma species. [ ] In a cross-sectional study of 736 women with PID, patients with Trichomonas infections demonstrated a 4-fold increase in the histologic evidence of acute endometritis

2014 eMedicine.com

270. Broad Ligament Disorders (Diagnosis)

the lower edge of the uterine corpus to the anterior wall of the rectum posteriorly. Ligamentopexy of the uterosacral ligaments is performed using 3-4 separate absorbable stitches or stapling. Reapproximation of the free edges of the peritoneum is performed. In their series, one case was complicated by intraoperative bleeding necessitating conversion to laparotomy, one by retroperitoneal hematoma, and another by postoperative endometritis. They observed the patients for an average of 2.9 years and noted (...) in the vagina or the possibility of an expanding vaginal hematoma. Jain et al suggested that a pelvic MRI should be used to evaluate patients with persistent postpartum localized pelvic pain, fullness or discomfort, or a sudden drop in hematocrit level with no apparent source of bleeding. They reported 7 cases of patients having postpartum hemorrhage nonapparent to the clinical examination; in these cases, hematoma was successfully diagnosed by MRI. [ ] Broad ligament hematoma may be treated either

2014 eMedicine.com

271. Bacterial Infections and Pregnancy (Diagnosis)

both a high degree of clinical awareness and adequate screening. Group B Streptococcus Group B Streptococcus (GBS; Streptococcus agalactiae ) is the most common cause of life-threatening infections in newborns and can also affect the mother. Features of GBS infection are as follows: GBS can be found as part of normal vaginal, rectal, and oral flora Intrapartum transmission occurs via ascending spread or at the time of delivery In pregnant women, GBS causes cystitis, amnionitis, endometritis (...) , and stillbirth; occasionally, GBS bacteremia leads to endocarditis or meningitis In postpartum women, GBS can cause urinary tract infections (UTIs) and pelvic abscesses In newborns, early-onset GBS infection occurs before age 7 days (mean age at presentation is age 12 hours) and primarily manifests as nonfocal sepsis, pneumonia, or meningitis Late-onset disease in neonates occurs at age 7-89 days (mean age, 36 days), and nonfocal bacteremia and meningitis are the most common presentations Babies who survive

2014 eMedicine.com

272. Broad Ligament Disorders (Follow-up)

the lower edge of the uterine corpus to the anterior wall of the rectum posteriorly. Ligamentopexy of the uterosacral ligaments is performed using 3-4 separate absorbable stitches or stapling. Reapproximation of the free edges of the peritoneum is performed. In their series, one case was complicated by intraoperative bleeding necessitating conversion to laparotomy, one by retroperitoneal hematoma, and another by postoperative endometritis. They observed the patients for an average of 2.9 years and noted (...) in the vagina or the possibility of an expanding vaginal hematoma. Jain et al suggested that a pelvic MRI should be used to evaluate patients with persistent postpartum localized pelvic pain, fullness or discomfort, or a sudden drop in hematocrit level with no apparent source of bleeding. They reported 7 cases of patients having postpartum hemorrhage nonapparent to the clinical examination; in these cases, hematoma was successfully diagnosed by MRI. [ ] Broad ligament hematoma may be treated either

2014 eMedicine.com

273. Vaginitis (Diagnosis)

with an increased risk of adverse pregnancy outcomes, including , , preterm delivery, low birth weight, and postpartum endometritis. [ ] Previous Next: Patient Education Safe sex and STD counseling may help decrease the rates of reinfection. Discuss further preventive efforts, including proper hygiene and toilet techniques, when it is appropriate to do so. Remind patients that douching can spread a vaginal or cervical infection into the uterus, increasing the likelihood of PID; douching can also be associated (...) to prevent HIV, bacterial vaginosis and sexually transmitted infections, including trichomoniasis, are considered to be risk factors for HIV. Chronic vaginal infection can facilitate the transmission of various STDs, including HIV. Complications of bacterial vaginosis include endometritis and . Untreated bacterial vaginosis may result in complications (eg, vaginal wound infections) after gynecologic surgical procedures. In pregnancy, Trichomonas infection and bacterial vaginosis are associated

2014 eMedicine.com

274. Fitz-Hugh-Curtis Syndrome (Diagnosis)

or postpartum uterus. Genetic factors Genetically mediated variation in immune response plays an important role in susceptibility to PID. [ ] Variants in the genes that regulate toll-like receptors (TLRs), an important component in the innate immune system, have been associated with an increased progression of C trachomatis infection to PID. [ ] Den Hartog et al found a possible contributing role of 5 single-nucleoside polymorphisms (SNPs) in 4 genes encoding pattern recognition receptors in local tubal (...) to vaginal inflammation, which could facilitate ascending infection with BV-associated organisms (eg, G vaginalis ). However evidence is unclear if detecting and treating BV reduces PID related infection. [ ] In some regions, PID may be from a granulomatous salpingitis caused by Mycobacterium tuberculosis or Schistosoma species. [ ] In a cross-sectional study of 736 women with PID, patients with Trichomonas infections demonstrated a 4-fold increase in the histologic evidence of acute endometritis

2014 eMedicine.com

275. Cesarean Delivery (Diagnosis)

with 5% dextrose) Placement of a Foley catheter (to drain the bladder and to monitor urine output) Placement of an external fetal monitor and monitors for the patient’s blood pressure, pulse, and oxygen saturation Preoperative antibiotic prophylaxis (decreases risk of endometritis after elective cesarean delivery by 76%, regardless of the type of cesarean delivery [emergent or elective]) [ ] Evaluation by the surgeon and the anesthesiologist Laboratory testing The following laboratory studies may (...) if patient received regional anesthesia, with/without a long-acting analgesic Ambulation on postoperative day 1; advance as tolerated If patient plans to breastfeed, initiate within a few hours after delivery; if patient plans to bottle feed, she may use a tight bra or breast binder in the postoperative period Discharge on postoperative day 2 to 4, if no complications [ ] Discuss contraception as well as refraining from intercourse for 4-6 weeks postpartum, unless the patient had LARC placed at the time

2014 eMedicine.com

276. Cardiomyopathy, Peripartum (Diagnosis)

. Consider transfer to a center that offers tertiary care services for both the mother and the fetus. If the mother is less than 37 weeks’ gestation, transfer her to a center with a neonatal ICU. Route of delivery Delivering the fetus decreases the metabolic demands on the mother, but afterload increases due to the loss of the low-resistance placental bed. Vaginal deliveries are preferred because they are associated with much lower rates of complications, such as endometritis and pulmonary embolism, 75 (...) when administered to nonpregnant outpatients with systolic dysfunction. However, clinical experience with potassium-sparing diuretics such as spironolactone in pregnancy is limited in comparison to that accumulated with furosemide. The use of spironolactone may be considered for patients with reduced left ventricular systolic function in the postpartum period. may be used when clinically indicated, and a thiazide may be added cautiously to a loop diuretic for a synergistic effect in diuretic

2014 eMedicine.com

277. Gardnerella (Diagnosis)

. Uncomplicated bacterial vaginosis that is assessed promptly typically resolves with standard antibiotic treatment. The prognosis for complicated cases of bacterial vaginosis leading to other infections varies depending on the particular infectious process. Note the following: Long-standing or untreated BV may lead to more serious sequelae, such as , , , or complications of pregnancy, including , premature labor, chorioamnionitis, and postpartum endometritis. BV leads to an increased risk for acquiring HIV (...) , postsurgical infections (eg, postcesarean endometritis, posthysterectomy vaginal cuff cellulitis), and adverse outcomes in pregnancy, including premature rupture of membranes, premature labor, chorioamnionitis, and postpartum endometritis. Mixed infections Mixed infections with Trichomonas and yeast can occur among patients with BV. Bacteremia Gardnerella vaginalis bacteremia occurs much more commonly in women than in men and occurs most commonly in postpartum and postgynecologic procedure infections (eg

2014 eMedicine.com

278. Fallopian Tube Reconstruction (Diagnosis)

a tubal sterilization reversal procedure delivered live children. The menstrual history is essential to evaluate a possible ovulatory factor. The obstetrical history establishes whether the woman has ever been able to conceive and whether she has had any pregnancy complications, such as an ectopic pregnancy or postpartum endometritis, that may have compromised her reproductive tract. The gynecological history reveals possible problems with the reproductive organs that may affect fertility (...) possible causes of ovulatory dysfunction secondary to hypothalamic/pituitary disorders or intrinsic ovarian malfunction. A history of PID, endometritis, and other causes of pelvic inflammation, such as endometriosis or appendicitis, should be elicited. Correctible medical contraindications to pregnancy (and surgery), such as uncontrolled diabetes, hypertension, or cardiac or renal disease, should be excluded or corrected. The surgical history should focus on the pelvis because any surgery

2014 eMedicine.com

279. Coccidioidomycosis (Infectious Diseases) (Diagnosis)

and in the immediate postpartum period, are at higher risk for dissemination than the general population. [ , , ] All age groups can be affected. Primary infection of the newborn rarely occurs. [ ] Infection of the genital tract of the mother can result in placental involvement, coccidioidal endometritis, and aspiration of infected amniotic fluid by the fetus. Both congenital and perinatal transmission of Coccidioides species have been reported. However, infants can experience severe disease within the first few

2014 eMedicine.com

280. Coccidioidomycosis (Diagnosis)

and in the immediate postpartum period, are at higher risk for dissemination than the general population. [ , , ] All age groups can be affected. Primary infection of the newborn rarely occurs. [ ] Infection of the genital tract of the mother can result in placental involvement, coccidioidal endometritis, and aspiration of infected amniotic fluid by the fetus. Both congenital and perinatal transmission of Coccidioides species have been reported. However, infants can experience severe disease within the first few

2014 eMedicine.com

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