Postpartum Care

Diagnosis and Presentation

Fever greater than 100.4°F (38.0°C) on more than two occasions more than 6 hours apart after the first 24 hours postpartum is a diagnostic criterion for postpartum infections, including endometritis, which usually presents 2-5 days postpartum with continuous fever 1
Postpartum endometritis should be suspected in women presenting with fever, abdominal pain, uterine tenderness, foul-smelling lochia, and possible chills, back pain, pelvic spasms, and passing of clots, as recommended by the Clinical Infectious Diseases guidelines 1, 2
The American College of Obstetricians and Gynecologists recommends considering the diagnosis of septic pelvic thrombophlebitis in patients with persistent fever despite appropriate antibiotic therapy for endometritis, with a classic presentation of minimal or absent abdominal pain 3

Cesarean delivery, especially unplanned, is a significant risk factor for postpartum endometritis, according to the Centers for Disease Control and Prevention 1
Prolonged labor, prolonged rupture of membranes, and multiple vaginal examinations are also risk factors for postpartum infections, as stated by the World Health Organization 1

The American College of Obstetricians and Gynecologists recommends administering antibiotic prophylaxis, typically a first-generation cephalosporin, within 60 minutes before skin incision during cesarean delivery, with consideration of adding azithromycin for women in labor or with ruptured membranes, and vaginal preparation with povidone-iodine solution to reduce infection rates 4
Antibiotic prophylaxis, typically cephalosporins, administered within 60 minutes before cesarean delivery skin incision, can reduce the incidence of postpartum endometritis, as suggested by the American College of Obstetricians and Gynecologists 4

The Infectious Diseases Society of America recommends clindamycin plus gentamicin as the first-line treatment for postpartum endometritis, with significantly fewer treatment failures compared to other regimens 1
The American College of Obstetricians and Gynecologists supports the use of a combination of clindamycin plus an aminoglycoside, typically gentamicin, as the first-line treatment for postpartum endometritis, due to its strong evidence and significantly fewer treatment failures compared to other regimens 4
Continued broad-spectrum antibiotics, such as clindamycin, gentamicin, and ampicillin, are recommended for septic pelvic thrombophlebitis, with controversy existing regarding the use of anticoagulation, as noted by the American College of Chest Physicians 3
The American Academy of Family Physicians recommends initiating antibiotics immediately upon diagnosis, as prevention of long-term sequelae is directly linked to prompt administration of appropriate antibiotics, with a strength of evidence based on American Family Physician guidelines 5

Contrast-enhanced CT or MRI is recommended for diagnosing septic pelvic thrombophlebitis, showing filling defects in pelvic veins, as suggested by the Radiological Society of North America 3
Ultrasound may show thickened endometrium in cases of endometritis, according to the American Institute of Ultrasound in Medicine 1
The American College of Obstetricians and Gynecologists recommends considering testing for Chlamydia trachomatis, Neisseria gonorrhoeae, Trichomonas vaginalis, and HIV in patients with suspected endometritis, with a strength of evidence based on Clinical Infectious Diseases guidelines 1, 2