Endometritis

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Chapter 113 Endometritis

INTRODUCTION

Description: Endometritis is an acute or chronic inflammation, usually of infectious origin, of the lining of the uterus. This is a general term that is used for this condition in either nonpregnant or recently pregnant patients; chorioamnionitis or endomyometritis are the terms commonly used for pregnant patients. Chronic endometritis is often characterized as an intermediate state in ascending infections.

Prevalence: Seventy-five percent of patients with pelvic inflammatory disease, 40% of patients with mucopurulent cervicitis.

Predominant Age: Reproductive.

Genetics: No genetic pattern.

ETIOLOGY AND PATHOGENESIS

Causes: Aseptic inflammation of the endometrium is commonly found in users of intrauterine contraceptive devices (IUCDs). Infection by organisms ascending from the cervix and lower tract are common (most often Chlamydia trachomatis, Neisseria gonorrhoeae, Ureaplasma urealyticum, and Streptococcus agalactiae). Less common are infections by Actinomyces israelii or tuberculosis.

Risk Factors: IUCD use, intrauterine instrumentation (biopsy, hysterosalpingography), cervicitis, sexually transmitted disease (STD), retained products of conception.

DIAGNOSTIC APPROACH

Workup and Evaluation

Laboratory: Complete blood count, cervical cultures for C. trachomatis and N. gonorrhoeae. (Tests for other STDs as indicated.)

Imaging: No imaging indicated. Ultrasonography with saline contrast may demonstrate a thickened endometrium but risks spreading an infection to the fallopian tubes, ovaries, and peritoneal cavity. Consequently, this should be reserved until the possibility of active infection has been evaluated.

Special Tests: Endometrial biopsy is generally confirmatory.

Diagnostic Procedures: Endometrial biopsy and culture.

Pathologic Findings

Inflammatory infiltrates (monocytes and plasma cells) in the basal layers and stroma of the endometrium. Sulfur granules may be present in Actinomyces infections.

MANAGEMENT AND THERAPY

Nonpharmacologic

General Measures: Evaluation, counseling about STDs (cervicitis).

Specific Measures: Antibiotic therapy (see later), removal of IUCD (if present).

Diet: No specific dietary changes indicated.

Activity: Pelvic rest (no tampons, douches, or intercourse) until therapy has been completed.

Patient Education: American College of Obstetricians and Gynecologists Patient Education Pamphlet AP095 (Abnormal Uterine Bleeding), AP099 (Pelvic Pain), AP077 (Pelvic Inflammatory Disease).

Drug(s) of Choice

Doxycycline (Vibramycin) 200 mg PO initially, 100 mg PO daily for 10 days. If Actinomyces is found in a tubo-ovarian abscess, oral penicillin therapy should be continued for 12 weeks.

Contraindications: Known or suspected allergy to tetracycline. Doxycycline is contraindicated in the last half of pregnancy.

Precautions: Photosensitivity may occur in patients taking doxycycline.

Interactions: Doxycycline may enhance the effect of warfarin. Doxycycline absorption is inhibited by most antacids and bismuth subsalicylate (Pepto-Bismol).

Alternative Drugs

Metronidazole or erythromycin may be substituted for doxycycline.

FOLLOW-UP

Patient Monitoring: Normal health maintenance, screening for STDs as needed.

Prevention/Avoidance: Reduce risk of cervicitis or STDs, asepsis during intrauterine procedures.

Possible Complications: Ascending infection resulting in salpingitis, tubo-ovarian abscesses, hydrosalpinx, peritonitis, and chronic pelvic pain.

Expected Outcome: Good with treatment.

MISCELLANEOUS

Pregnancy Considerations: Generally not applicable. Ureaplasma urealyticum infection has been implicated as a rare cause of early pregnancy loss.

ICD-9-CM Codes: 615.0 (Acute), 615.1 (Chronic), 670 (Following delivery, excludes pregnancy, abortion, ectopic and molar pregnancies).

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