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Postpartum Endometritis

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321. 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

322. 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

323. 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

324. 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

325. 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 (...) genitalium [ , ] Ureaplasma urealyticum Herpes simplex virus 2 (HSV-2) Trichomonas vaginalis (CMV) Haemophilus influenzae Streptococcus agalactiae Enteric gram-negative rods (eg, Escherichia coli ) Enterococcus, described in 2 individuals post IUD insertion [ ] Peptococcus species Anaerobes The microbiology of PID reflects the predominant sexually transmitted pathogens within a specific population, as well as some organisms less commonly seen in that population. Bacterial vaginosis (BV) may lead

2014 eMedicine.com

326. Postterm Pregnancy (Diagnosis)

’ 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

327. Placenta Previa (Diagnosis)

in cases of placenta previa as well as placenta accreta, increta, and percreta.) Higher rates of blood transfusion [ , ] Placental abruption Preterm delivery Increased incidence of postpartum endometritis [ ] Mortality rate (2-3%); in the US, the maternal mortality rate is 0.03%, the great majority of which is related to uterine bleeding and the complication of The Table, below, summarizes the relative risk of some morbidities in women with placenta previa. Table. Relative Risk of Morbidities (...) birth is highly associated with placenta previa, with 16.9% of women delivering at less than 34 weeks and 27.5% delivering between 34 and 37 weeks in a population-based study from 1989 to 1997. [ ] There is a significant increase in the risk of postpartum hemorrhage and need for emergency hysterectomy in women with placenta previa. [ ] Maternal complications of placenta previa are summarized as follows: Hemorrhage, [ ] including rebleeding (Planning delivery and control of hemorrhage is critical

2014 eMedicine.com

328. Maternal Chorioamnionitis (Overview)

or metronidazole when endometritis is suspected (postdelivery) Vancomycin for penicillin-allergic patients Alternatives: Monotherapy with ampicillin-sulbactam, ticarcillin-clavulanate, cefoxitin, cefotetan, or piperacillin-tazobactam Penicillin G: Used exclusively for GBS intrapartum prophylaxis; if intraamniotic infection is suspected, broaden the antibiotic coverage. Nonpharmacotherapy Supportive care of the septic neonate may include the following: Warmth, monitoring of vital signs Preparedness to perform (...) of chorioamnionitis. [ , , ] Previous Next: Prognosis Maternal sequelae Acute chorioamnionitis may result in labor abnormalities (dysfunctional labor) that increase the risk for cesarean delivery, uterine atony, and postpartum bleeding, as well as the need for blood transfusion. [ , ] These complications are likely to occur more often when the amniotic fluid is infected with invasive organisms (eg, E coli and group B Streptococcus [GBS]) as compared with low-virulence organisms (eg, Ureaplasma urealyticum

2014 eMedicine Pediatrics

329. Coccidioidomycosis (Overview)

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 Pediatrics

330. Imperforate Hymen (Treatment)

are not recommended, postoperative fever or abdominal pain must be evaluated and treated promptly. Potential complications include endometritis, salpingitis, or tubo-ovarian abscess—any of which can affect subsequent fertility. Concern for secondary endometriosis resulting from retrograde menstruation is sufficient for some authors to advocate irrigation of the peritoneal cavity by using a laparoscopic technique. No definitive information regarding the frequency of this condition is available, and most surgeons (...) ):234-6. . Garcia Rodriguez R, Pérez González J, Garcia Delgado R, Rodriguez Guedes A, de Luis Alvarado M, Medina Castellano M, et al. Fetal hydrometrocolpos and congenital imperforate hymen: Prenatal and postnatal imaging features. J Clin Ultrasound . 2018 Mar 23. . Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg . 1999 Oct. 34 (10):1555-6. . Frega A, Verrone A, Schimberni M, Manzara

2014 eMedicine Pediatrics

331. Maternal Chorioamnionitis (Treatment)

neonatal disease caused by GBS, the most recent guidelines were published , [ ] with an update . [ ] A retrospective study evaluating daily gentamicin for the treatment of intrapartum chorioamnionitis in 500 women found that daily gentamicin dosing using ideal body weight compared with traditional 8-hour dosing regimens was associated with a 64% lower risk of postpartum endometritis and a 5% higher chance of successful outcome. [ ] These results were adjusted for maternal factors such as race, parity (...) . Upon signs of serious fetal distress, delivery must be emergent. Withholding maternal antibiotics to obtain postnatal cultures from the neonate is no longer appropriate. This strategy was once an accepted practice based on the assumption that waiting to obtain cultures from the newborn helps to determine the cause of infection. The morbidity and mortality in the mother and newborn may actually increase because of a delay in administering antibiotics. The neonatal care provider (neonatologist

2014 eMedicine Pediatrics

332. Imperforate Hymen (Follow-up)

are not recommended, postoperative fever or abdominal pain must be evaluated and treated promptly. Potential complications include endometritis, salpingitis, or tubo-ovarian abscess—any of which can affect subsequent fertility. Concern for secondary endometriosis resulting from retrograde menstruation is sufficient for some authors to advocate irrigation of the peritoneal cavity by using a laparoscopic technique. No definitive information regarding the frequency of this condition is available, and most surgeons (...) ):234-6. . Garcia Rodriguez R, Pérez González J, Garcia Delgado R, Rodriguez Guedes A, de Luis Alvarado M, Medina Castellano M, et al. Fetal hydrometrocolpos and congenital imperforate hymen: Prenatal and postnatal imaging features. J Clin Ultrasound . 2018 Mar 23. . Ahmed S, Morris LL, Atkinson E. Distal mucocolpos and proximal hematocolpos secondary to concurrent imperforate hymen and transverse vaginal septum. J Pediatr Surg . 1999 Oct. 34 (10):1555-6. . Frega A, Verrone A, Schimberni M, Manzara

2014 eMedicine Pediatrics

333. Maternal Chorioamnionitis (Follow-up)

neonatal disease caused by GBS, the most recent guidelines were published , [ ] with an update . [ ] A retrospective study evaluating daily gentamicin for the treatment of intrapartum chorioamnionitis in 500 women found that daily gentamicin dosing using ideal body weight compared with traditional 8-hour dosing regimens was associated with a 64% lower risk of postpartum endometritis and a 5% higher chance of successful outcome. [ ] These results were adjusted for maternal factors such as race, parity (...) . Upon signs of serious fetal distress, delivery must be emergent. Withholding maternal antibiotics to obtain postnatal cultures from the neonate is no longer appropriate. This strategy was once an accepted practice based on the assumption that waiting to obtain cultures from the newborn helps to determine the cause of infection. The morbidity and mortality in the mother and newborn may actually increase because of a delay in administering antibiotics. The neonatal care provider (neonatologist

2014 eMedicine Pediatrics

334. Maternal Chorioamnionitis (Diagnosis)

or metronidazole when endometritis is suspected (postdelivery) Vancomycin for penicillin-allergic patients Alternatives: Monotherapy with ampicillin-sulbactam, ticarcillin-clavulanate, cefoxitin, cefotetan, or piperacillin-tazobactam Penicillin G: Used exclusively for GBS intrapartum prophylaxis; if intraamniotic infection is suspected, broaden the antibiotic coverage. Nonpharmacotherapy Supportive care of the septic neonate may include the following: Warmth, monitoring of vital signs Preparedness to perform (...) of chorioamnionitis. [ , , ] Previous Next: Prognosis Maternal sequelae Acute chorioamnionitis may result in labor abnormalities (dysfunctional labor) that increase the risk for cesarean delivery, uterine atony, and postpartum bleeding, as well as the need for blood transfusion. [ , ] These complications are likely to occur more often when the amniotic fluid is infected with invasive organisms (eg, E coli and group B Streptococcus [GBS]) as compared with low-virulence organisms (eg, Ureaplasma urealyticum

2014 eMedicine Pediatrics

335. Placenta Previa (Follow-up)

in cases of placenta previa as well as placenta accreta, increta, and percreta.) Higher rates of blood transfusion [ , ] Placental abruption Preterm delivery Increased incidence of postpartum endometritis [ ] Mortality rate (2-3%); in the US, the maternal mortality rate is 0.03%, the great majority of which is related to uterine bleeding and the complication of The Table, below, summarizes the relative risk of some morbidities in women with placenta previa. Table. Relative Risk of Morbidities (...) birth is highly associated with placenta previa, with 16.9% of women delivering at less than 34 weeks and 27.5% delivering between 34 and 37 weeks in a population-based study from 1989 to 1997. [ ] There is a significant increase in the risk of postpartum hemorrhage and need for emergency hysterectomy in women with placenta previa. [ ] Maternal complications of placenta previa are summarized as follows: Hemorrhage, [ ] including rebleeding (Planning delivery and control of hemorrhage is critical

2014 eMedicine Emergency Medicine

336. 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 Emergency Medicine

337. 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 Pediatrics

338. Ultrasonography, Pelvic (Follow-up)

. Role of pelvic ultrasonography in evaluation of symptomatic first-trimester pregnancy. Ann Emerg Med . 1999 Mar. 33(3):310-20. . Lee NK, Kim S, Lee JW, Sol YL, Kim CW, Hyun Sung K, et al. Postpartum hemorrhage: Clinical and radiologic aspects. Eur J Radiol . 2009 May 22. . Brown DL. Pelvic ultrasound in the postabortion and postpartum patient. Ultrasound Q . 2005 Mar. 21(1):27-37. . Matijevic R, Knezevic M, Grgic O, Zlodi-Hrsak L. Diagnostic accuracy of sonographic and clinical parameters (...) stripe (st) is thickened. The arcuate vessels (arc) can be seen within the uterus and should not be confused with free fluid in the cul-de-sac. Endovaginal view of the ovary: Note its location adjacent to an iliac vessel. Endovaginal ultrasound scan. Endometritis with air in the endometrial cavity and bilateral tubo-ovarian abscesses are shown. Video depicts 2 findings: first, it shows an enlarged hypovascular left ovary; second, it shows flow in the healthy right ovary. A small amount

2014 eMedicine Emergency Medicine

339. Vaginitis (Overview)

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 Emergency Medicine

340. Ultrasonography, Pelvic (Overview)

evaluation in the emergency department. Emerg Med Clin North Am . 2001 Aug. 19(3):799-816. . Moloney F, Ryan D, Twomey M, Hewitt M, Barry J. Comparison of MRI and high-resolution transvaginal sonography for the local staging of cervical cancer. J Clin Ultrasound . 2016 Feb. 44 (2):78-84. . Dart RG. Role of pelvic ultrasonography in evaluation of symptomatic first-trimester pregnancy. Ann Emerg Med . 1999 Mar. 33(3):310-20. . Lee NK, Kim S, Lee JW, Sol YL, Kim CW, Hyun Sung K, et al. Postpartum hemorrhage (...) : Clinical and radiologic aspects. Eur J Radiol . 2009 May 22. . Brown DL. Pelvic ultrasound in the postabortion and postpartum patient. Ultrasound Q . 2005 Mar. 21(1):27-37. . Matijevic R, Knezevic M, Grgic O, Zlodi-Hrsak L. Diagnostic accuracy of sonographic and clinical parameters in the prediction of retained products of conception. J Ultrasound Med . 2009 Mar. 28(3):295-9. . Wolman I, Altman E, Fait G, Har-Toov J, Gull I, Amster R, et al. Evacuating retained products of conception in the setting

2014 eMedicine Emergency Medicine

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