A 29-year-old woman comes to the emergency department due to fever, chills, and lower abdominal pain. Two days ago, the patient underwent dilation and curettage for a 9-week missed abortion. After the procedure, she initially had light spotting, but the bleeding has become increasingly heavy and malodorous within the last few hours. She has also developed increasing abdominal pain and a fever unrelieved by acetaminophen. The patient has no chronic medical conditions and has had no other surgeries. Temperature is 39.4 C (103 F), blood pressure is 88/50 mm Hg, and pulse is 118/min. On speculum examination, the cervix is visibly 1 cm dilated and has purulent discharge at the os. The uterus is enlarged and has cervical motion tenderness. Transvaginal ultrasound shows a thickened endometrial stripe. Urine pregnancy test is positive. The patient is started on broad-spectrum intravenous antibiotics and undergoes a suction dilation and sharp curettage. This patient is at increased risk for which of the following conditions?

Question

A 29-year-old woman comes to the emergency department due to fever, chills, and lower abdominal pain.  Two days ago, the patient underwent dilation and curettage for a 9-week missed abortion.  After the procedure, she initially had light spotting, but the bleeding has become increasingly heavy and malodorous within the last few hours.  She has also developed increasing abdominal pain and a fever unrelieved by acetaminophen.  The patient has no chronic medical conditions and has had no other surgeries.  Temperature is 39.4 C (103 F), blood pressure is 88/50 mm Hg, and pulse is 118/min.  On speculum examination, the cervix is visibly 1 cm dilated and has purulent discharge at the os.  The uterus is enlarged and has cervical motion tenderness.  Transvaginal ultrasound shows a thickened endometrial stripe.  Urine pregnancy test is positive.  The patient is started on broad-spectrum intravenous antibiotics and undergoes a suction dilation and sharp curettage.  This patient is at increased risk for which of the following conditions?

Quizplus · Accepted Answer

11ec25c8_d9a3_a47b_bc81_ed77d582618c_MD0003_00 This patient's fever, lower abdominal pain, and purulent cervical discharge after dilation and curettage for a missed abortion are due to a septic abortion, a polymicrobial intrauterine infection. The treatment of a septic abortion is broad-spectrum antibiotics and a suction dilation with sharp curettage, which removes the infected retained products of conception. During a suction dilation with sharp curettage, the endometrium can be removed along with the products of conception, particularly during infection (eg, septic abortion), as the infected tissues are more adherent to one another and the uterus becomes softer and more enlarged. This often results in more aggressive curettage, which denudes the endometrial basalis layer and causes an inflamed, obliterated uterine cavity prone to intrauterine synechiae development (ie, adhesions) known as Asherman syndrome. (Choice B) Dysplastic changes to the cervical epithelium, which result in cervical intraepithelial neoplasia or cancer, occur due to persistent human papillomavirus infection. There is no association with septic abortion or intrauterine surgery. (Choice C) Endometriosis (implantation of endometrial tissue outside of the uterus) is not associated with intrauterine surgery or infection. (Choice D) Sheehan syndrome (infarction of the pituitary gland) can occur due to obstetric blood loss (eg, postpartum hemorrhage). Pituitary enlargement does not occur until after 20 weeks gestation and, therefore, is not prone to ischemia in patients with first trimester spontaneous abortions regardless of hemodynamic instability. (Choice E) Gestational trophoblastic disease (the malignant transformation of trophoblastic tissue) typically occurs after a hydatidiform mole pregnancy, but can occur after any pregnancy. Patients with a complete hydatidiform mole have a "snowstorm" appearance on ultrasound rather than a missed abortion (ie, fetus with no cardiac activity) or thickened endometrial stripe. A positive pregnancy test is common in patients with a septic abortion (even after dilation and curettage) due to retained products of conception. Educational objective: Asherman syndrome (the development of intrauterine adhesions) is a possible complication of intrauterine surgery (eg, curettage) caused by scarring and obliteration of endometrial tissue. The risk of adhesion formation increases with a concomitant intrauterine infection (eg, septic abortion). References: A comprehensive review of Asherman's syndrome: causes, symptoms and treatment options. (http://www.ncbi.nlm.nih.gov/pubmed/28582327) The management of Asherman syndrome: a review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/24373209) Treating spontaneous and induced septic abortions. (http://www.ncbi.nlm.nih.gov/pubmed/25932831)

A 29-Year-Old Woman Comes to the Emergency Department Due to Fever