Puerperal fetid lochia

Specialty: Gynecology and breast.

• Smelly postpartum discharge
• fetid pathological lochia
• suspected puerperal endometritis

Why it occurs

• Postpartum endometritis (mixed ascending bacterial infection of the endometrium, very common after prolonged cesarean section or instrumental delivery)
• Retention of placental remains or ovular membranes that suffer necrosis and superinfection
• Presence of a forgotten intravaginal foreign body (gauze or compresses used on the perineum during suturing)
• Infection of extensive cervical or vaginal tears

Initial workup

Detailed vaginal examination with a speculum to extract free remains or identify foreign bodies. Vaginal touch to assess the consistency of the uterus, the opening of the cervical canal and the degree of subinvolution. Transvaginal or abdominal ultrasound to evaluate the endometrial cavity for mixed echoes suggestive of retained placental remains. CBC with formula, PCR and blood cultures if there is high fever.

Standard management

• Clindamycin 900 mg intravenously every 8 hours associated with Gentamicin 1.5 mg/kg intravenously every 8 hours — first choice hospital gold standard guideline
• Amoxicillin/clavulanic acid 1000/200 mg intravenously every 8 hours as an alternative
• Transition to Amoxicillin/Clavulanic acid 875/125 mg orally every 8 hours until completing 10-14 days once the patient is afebrile for 48 hours (note: if significant placental remains are confirmed by ultrasound, uterine evacuation is required by instrumental curettage under anesthesia).