# Abnormal lochia (postpartum vaginal discharge) - Category: infectious - Review status: reviewed (every claim checked against a document named on this page) - Sources: Egyptian National Drug Formulary - Antimicrobial 2023: endometritis appears only under injectable agents (cefoperazone, cefoperazone/sulbactam, cefotaxime, clindamycin) · No dose - referral pathway, no medicine given in primary care · Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) - Verified date: 2026-08 ## Verified against - Egyptian National Drug Formulary - Antimicrobial 2023: endometritis appears only under injectable agents (cefoperazone, cefoperazone/sulbactam, cefotaxime, clindamycin) - No dose - referral pathway, no medicine given in primary care - Abnormal lochia (postpartum vaginal discharge) - disease-level clinical article (abnormal-lochia-clinical.txt) - Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) ## Treatment metadata - No drug therapy in primary care (Referral & Advice) - Amoxicillin + Clavulanic acid — 1000 mg — oral.solid - Amoxicillin — 500 mg — oral.solid - Metronidazole — 500 mg — oral.solid ## Complete treatment card ```text ABNORMAL LOCHIA (POSTPARTUM VAGINAL DISCHARGE) Sources: Egyptian National Drug Formulary - Antimicrobial 2023: endometritis appears only under injectable agents (cefoperazone, cefoperazone/sulbactam, cefotaxime, clindamycin) · No dose - referral pathway, no medicine given in primary care · Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) Review status: REVIEWED against Egyptian National Drug Formulary - Antimicrobial 2023: endometritis appears only under injectable agents (cefoperazone, cefoperazone/sulbactam, cefotaxime, clindamycin), No dose - referral pathway, no medicine given in primary care, Abnormal lochia (postpartum vaginal discharge) - disease-level clinical article (abnormal-lochia-clinical.txt), Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) (2026-08) IS IT THIS? - reference only, to read alongside your own examination SYMPTOMS - what the patient reports (4) - Foul-smelling lochia or heavier-than-expected vaginal bleeding after delivery [vaginal bleeding] - History should cover the time since delivery or abortion, the mode of delivery, and any episiotomy or laceration - Pregnancy complications such as gestational diabetes, prolonged or early rupture of membranes, chorioamnionitis, or preeclampsia raise risk - Delivery complications like prolonged labor, operative vaginal delivery, unplanned cesarean, or postpartum hemorrhage matter [postpartum haemorrhage] SIGNS - what you find (6) - Fever comes first, followed by uterine tenderness and foul lochia, in endomyometritis [abdominal pain · fever · pelvic pain] - Shock or pain out of proportion to exam findings should raise concern for group A strep infection [shock] - Superficial wound infection shows redness, warmth, pain, and possibly pus at the site, usually 4 to 7 days after surgery [pus · redness] - Deep wound infections often look unremarkable outwardly, but pain disproportionate to exam suggests necrotizing fasciitis - Skin necrosis, bruising, crepitus, and blistering can appear on exam in deep incisional infection [bruising · crepitus · necrosis] - Persistent spiking fevers despite 3 to 5 days of adequate antibiotics suggest septic pelvic thrombophlebitis [sepsis] TESTS (6) - Blood and wound cultures should be drawn before starting antibiotics, when time allows - Elevated white cells with a left shift and lactic acidosis are typical infection findings, but normal labs do not rule it out - Ultrasound looks for retained products of conception when septic abortion is suspected - Gas within the uterine wall on x-ray or CT signals the infection has invaded the uterus - CT with IV contrast can help diagnose a suspected deep postsurgical organ infection - CT or MRI typically identifies the pelvic vein clot in septic pelvic thrombophlebitis IF NOT THIS - what else fits (8) - Deep vein thrombosis and breast engorgement can both cause postpartum fever besides infection - Muscle aches and breast redness favor mastitis over simple engorgement, since no fixed temperature cutoff separates them - Unrelated infections like a urinary tract infection or pneumonia should also be screened for postpartum - Serotonin syndrome, neuroleptic malignant syndrome, drug overdose, alcohol or benzodiazepine withdrawal, aspirin toxicity, and thyroid storm are noninfectious causes of high fever to weigh - Delivery itself can trigger thyroid storm, presenting with high fever, hyperreflexia, nausea, vomiting, and abdominal pain - Hyperreflexia with clonus points to serotonin syndrome, while lead-pipe rigidity points to neuroleptic malignant syndrome - Tachycardia, high blood pressure, sweating, and agitation suggest sympathomimetic overdose - Altered mental status, dry overheated skin, dilated pupils, flushing, and urinary retention suggest anticholinergic toxicity Source StatPearls "Postpartum Infection" - disease-level clinical article Status traced to the source above !! MULTI-DRUG REGIMEN - all 2 drugs are given TOGETHER. Not a choice between them. !! the regimen: Amoxicillin + Metronidazole 1. NO DRUG THERAPY IN PRIMARY CARE (REFERRAL & ADVICE) [1st line] Adult Lochia that turns offensive, becomes heavy again after settling, or comes with fever or lower abdominal pain is postpartum endometritis or retained products until proved otherwise. Both are assessed with an examination, a swab and an ultrasound, and both are treated with intravenous antibiotics or evacuation. Neither is a prescription written in a clinic. - Refer, with advice Peds Adult-only condition - paediatric section not applicable Source No dose - referral pathway, no medicine given in primary care Why The Egyptian National Drug Formulary lists endometritis only under injectable agents - cefoperazone, cefoperazone with sulbactam, cefotaxime and clindamycin. It holds no oral course, so recognise this and refer the same day. The oral regimens below come from an international source rather than the formulary, and they apply only to the woman who is systemically well. Caution Fever, offensive lochia, uterine tenderness, or a uterus that is not involuting: refer the same day. Heavy fresh bleeding after the first 24 hours is secondary postpartum haemorrhage. That is an emergency, not a discharge problem. Normal lochia is red for about 3-4 days, then brownish, then pale, and has finished by 4-6 weeks. Bright red bleeding returning after it has gone pale is abnormal. Ask about the delivery. Prolonged rupture of membranes, caesarean section, manual removal of the placenta and repeated vaginal examinations all raise the risk of endometritis. Never start an oral antibiotic and review in a week. Postpartum sepsis moves faster than that, and it remains a leading cause of maternal death. The oral courses below are for the systemically well woman only - afebrile, normal pulse and blood pressure, no rigors, no severe pain, no heavy bleeding - and they are reviewed at 48 hours. Take the observations. A postpartum woman compensates well and then decompensates suddenly - a normal-looking patient with a tachycardia is the one to worry about. RED FLAG - Keep a high index of suspicion for sepsis in postpartum patients with unexplained end-organ dysfunction, even in the absence of fever. 2. AMOXICILLIN + CLAVULANIC ACID [2nd line] Adult 875/125 mg orally twice daily x 14 days Peds Adult-only condition - paediatric section not applicable Choice ONLY for the woman who is systemically well: no fever, pulse and blood pressure normal, no rigors, no severe pain, no heavy bleeding, and the uterus involuting. Review her in 48 hours, not a week. Anything less than well is a same-day referral, not a prescription. Co-amoxiclav is put first of the two because it is one tablet twice a day for a woman caring for a newborn; the source lists them without ranking. Source Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) - verbatim: "Potential 14-day regimens for treatment of postpartum endomyometritis include clindamycin 600 mg orally every 6 hours plus gentamicin intramuscularly 4.5 mg/kg every 24 hours; amoxicillin-clavulanate 875 mg orally twice daily; cefotetan 2g intramuscularly every 8 hours; meropenem or imipenem-cilastatin 500 mg intramuscularly every 8 hours; or oral amoxicillin 500 mg and metronidazole 500 mg every 8 hours." The same source states the outpatient regimens are safe in breastfeeding and cure over 85% of early cases. Why Single-agent oral cover for the mixed aerobic and anaerobic flora of postpartum endometritis, for the systemically well woman only, reviewed at 48 hours. It is an international regimen, not an Egyptian National Drug Formulary one - the formulary lists endometritis only under injectable agents. Caution The gate, before the dose: she must be afebrile with normal pulse and blood pressure, no rigors, no severe pain, no heavy bleeding, and a uterus that is involuting. Review in 48 hours. Fail any one of those and she is referred the same day. Take the observations before deciding. A postpartum woman compensates well and then decompensates suddenly - a normal-looking patient with a tachycardia is not a well woman. Safe while breastfeeding. StatPearls' postpartum infection article rates these oral regimens safe during breastfeeding, with a cure rate above 85% in early endometritis. There is no need to stop feeding. The full 14 days. This is not a 5-day course: a short one relapses and risks pelvic infection. No oral penicillin-free option exists at GP level here. The source's only non-beta- lactam regimen is clindamycin plus INTRAMUSCULAR gentamicin, so a woman with penicillin allergy needs referral, not a substitution. Egypt E-MOXCLAV 1G 10 F.C. TAB. EIPICO 14.00 EGP (1.40/unit) JULMENTIN 2X 1GM 15 TAB. JULPHAR 57.50 EGP (3.83/unit) DEXICLAVE 1 GM 10 F.C. TABS. RAMEDA > NOVE... 38.50 EGP (3.85/unit) MACLAVEX 1 GM 14 F.C.TABS. MASH PREMIERE 105.00 EGP (7.50/unit) CLAVIMOX 1 GM 12 F.C.TABS. PHARCO 130.00 EGP (10.83/unit) MEGAMOX 1 GM 14 F.C. TABS. AL JAZEERA PH... 178.00 EGP (12.71/unit) CLAVOCILLIN 1 GM 10 DISPERSIBLE TABS. RAMEDA > ORGANOPHARMA 106.00 EGP AUGMENTIN ADULTS 1GM/125MG 12 PWD. ORAL SUSP. SACHETS GLAXO SMITHKLINE 169.00 EGP LARYNCLAVE 125/31 PD. FOR ORAL SUSP. 70ML MISR > AL ROWAD PHARMACEUTICAL... 8.00 EGP -> ? strength differs, ? different route - not oral solid MEGACLAVOX 156MG/5ML PD. FOR SUSP. 60 ML CID 8.00 EGP -> ? strength differs, ? different route - not oral solid 3. AMOXICILLIN [1 of 2 - GIVE ALL TOGETHER] Adult 500 mg orally every 8 hours, given together with metronidazole x 14 days Peds Adult-only condition - paediatric section not applicable Source Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) - verbatim: "... or oral amoxicillin 500 mg and metronidazole 500 mg every 8 hours", from the same sentence naming these as 14-day regimens for postpartum endomyometritis. Why The two-drug oral alternative when co-amoxiclav is not available or not tolerated, for the systemically well woman only. Amoxicillin covers the aerobes; metronidazole covers the anaerobes. Caution The gate, before the dose: she must be afebrile with normal pulse and blood pressure, no rigors, no severe pain, no heavy bleeding, and a uterus that is involuting. Review in 48 hours. Fail any one of those and she is referred the same day. Both drugs, not one. Amoxicillin alone does not cover the anaerobes that cause the offensive smell. Safe while breastfeeding. StatPearls' postpartum infection article rates these regimens safe during breastfeeding, with a cure rate above 85% in early endometritis. Egypt AMOXYCILLIN 500MG 10 CAPS B.P.2013 ARAB DRUG COMPANY (ADCO) 6.50 EGP (0.65/unit) AMOXICILLIN 500MG 12 CAPS. USP 28 OCTOBER PHARMA 8.10 EGP (0.67/unit) AMOXIL 500MG 12 CAPS. MUP > SMITHKL... 9.00 EGP (0.75/unit) AMOXICID 500 MG 12 CAPS. CID 9.50 EGP (0.79/unit) E-MOX 500 MG 16 CAPS. EIPICO 15.60 EGP (0.97/unit) HICONCIL 500MG 12 CAPS. PHARCO 11.60 EGP (0.97/unit) BIOMOX 500MG 12 CAPS. SEDICO 19.50 EGP (1.62/unit) IBIAMOX 500 MG 12 CAPS. AMOUN 45.00 EGP (3.75/unit) HICILLIN 125MG/5ML SUSP. 80ML EL NASR 3.00 EGP -> ? strength differs, ? different route - not oral solid AMOXIL FORT 250MG/5ML SUSP. 60ML MUP > SMITHKL... 5.50 EGP -> ? strength differs, ? different route - not oral solid 4. METRONIDAZOLE [2 of 2 - GIVE ALL TOGETHER] Adult 500 mg orally every 8 hours, given together with amoxicillin x 14 days Peds Adult-only condition - paediatric section not applicable Source Postpartum Infection - StatPearls - NCBI Bookshelf (NBK560804) - verbatim: "... or oral amoxicillin 500 mg and metronidazole 500 mg every 8 hours", from the same sentence naming these as 14-day regimens for postpartum endomyometritis. Why The anaerobic half of the two-drug oral regimen, for the systemically well woman only. Anaerobes are what make the lochia offensive. Caution The gate, before the dose: she must be afebrile with normal pulse and blood pressure, no rigors, no severe pain, no heavy bleeding, and a uterus that is involuting. Review in 48 hours. Fail any one of those and she is referred the same day. Strictly no alcohol during the course and for 3 days (72 hours) after the last dose - Egyptian National Drug Formulary, Antimicrobial 2023. Safe while breastfeeding. StatPearls' postpartum infection article rates these regimens safe during breastfeeding, with a cure rate above 85% in early endometritis. It can give the milk a bitter taste - that is not a reason to stop feeding. May cause a metallic taste and nausea. Egypt DUMOZOL 500MG 20 F.C. TABS. MINA PHARM > ... 7.00 EGP (0.35/unit) ZOLGUARD 500MG 20 TAB. UNIPHARMA CO.... 9.00 EGP (0.45/unit) NITROFECTAZOLE 500 MG 20 F.C. TABS. GYPTO PHARMA 10.50 EGP (0.53/unit) FLAGICURE FORTE 500 MG 20 F.C. TAB KAHIRA 23.00 EGP (1.15/unit) TRICHOGYL 500MG 12 F.C.TAB. EL NASR 15.00 EGP (1.25/unit) FLAGELLAT FORTE 500MG 20 F.C.TABS. MUP 30.00 EGP (1.50/unit) GEDAZOLE 500MG 20 TAB. JEDCO INT. CO... 34.00 EGP (1.70/unit) METROGYPTON 500 MG 20 F.C. TABS. GYPTO PHARMA 34.00 EGP (1.70/unit) DUMOZOL 125MG/5ML SUSP. 125ML MINA PHARM > ... 5.75 EGP -> ? strength differs, ? different route - not oral solid METROZOLE 125MG/5ML SUSP. 120 ML MEMPHIS 19.50 EGP -> ? strength differs, ? different route - not oral solid Prices are indicative (dataset snapshot 2026-06); verify with the pharmacy. ``` --- Dawaa Reference is a reference for prescribers, not a medical device, and does not replace clinical judgement. [Privacy policy](/privacy)