Diagnostic Ultrasound - Abdomen and Pelvis

Endometritis
Diagnoses: Female Pelvis
CLINICAL ISSUES
Presentation
• Most common signs/symptoms
○ Fever (> 100.4° F) within 36 hours following delivery
○ Pelvic/abdominal pain
○ Uterine tenderness on physical exam and during
ultrasound
○ ↑ white blood cell count
• Other signs/symptoms
○ Malodorous lochia
○ Vaginal bleeding
○ Vaginal discharge
○ Tachycardia
• Clinical profile
○ Endometritis occurs in 2 clinical settings
– Fever and pain in postpartum period (most common)
– Associated with PID in nonobstetric patient
Demographics
• Epidemiology
○ Most common cause of postpartum fever
○ Occurs in 1-3% of vaginal deliveries
○ Much more common following cesarean section (15-
20%)
– Prophylactic antibiotics highly effective in reducing
risk of endometritis after cesarean section
– 50-60% of women undergoing cesarean section
without antibiotics will develop endometritis
○ Risk factors in obstetric patients
– Cesarean section
– Preexisting lower genital tract infection
– Prolonged labor
– Prolonged rupture of membranes
– RPOC
– Retained clots
○ Risk factors in nonobstetric patients
– 70-90% of patients with PID have coexistent
endometritis
– May also occur after invasive gynecologic procedure
– Intrauterine device
○ Uterine artery embolization
– Both infectious and noninfectious endometritis
reported in 0.5% of cases after uterine artery
embolization
○ Chronic endometritis may occur
– Associated with RPOC in obstetric population
– In nonobstetric population associated with
intrauterine device
Natural History & Prognosis
• Cure rates approach 95% with appropriate therapy
• May extend to myometrium/parametrium if untreated or if
caused by drug-resistant organisms
○ Potential complications include pyometrium and pelvic
abscess
• Rarely leads to development of pelvic septic
thrombophlebitis
○ 1-2% of cases of endometritis
○ Associated with parametrial spread of infection
Treatment
• Parenteral broad spectrum antibiotics
○ 90-95% defervesce with 48-72 hr
○ Therapy continued until patient is afebrile for 24-48 hr
and white blood cell count returns to normal
• Persistent fever
○ Resistant organism → triple antibiotic therapy
○ Abscess → surgical or percutaneous drainage
• RPOC, uterine hematoma → evacuation
• Septic thrombophlebitis → anticoagulation in addition to
antibiotics
DIAGNOSTIC CHECKLIST
Consider
• Endometritis is predominantly a clinical diagnosis
○ Imaging findings frequently normal in uncomplicated
endometritis
• Imaging usually ordered to look for complications
○ Pyometrium
○ Abscess
○ RPOC
Image Interpretation Pearls
• In appropriate clinical setting (postpartum fever and pain)
the presence of endometrial fluid and bubbles is highly
suggestive of endometritis
• Conversely, endometrial gas in asymptomatic postpartum
patient is likely normal
SELECTED REFERENCES
1. Plunk M et al: Imaging of postpartum complications: a multimodality review.
AJR Am J Roentgenol. 200(2):W143-54, 2013
2. Cicchiello LA et al: Ultrasound evaluation of gynecologic causes of pelvic
pain. Obstet Gynecol Clin North Am. 38(1):85-114, viii, 2011
3. Müngen E et al: Postabortion Doppler evaluation of the uterus: incidence
and causes of myometrial hypervascularity. J Ultrasound Med. 28(8):1053-
60, 2009
4. Vandermeer FQ et al: Imaging of acute pelvic pain. Clin Obstet Gynecol.
52(1):2-20, 2009
5. Rufener SL et al: Sonography of uterine abnormalities in postpartum and
postabortion patients: a potential pitfall of interpretation. J Ultrasound Med.
27(3):343-8, 2008
6. Faro S: Postpartum endometritis. Clin Perinatol. 32(3):803-14, 2005
7. Ledger WJ: Post-partum endomyometritis diagnosis and treatment: a
review. J Obstet Gynaecol Res. 29(6):364-73, 2003
8. Savelli L et al: Transvaginal sonographic appearance of anaerobic
endometritis. Ultrasound Obstet Gynecol. 21(6):624-5, 2003
9. Eckert LO et al: Endometritis: the clinical-pathologic syndrome. Am J Obstet
Gynecol. 186(4):690-5, 2002
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