Infections of the Uterus - A Detailed Review

Introduction:

Infections of the uterus occur due to the inflammation of the uterus lining or endometrium due to bacterial or viral infections. It is also known as endometritis or uterine infections. The uterus is a vital part of the female reproductive system. The uterus is aseptic, but the travel of microbes from the cervix and vagina leads to inflammation and infection. It is prone to infections when there is an injury to the endometrial tissue, such as during childbirth, abortion, or certain gynecological procedures.

What Are the Types of Uterine Infections?

Types of infections are-

1. Endometritis: Endometritis is inflammation of the uterine lining affecting all layers of the uterus. It occurs due to the rupture of membranes during childbirth and is the most common postpartum infection. It is caused by the amniotic sac rupture that results in the movement of normal bacterial flora from the vagina and cervix to the aseptic uterus. The bacteria colonize the uterine tissue that is devitalized, damaged, or bleeding. These bacteria invade the endometrium, myometrium, and perimetrium resulting in inflammation and infection.

2. Pelvic Inflammatory Disease: An infection in women results in the inflammation of the upper genital tract and affects the uterus, ovaries, cervix, and fallopian tubes. It is an ascending infection, spreading from the lower genital tract. They are mainly associated with sexually transmitted infections. The diagnosis is based on lower abdominal pain, pelvic pain, and genital tract tenderness.

3. Septic Abortion: It is caused due to unsafe or self-induced abortion in women that is complicated by infection of the uterus involving the endometrium. Septic abortion is mainly seen in patients attempting self-induced abortion through intrauterine insertion using devices such as metal hangers that induce sepsis complications. The symptoms include severe abdominal pain, emesis, vaginal bleeding or spotting (history of irregular menses). The methods to induce abortion are divided into four categories:

• Oral and Injectable Medicines: Metal salts, kerosene, oral contraceptives, lead uterine stimulants, etc.

• Vaginal Preparations and Cervical Dilators: Potassium permanganate, herbal preparations, dried asparagus, etc.

• Uterine instrumentation includes a coat hanger, knitting needle, rubber catheter, etc.

• Trauma to the Abdomen: Self-inflicted blows, abdominal pressure, jumping from a height.

• These seriously impact life and well-being, pregnancy associated with maternal morbidity, and mortality with abortions. A rigid foreign object inserted into the uterus increases the risk of perforation, and the instillation of intrauterine soap solutions increases the risk of renal failure, uterine necrosis, cardiac depression, central nervous system toxicity, and respiratory arrest. Septic abortions are the major complication of legal and illegal abortions associated with fever, endometritis, and parametritis. Septic abortion is considered when a female presents with abdominal pain, vaginal bleeding, a positive pregnancy test, and fever.

4. Cervicitis: Cervicitis is the inflammation of the ectocervix which may or may not be infectious. It is a clinical syndrome characterized by inflammation of primarily the columnar epithelium of the uterine endocervix. It can be chronic (non-infectious) or acute (infectious). Cervicitis should be diagnosed and treated promptly due to its association with serious complications such as infertility and pelvic inflammatory disease. While screening, the patient is asked for a detailed history using the five Ps- partners, practices, prevention of pregnancy, protection from STIs (Sexually transmitted infections), and previous STIs. The classic sign of cervicitis includes yellow or mucoid discharge and easy bleeding of the endocervix on touching with a cotton applicator (friability).

What Are the Causes of Uterine Infections?

The uterus infections are caused by:

• Bacteria: Streptococcus, Staphylococcus, Escherichia coli, Haemophilus influenzae.

• Sexually Transmitted Infections: Chlamydia and gonorrhea.

• Other medical conditions such as endometriosis or pelvic inflammatory disease, abortion.

What Are the Symptoms of Uterine Infections?

The symptoms vary depending on the cause and severity of the infection. Common symptoms include

• Fever.

• Abdominal pain.

• Foul-smelling vaginal discharge.

• Pain during sex.

• Unusual bleeding.

• Uterine tenderness.

• Cervical discharge.

What Are the Risk Factors?

The risk factors for infection are

• Chorioamnionitis.

• Low socioeconomic status.

• Prolonged labor.

• Membrane rupture.

• Multiple cervical examinations.

• Internal fetal monitoring.

• Young maternal age.

• Nulliparity.

• Obesity.

• Meconium-stained amniotic fluid.

• Bacterial colonization.

• Route of delivery.

• Intercourse with multiple partners.

• History of pelvic inflammatory disease.

• Intrauterine devices.

• Tubal ligation.

• Unsafe abortions.

How Are the Infections of Uterus Diagnosed?

The diagnosis of uterine infections includes

1. Physical Examination: A detailed history of symptoms is taken, and pelvic or abdominal examination is for pain and tenderness, cervical discharge, cervical motion tenderness, uterine tenderness, or masses.

2. Laboratory Tests: Laboratory tests includes pregnancy test to exclude the possibility of ectopic pregnancy in the case of PID (pelvic inflammatory disease).

• Nucleic acid amplification tests (NAAT) for C. trachomatis and N. gonorrhea.

• Blood tests: leucocytosis of 15000 to 30000 cells/microL familiar. CBC will help in a more significant clinical picture and aid in diagnosis.

• Cervical and vaginal cultures for antibiotic selection.

• Blood cultures in case of suspicion of sepsis or bacteremia.

• Positive pregnancy test is a sign in septic abortion cases and includes complete blood count, RH status, hepatic and renal function, serum electrolytes, platelet count, etc.

3. Imaging Tests:

• Ultrasound aids to rule out other diagnoses in postpartum patients with abdominal pain and fever. In the case of endometritis, the ultrasound imaging shows a thickened, heterogenous endometrium intracavitary fluid and air foci.

• CT scan (computed tomography) shows possible infection and inflammation of the intrauterine and perimetrium.

What Is the Treatment for Uterine Infections?

The treatment for uterine infections is primarily broad-spectrum antibiotics due to their polymicrobial activity. The antibiotic treatment includes

• Septic abortion:

• Ampicillin.

• Gentamycin.

• Metronidazole.

• Pelvic Inflammatory Disease (PID):

• Clindamycin and Gentamicin.

• Cefotetan and Doxycycline.

• Cefoxitin and doxycycline.

• Ceftriaxone plus Doxycycline.

• Metronidazole.

• Endometritis:

  • Doxycycline plus Metronidazole.

  • Levofloxacin plus Metronidazole.

  • Amoxicillin-Clavulanate.

  • Gentamicin and Clindamycin.

• The treatment for infectious agents identified by laboratory tests includes-

• Chlamydia: Azithromycin or Doxycycline.

• Gonorrhea: Ceftriaxone plus Azithromycin.

• Mycoplasma: Moxifloxacin if unresponsive to Azithromycin.

• Trichomonas: Metronidazole or Tinidazole.

• Bacterial vaginosis: Metronidazole.

• HSV: Acyclovir.

What Are the Complications of Uterine Infection?

Complications include

• Sepsis.

• Abscesses.

• Hematomas.

• Septic pelvic thrombophlebitis.

• Necrotizing fasciitis.

• Uterine necrosis.

• Infertility.

• Recurrent infections.

• Fallopian tube damage.

• Ectopic pregnancy.

How to Prevent Uterine Infections?

Preventing uterine infection can be done by:

• Practicing safe sex using condoms and avoiding sexual partners with sexually transmitted infections.

• Maintaining good hygiene- regular washing and drying of the genital area.

• Seeking immediate treatment for gynecological-related issues.

• Regular checkups and monitoring of reproductive health.

Conclusion:

Uterine infections are polymicrobial and serious diseases that impact women's health and fertility. Females should recognize signs and symptoms and seek immediate and early treatment. The infections related to the uterus are endometritis, pelvic inflammatory diseases, septic abortions, and cervicitis. These infections, if not treated promptly, have various associated complications. Infections can be prevented by practicing safe sex, maintaining good genital hygiene, and having regular checkups with gynecologists.

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