ENDOMETRITIS obstetric and gynecology .

Endometritis
Endometritis is an inflammation or irritation of the lining of the uterus (the endometrium). It is not the same as endometriosis.

Causes
Endometritis is caused by an infection in the uterus. It can be due to chlamydia, gonorrhea, tuberculosis, or a mix of normal vaginal bacteria. It is more likely to occur after miscarriage or childbirth. It is also more common after a long labor or C-section.

The risk for endometritis is higher after having a pelvic procedure that is done through the cervix. Such procedures include:

D and C (dilation and curettage)
Endometrial biopsy
Hysteroscopy
Placement of an intrauterine device (IUD)
Childbirth (more common after C-section than vaginal birth)
Endometritis can occur at the same time as other pelvic infections.

1. ENDOMETRITIS MAVUMNKAL BIJU BRINCELET GROUP:733

2. INTODUCTION Endometritis is the Inflammation or an irritation of the endometrium, the inner layer of the uterus. TYPES; Acute endometritis. Chronic endometritis. chronic non-specific endometritis(puerperal endometritis). chronic specific endometritis:TB,actinomycosis etc.... Atrophic endometritis.

3. Endometritis can be divided into pregnancy-related endometritis and endometritis unrelated to pregnancy. When the condition is unrelated to pregnancy, it is referred to as pelvic inflammatory disease (PID). Endometritis is often associated with inflammation of the fallopian tubes (salpingitis), ovaries (oophoritis), and pelvic peritoneum (pelvic peritonitis). The Centers for Disease Control and Prevention (CDC) 2015 sexually transmitted diseases treatment guideline defines PID as any combination of endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis

4. CAUSES Endometritis is caused by an infection in the uterus. It can be due to chlamydia, gonorrhea, tuberculosis, or a mix of normal vaginal bacteria. It is more likely to occur after miscarriage or childbirth. It is also more common after a long labor or C-section. Bacterial invasion of endometrial cavity; Retained gestational contents Endometrial polyp fibromyoma Secondary to introduction of foreign objects;

5. viral infections Placement of an intrauterine device (IUD) Childbirth (more common after C-section than vaginal birth) Endometritis can occur at the same time as. The risk for endometritis is higher after having a pelvic procedure that is done through the cervix. Such procedures include: D and C (dilation and curettage) Endometrial biopsy Hysteroscopy other PID

6. Symptoms Dysmenorrhea Dyspareunia Abnormal vaginal discharge -increased amount -unusual color,consistency,color Discomfort with bowel movement(including Constipation). Fever(range from 37.8 to 40C) General discomfort, uneasiness, or ill feeling(malaise). Pain in lower abdomen or pelvic region. Pain is typically chronic and crampy. Infertility.

7. PUERPERAL ENDOMETRITIS CAUSES; Puerperal endometritis is uterine infection, typically caused by bacteria ascending from the lower genital or gastrointestinal tract,following a bacterial invasion in abortion or labour CLINICALLY vaginal bleeding offensive vaginal discharge fresh or clotted blood with endometrial cells

8. Typically, the first symptoms of puerperal endometritis are lower abdominal pain and uterine tenderness, followed by fever—most commonly within the first 24 to 72 hours postpartum. Chills, headache, malaise, and anorexia are common. Morphologic features of nonspecific endometritis. Plasma cell infiltrate Increased number of lymphocytes and lymphoid follicles Variable presence of neutrophils in surface epithelium and glands Reactive stromal response Altered gland development Breakdown and bleeding

9. Physical Examination Physical examination findings include the following: Fever, usually occurring within 36 hours of delivery, in the obstetric population Lower abdominal pain Uterine tenderness Adnexal tenderness if there is an associated salpingitis Foul-smelling lochia Tachycardia Uterine tenderness is the hallmark of the disease. An oral temperature of 38°C or higher within the first 10 days postpartum or 38.7°C within the first 24 hours postpartum is required to make the diagnosis of postpartum endometritis. For PID, the minimum diagnostic criteria are lower abdominal tenderness, cervical motion tenderness, or adnexal tenderness. In severe cases, the patient may appear septic.

10. Potential complications of endometritis include the following: Wound infection Peritonitis Adnexal infection Parametrial phlegmon Pelvic abscess Pelvic hematoma Septic pelvic thrombophlebitis Spread of infection from the endometrium to the fallopian tubes, ovaries, or the peritoneal cavity may result in salpingitis, oophoritis, localized peritonitis, or tubo-ovarian abscesses. Salpingitis subsequently leads to tubal dysmotility and adhesions that result in infertility, higher incidence of ectopic pregnancy, and chronic pelvic pain .

11. Diagnostic Considerations Because of the physiologic changes associated with pregnancy, the presence of an elevated leukocyte count or neutrophil count does not indicate endometritis. Therefore, clinical findings are more reliable than laboratory findings in diagnosing postpartum endometritis. Other problems to be considered in patients with possible endometritis include the following: Pyelonephritis Viral syndrome Pelvic thrombophlebitis Chorioamnionitis Differential Diagnoses Appendicitis Pediatric Urinary Tract Infection Pelvic Inflammatory Disease

12. DIAGNOSIS Complete Blood Cell Count The CBC count typically reveals leukocytosis with a left shift. However, in the postpartum period, this finding may reflect the physiological leukocytosis of pregnancy and it is therefore unreliable for diagnosis. Anemia is a risk factor for the development of endometritis. Cultures Blood culture is positive in 10-30% of cases, and a urine culture should be ordered. The role of endocervical cultures is controversial. They are not generally helpful in management, as positive results are usually the result of contamination from normal resident cervicovaginal flora. However, endocervical cultures (or DNA probe) are obtained for gonorrhea and chlamydia when appropriate. Gram Stain Gram stain or wet mount of the vaginal discharge may be useful in ruling out endometritis. If no pus cells are observed in the Gram stain, the negative predictive value for endometritis is 95%.

13. Imaging Studies Perform imaging studies on patients who do not respond to adequate antimicrobial therapy in 48-72 hours. CT scanning of the abdomen and pelvis may be helpful for excluding broad ligament masses, septic pelvic thrombophlebitis, ovarian vein thrombosis, and phlegmon. Pelvic ultrasound is the primary imaging modality to identify and differentiate locations to the ovary (endometriomas) and the bladder wall. Characteristic sonographic features of endometriomas are diffuse low-level internal echos, multilocularity and hyperchoic foci in the wall. Ultrasonography of the abdomen and pelvis may yield normal findings in patients with a clinical diagnosis of endometritis. Abnormal findings overlap with those of retained products of conception and intrauterine hematoma. Diagnosis of acute endometritis is usually performed via double-guarded uterine culture swab and cytology brush. This allows for detection, identification, and characterization of microbial organisms and evaluates the uterine lumen for the presence of polymorphic neutrophils (PMNs), which are indicative of activeinflammation.

14. Hysteroscopic view of chronic endometritis in a 30-year-old infertile woman.in this we can see the micropolyps, which appear as small pedunculated, vascularized protrusions (<1 mm) on the uterine mucosa (A). The close-up view clearly shows a marked accentuation of the vascular network at the level of the uterine fundus ( B). To right, an overt stromal edema is evident (C), though the examination was carried out in the early proliferative phase.

15. D etail of micropolyps under hysteroscopic examination using a liquid distension medium: the micropolyps, which appear with a varied morphology, are scattered over the uterine wall and may often be encountered with polyps (A) and/or pseudopolyps.

16. TREATMENT The therapy for endometritis is pharmacological and is based on the administration of broad-spectrum antibiotics Most appropriate agent limited spectrum cephalsporin Cefazolin 1-2 g Second dose 8 hours after first dose High-risk patients Operating time greater than 1 hour Extended spectrum penicillins and cephalosporins effective, but no advantage Use of extended spectrum drugs may limit usefulness for treatment For B-lactam hypersensitivity Clindamycin 900 mg plus gentamicin 1.5 mg/kg as a single dose

17. Combination Antibiotic Regimens for the Treatment of Postpartum Endometritis Antibiotics Intravenous Dose Clindamycin ; 900 mg q8h Gentamicin ; 1.5 mg/kg q8h or 5-7 mg/kg ideal body weight q24h.

18. PREVENTION Endometritis caused by sexually transmitted infections can be prevented by: Early diagnosis and complete Treatment of sexually transmitted infections (STIs) in the patient and all sexual partners. Following safer sex practices, such as using condoms. The risk of Endometritis is reduced by careful, sterile techniques used by appropriate providers in performing deliveries , Abortions IUD placement and other Gynecological Procedures.

19. Treatment with antibiotics is important to prevent complications of endometritis. Complicated cases (those occurring after childbirth, or involving severe symptoms) may require the patient to be admitted to a hospital. Intravenous (in the vein) antibiotics are usually needed, followed by antibiotics taken by mouth. Rest and hydration are important. Treatment for sexual partner(s), when appropriate, and the use of condoms throughout the course of treatment, are essential

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