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Endometritis (Postpartum)

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General Information

Description

  • postpartum bacterial infection of the endometrial lining, myometrium, and/or parametrium1,3

Also called

  • metritis (postpartum)
  • postpartum endometritis
  • endomyometritis
  • endoparametritis

Types

  • early postpartum endometritis
    • may be unimicrobial infection1
    • develops within 48 hours after delivery3
  • late postpartum endometritis
    • usually polymicrobial infection including facultative and obligate anaerobes1
    • may occur up to 6 weeks after delivery3

References

General references used

  1. Faro S. Postpartum endometritis. Clin Perinatol. 2005 Sep;32(3):803-14OpenInNew
  2. Bratzler DW, Dellinger EP, Olsen KM, et al; American Society of Health-System Pharmacists, Infectious Disease Society of America, Surgical Infection Society, Society for Healthcare Epidemiology of America. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013 Feb 1;70(3):195-283OpenInNew
  3. Karsnitz DB. Puerperal infections of the genital tract: a clinical review. J Midwifery Womens Health. 2013 Nov-Dec;58(6):632-42OpenInNew

Recommendation grading systems used

  • American Society of Health-System Pharmacists/Infectious Diseases Society of America/Surgical Infection Society/Society for Healthcare Epidemiology of America (ASHP/IDSA/SIS/SHEA) recommendation grading system
    • categories of recommendation
      • Category A - based on levels I-III
      • Category B - based on levels IV-VI
      • Category C - based on level VII
    • levels of evidence
      • Level I - evidence from large, well-conducted, randomized controlled clinical trials, or a meta-analysis
      • Level II - evidence from small, well-conducted, randomized controlled clinical trials
      • Level III - evidence from well-conducted cohort studies
      • Level IV - evidence from well-conducted case-control studies
      • Level V - evidence from uncontrolled studies that were not well conducted
      • Level VI - conflicting evidence that tends to favor the recommendation
      • Level VII - expert opinion or data extrapolated from evidence for general principles and other procedures
  • Society of Obstetricians and Gynaecologists of Canada (SOGC) recommendation grading system
    • classifications of recommendations
      • Grade A - good evidence to recommend clinical preventive action
      • Grade B - fair evidence to recommend clinical preventive action
      • Grade C - existing evidence is conflicting and does not allow to make recommendation for or against use of clinical preventive action; however other factors may influence decision-making
      • Grade D - fair evidence to recommend against clinical preventive action
      • Grade E - good evidence to recommend against clinical preventive action
      • Grade L - insufficient evidence (in quantity or quality) to make recommendation; however other factors may influence decision-making
    • levels of evidence
      • Level I - evidence obtained from ≥ 1 properly randomized controlled trial
      • Level II-1 - evidence from well-designed controlled trials without randomization
      • Level II-2 - evidence from well-designed cohort (prospective or retrospective) or case-control studies, preferably from > 1 center or research group
      • Level II-3 - evidence obtained from comparisons between times or places with or without the intervention; dramatic results in uncontrolled experiments (such as the results of treatment with penicillin in the 1940s) could also be included in this category
      • Level III - opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
  • Royal College of Obstetricians & Gynaecologists (RCOG) grades of recommedations and classification of evidence levels
    • grades of recommendations
      • Grade A
        • ≥ 1 meta-analysis, systematic review, or randomized controlled trial rated as 1++ and directly applicable to target population, or
        • systematic review of randomized controlled trials or body of evidence consisting principally of studies rated as 1+ directly applicable to target population and demonstrating overall consistency of results
      • Grade B
        • body of evidence including studies rated as 2++ directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 1++ or 1+
      • Grade C
        • body of evidence including studies rated as 2+ directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 2++
      • Grade D
        • evidence level 3 or 4, or
        • extrapolated evidence from studies rated as 2+
      • Good practice point (GPP) - recommended best practice based on clinical experience of guideline development group
    • classification of evidence levels
      • Level 1++ - high-quality meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with very low risk of bias
      • Level 1+ - well-conducted meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with low risk of bias
      • Level 1- - meta-analyses, systematic reviews of randomized controlled trials, or randomized controlled trials with high risk of bias
      • Level 2++ - high-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with very low risk of confounding, bias, or chance and high probability that relationship is causal
      • Level 2+ - well-conducted case-control or cohort studies with low risk of confounding, bias, or chance and moderate probability that relationship is causal
      • Level 2- - case-control or cohort studies with high risk of confounding, bias, or chance and significant risk that relationship is not causal
      • Level 3 - nonanalytical studies, such as case reports or case series
      • Level 4 - expert opinion
    • References
  • World Health Organization (WHO) classification of recommendations
    • strength of recommendation
      • Strong - panel is confident that desirable effects of adherence to recommendation outweigh undesirable effects
      • Conditional - panel concludes that desirable effects of adherence to recommendation probably outweigh undesirable effects, but 1 of following conditions applies
        • recommendation only applicable to specific group, population, or setting
        • new evidence may result in changing balance of risk to benefit
        • benefits may not warrant cost or resource requirements in all settings
      • No recommendation possible - further research required before any recommendation can be made
    • quality of evidence
      • High - further research very unlikely to change confidence in estimate of effect
      • Moderate - further research likely to have important impact on confidence in estimate of effect and may change estimate
      • Low - further research very likely to have an important impact on confidence in estimate of effect and likely to change estimate
      • Very low - any estimate of effect very uncertain
    • Guidelines Development Group (GDG) consensus - insufficient evidence to make a recommendation so GDG consensus used as the basis of recommendation
    • Reference - World Health Organization (WHO) recommendations for prevention and treatment of maternal peripartum infections can be found at WHO 2015 PDFPictureAsPdf

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T113859, Endometritis (Postpartum); [updated 2018 Dec 03, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T113859. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Also called

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Who is most affected

    • Incidence/Prevalence

    • Likely risk factors

    • Possible risk factors

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

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    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Past medical history (PMH)

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      Physical

      • General physical

      • Abdomen

      • Pelvic

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    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

  • KeyboardArrowRight

    Management

    • Management overview

    • Treatment setting

    • Medications

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • KeyboardArrowRight

      Prevention

      • KeyboardArrowRight

        Antibiotics for prophylaxis

        • Recommendations from professional organizations and general considerations

        • Evidence for efficacy after cesarean section

        • Evidence for efficacy after assisted (instrumental) vaginal delivery

        • Considerations in women with overweight/obesity

        • Timing of administration

      • Cleansing washes and irrigations

      • Supplemental oxygen

      • Placenta delivery

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • Canadian guidelines

      • Asian guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Elliot M. Levine MD, FACOG
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Affiliations

Assistant Professor, Department of Obstetrics and Gynecology, Rush University Medical Center; Site Director of Informatics and Director of Informatics and Research, Department of Obstetrics and Gynecology, Advocate Illinois Masonic Medical Center

Conflicts of Interest

Dr. Levine declares no relevant financial conflicts of interest.

Recommendations Editor
Zbys Fedorowicz MSc, DPH, BDS, LDSRCS
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Affiliations

Director of Bahrain Branch of the United Kingdom Cochrane Center, The Cochrane Collaboration; Awali, Bahrain

Conflicts of Interest

Dr. Fedorowicz declares no relevant financial conflicts of interest.

Deputy Editor
Alan Ehrlich MD, FAAFP
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Affiliations

Executive Editor, DynaMed; Associate Professor of Family Medicine, University of Massachusetts Medical School; Massachusetts, United States

Conflicts of Interest

Dr. Ehrlich declares no relevant financial conflicts of interest.

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