Causes and routes of infection spread
The pathology develops against the background of prior chorioamnionitis or infection of the uterine mucosa. The risk is especially high after surgical interventions such as caesarean section, vacuum extraction of the fetus, as well as manual removal of the placenta and exploration of the uterine cavity.
Infection enters the body through the following routes:
- Ascending route: associated with opportunistic vaginal microflora and plays a crucial role.
- Hematogenous and lymphogenous routes.
- Intraamniotic route: triggered by invasive procedures, including amnioscopy, amniocentesis, cordocentesis, or embryo reduction.
The etiology is dominated by microbial associations of facultative aerobes and obligate non-spore-forming anaerobes, including Escherichia coli, various strains of Enterobacter spp., Enterococcus spp., Proteus spp., Klebsiella spp., Bacteroides spp., Peptostreptococcus spp., Streptococcus spp., and Staphylococcus spp.
Classification and forms of the disease
The disease is classified according to several criteria:
- By type of delivery: endometritis after spontaneous labour and after caesarean section are distinguished.
- By clinical course: mild, moderate, and severe forms.
- By manifestation features: classical and erased (subclinical) forms.
The pathogenesis is based on inflammation of the decidua. When the process extends beyond the basement membrane, endomyometritis develops with leukocyte infiltration of the myometrium. The mucosa becomes loose, edematous, and bleeding, and after caesarean section, the greatest changes are concentrated near the uterine incision, which can threaten suture dehiscence.
Clinical manifestations by severity
The clinical picture is determined by the depth of the lesion, the pathogen, and the patient's immune status:
- Mild form: manifests on days 5–12 with a temperature rise up to 38 °C, uterine subinvolution, and lochia discharge with moderate leukocytosis (up to 12×10⁹/L).
- Moderate endometritis: develops on days 2–7, characterized by a temperature up to 38.5 °C, uterine tenderness, altered lochia, and moderate intoxication.
- Severe form: presents on days 2–3 with a temperature spike to 38.5–39 °C, chills, tachycardia, and pronounced leukocytosis (up to 30×10⁹/L) with a left shift.
- Erased form: occurs within the first 7 days with low-grade fever (up to 37.5 °C) and moderate tachycardia, where retained blood clots maintain constant toxin resorption.
Diagnostic methods
To confirm the diagnosis, the physician evaluates the clinical picture and utilizes additional diagnostic methods:
- Complete blood count to assess inflammatory markers.
- Bacteriological analysis of lochia to determine the pathogen spectrum.
- Morphological examination of endometrium biopsy specimens.
- Ultrasound examination (ultrasound), which plays a vital role in establishing an accurate diagnosis.
Briefly: answers to topical questions
What ultrasound signs are characteristic of postpartum endometritis?
Postpartum endometritis is characterized by enlarged uterine dimensions, altered myometrial echogenicity, and the presence of pathological contents in the uterine cavity.
The following ultrasound criteria are distinguished:
- Uterine enlargement — increase in volume and anteroposterior diameter, as well as subinvolution (slow reduction in volume).
- Myometrial changes — hypoechogenicity and an unclear, blurred boundary with the uterine cavity.
- Lochiometra — expansion of the cavity throughout its length with anechoic contents and parietal hyperechoic structures.
- Niche sign — a tissue defect in the lower segment (suture dehiscence) and inflammatory changes in the caesarean section wound.
What groups of antibacterial drugs are used for empirical therapy of postpartum endometritis?
For the treatment of postpartum endometritis, broad-spectrum antibacterial therapy is used.
Antibacterial therapy tactics:
- initially, drugs are prescribed empirically;
- subsequently, treatment is adjusted taking into account the sensitivity of the microflora.
Concurrently with antibiotics, medications for the prevention and treatment of candidiasis and dysbiosis may be prescribed.
What complications can arise with the progression of postpartum endometritis?
With the progression or prolonged course of postpartum endometritis, severe purulent-septic consequences are possible.
Conditions supported by literature sources include:
- Purulent tissue lysis with the formation of a dense fibrous coating during a prolonged course.
- Uterine suture dehiscence after caesarean section — when changes are most pronounced in the area of the uterine incision.
- Obstetric peritonitis — may develop in severe endometritis due to the spread of infection through the fallopian tubes, as well as when infectious agents and detritus enter from the uterine cavity through incompetent sutures.
- Sepsis — purulent peritonitis in obstetrics can lead to the development of sepsis.
Endometritis: E — era of cesarean section and childbirth, N — impaired uterine contraction, D — decade of the first days (onset), O — chills and fever, M — microbial associations.
Class and exam questions
What are the main risk factors contributing to the development of postpartum endometritis?
The main risk factors are caesarean section, vacuum extraction of the fetus, manual removal of the placenta and delivery of the placenta, as well as manual exploration of the uterine cavity and prior chorioamnionitis.
Within what timeframe does the mild form of endometritis typically manifest?
The mild form of endometritis most often manifests on days 5–12 of the postpartum period with an acute onset, fever, and uterine subinvolution.
Which examination is of key importance for establishing the diagnosis?
Ultrasound examination, along with a complete blood count, lochia culture, and morphological examination of biopsies, is of substantial importance in diagnostics.
What else to study on this topic
- Pathogenetic features in a prolonged course with purulent tissue lysis
- Coagulogram changes in moderate endometritis
- Pathogenetic nuances of the erased form and the role of blood clot retention
- Spectrum of anaerobic and aerobic microflora in microbial associations
- Comparison of ascending and intraamniotic routes of infection
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