Prevention and treatment of postpartum endometritis

Postpartum endometritis is an important cause of maternal morbidity after cesarean section. Prophylactic antibiotic therapy reduces the risk by approximately 60%. The benefit of antibiotic therapy for laboring women has been established. For nonlaboring patients, there is still some uncertainty. Intravaginal metronidazole as surgical preparation and oral methylergometrine after delivery are two interventions that show promise as additional prophylactic interventions. The gold standard therapy, once endometritis has been diagnosed, is intravenous clindamycin and gentamicin. If an alternative regimen is chosen, it should have a similar spectrum, including good coverage for gram-positive anaerobes such as Bacteroides fragilis. Antibiotic therapy can be discontinued once the patient is afebrile without continued oral antibiotics. Treatment failure occurs in approximately 10% of cases and should trigger investigation of other infectious complications. Prolonged fever of undetermined etiology is not uncommon and requires prolonged antibiotic therapy, with or without heparin.