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(endometritis,endomyometritis, endoparametrits)
• We call them so because uterine infection not only infect decidua but also
myometrium and Parametrial tissue causing inflammation and swelling of
that particular area.
Predisposing factor
The main factor that is responsible for uterine infection is “DELIVERY”
Which can be either:
1) vaginal delivery or
2) cesarean delivery
Vaginal delivery
In compared to cesarean delivery, vaginal delivery has less chance of occurrence
of metritis, still :
1)When a women delivers vaginally there is only 1 to 2% of chances of metritis.
2)When a women have prolonged labor and multiple examination, there occur
membrane rupture which leads to 5 to 6 % of occurrence of metritis.
3)If there is intrapartum chorioamnionitis, the risk becomes 13%.
4) And if there is manual removal of placenta the puerperal metritis rate increases
to three folds.
Cesarean delivery
Since cesarean delivery poses more threat ,the patient should be given single-
dose antimicrobial prophylaxis which decreases the threat upto 65 to 75%.
Still the important risk factor for infection following surgery includes:
• Prolonged labor
• Membrane rupture
• Multiple cervical examination and
• Internal fetal monitoring
Treatment
• If nonsevere metritis develops with vaginal delivery then it can be treated
with oral antimicrobial.
• For moderate to severe cases, broad-spectrum antimicrobial should be
used intravenously.
• There are nearly 90% improvement in 48 to 72 hours .
• However there might can be persistent fever even after usage of drug due
to antimicrobial resistant bacteria or due to drug side effect.
• The patient can be discharged after she has been afebrile for at least 24
hours and no futher medication is needed.
Choice of antimicrobial
• Infection following vaginal delivery, 90% respond to ampicillin +
gentamicin.
• Women given clindamycin-gentamicin had 95% response rate but incase
there is no response in 48 to 72 hours then ampicillin is added to regimen.
• But gentamycin has nephrotoxicity effect that’s why it is often replaced by
combination of clindamycin + 2nd generation cephalosporin( if the women
faces with real problem).
• Some drug like B-lactam antimicrobials( cefoxitin, cefotetan, piperacillin
etc), B-lactamase inhibitor ( clavulanic acid, sulbactam combined with
ampicillin,amoxicillin),
• Metronidazole has superior in vitro activity against most anaerobes.
• Vancomycin is used against gram-positive bacteria, patient having type 1
allergic reaction caused due to S. aureus and to treat C. dificile colitis.
Perioperative prophylaxis
• As we know that administration of antimicrobial prophylaxis at time of
cesarean delivery reduces infection, studies have shown that prophylactic
antimicrobials reduce pelvic infection rate by 70 to 80 %.
• Single-dose prophylaxis with ampicillin or 1st generation cephalosporin is as
effective as broad-spectrum or multi-dose regimen.
• Extended-spectrum prophylaxis with azithromycin added to standard
single-dose prophylaxis has shown further reduction in postcesarean
metritis rate.