O86.12 Endometritis following delivery

Name of the Condition

• Endometritis following delivery (O86.12)

Summary

Endometritis following delivery is an infection of the uterine lining (endometrium) that occurs after childbirth. It is a common postpartum complication requiring prompt treatment to prevent further morbidity. The condition typically presents with fever and uterine tenderness, and it may involve bacterial invasion of the uterine cavity.

Causes

Endometritis following delivery is usually caused by bacterial contamination of the uterine cavity after delivery. Common pathogens include group A Streptococcus, Staphylococcus aureus, and anaerobic bacteria. Risk increases with prolonged labor, cesarean delivery, or retained placental tissue.

Risk Factors

• Prolonged labor or membrane rupture
• Cesarean delivery
• Retained placental fragments
• Multiple vaginal examinations during labor
• Preexisting infections (e.g., chorioamnionitis)
• Poor perineal hygiene
• Immunosuppression or underlying medical conditions

Symptoms

• Fever (temperature >38°C or 100.4°F)
• Abdominal or pelvic pain
• Foul-smelling vaginal discharge
• Uterine tenderness
• Malaise or fatigue
• Increased uterine size or tenderness on palpation

Diagnosis

Diagnosis involves clinical evaluation of symptoms, physical examination (e.g., uterine tenderness, discharge assessment), and laboratory tests (e.g., blood cultures, complete blood count). Imaging may be used to rule out other complications like abscess formation.

Treatment Options

Treatment typically includes broad-spectrum antibiotics to target common pathogens. Supportive care, such as hydration and pain management, may also be provided. In severe cases, hospitalization and intravenous antibiotics may be necessary.

Prognosis and Follow-Up

With prompt treatment, most patients recover without long-term complications. Follow-up care may include monitoring for symptom resolution and ensuring complete healing of the uterine lining. Recurrence is rare with appropriate management.

Complications

Untreated endometritis can lead to sepsis, pelvic abscess, or chronic pelvic pain. Rarely, it may result in infertility or other reproductive complications.

Lifestyle & Prevention

• Maintain good perineal hygiene during and after delivery.
• Follow healthcare provider instructions for wound care (if applicable).
• Attend all postpartum check-ups to monitor recovery.
• Report any unusual symptoms (e.g., fever, discharge) promptly.

When to Seek Professional Help

Seek medical attention if you experience fever, severe abdominal pain, foul-smelling discharge, or signs of infection after delivery. Early intervention is critical to prevent complications.

Tips for Medical Coders

Document the presence of fever, uterine tenderness, or foul-smelling discharge to support the diagnosis. Ensure the code is assigned when endometritis is confirmed following delivery, and note any contributing factors like cesarean delivery or retained placental tissue for accurate coding.