A 39-year-old woman, gravida 4 para 3, comes to the emergency department after 2 days of fever, heavy vaginal bleeding, and lower abdominal pain. Six days ago, she had an elective abortion at an outside clinic at 8 weeks gestation. Since the procedure, the patient has had bleeding that has become increasingly heavy and malodorous and is now soaking through a pad every 2-3 hours. She has no medical problems, takes no medications, and has no allergies. Temperature is 39.8 C (103.7 F), blood pressure is 100/65 mm Hg, pulse is 108/min, and respirations are 16/min. Physical examination reveals lower abdominal tenderness but no rigidity or guarding. Pelvic examination shows copious foul-smelling, purulent, and bloody discharge from the cervical os. Bimanual examination shows a tender, anteverted, soft uterus that is 12 weeks in size. Transvaginal ultrasound reveals a 12-cm uterus with an irregularly thickened echogenic endometrial stripe with active blood flow. The adnexa are normal bilaterally, and there is a small amount of free fluid in the pelvis. She is started on broad-spectrum intravenous antibiotics. Which of the following is the most appropriate next step in management of this patient?

Question

A 39-year-old woman, gravida 4 para 3, comes to the emergency department after 2 days of fever, heavy vaginal bleeding, and lower abdominal pain.  Six days ago, she had an elective abortion at an outside clinic at 8 weeks gestation.  Since the procedure, the patient has had bleeding that has become increasingly heavy and malodorous and is now soaking through a pad every 2-3 hours.  She has no medical problems, takes no medications, and has no allergies.  Temperature is 39.8 C (103.7 F), blood pressure is 100/65 mm Hg, pulse is 108/min, and respirations are 16/min.  Physical examination reveals lower abdominal tenderness but no rigidity or guarding.  Pelvic examination shows copious foul-smelling, purulent, and bloody discharge from the cervical os.  Bimanual examination shows a tender, anteverted, soft uterus that is 12 weeks in size.  Transvaginal ultrasound reveals a 12-cm uterus with an irregularly thickened echogenic endometrial stripe with active blood flow.  The adnexa are normal bilaterally, and there is a small amount of free fluid in the pelvis.  She is started on broad-spectrum intravenous antibiotics.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_da0c_5209_bc81_f9a510c9938b_MD0003_00 This patient's presentation is consistent with a septic abortion, which typically presents with fever; lower abdominal pain; heavy vaginal bleeding; and a malodorous, purulent vaginal discharge. It can occur as a complication of any type of abortion but most frequently follows an unsterile and/or incomplete procedure for an elective abortion. Findings of a purulent discharge and enlarged, boggy, tender uterus on pelvic examination and an ultrasound showing intrauterine echogenic material with blood flow are consistent with inflammation and infection from retained products of conception. Although the infection usually remains confined to the placental tissue of the retained products of conception, if untreated or observed (Choice D) it can spread into the uterine myometrium and can cause widespread infection. Due to these potential complications, a septic abortion is a medical emergency that requires prompt treatment to prevent progression to peritonitis, septic shock, and death. Treatment includes broad-spectrum antibiotics and uterine evacuation with suction curettage. (Choice A) A hysterectomy is indicated for a pelvic abscess or if the patient does not improve after suction curettage and 48 hours of broad-spectrum antibiotics. (Choice B) Methotrexate, a dihydrofolate reductase inhibitor, is used in the management of hemodynamically stable ectopic pregnancies and of gestational trophoblastic neoplasia. Methotrexate is not used in abortion management and would not treat this patient's infection. (Choice C) Misoprostol, a synthetic prostaglandin, causes uterine contractions and expulsion of retained products of conception. It is commonly used in medical management of spontaneous abortions, but the onset of action is too slow for the treatment of septic abortion, which requires prompt uterine evacuation to minimize the risk of sepsis. Educational objective: Septic abortion most commonly occurs after an unsterile and/or incomplete procedure for an elective abortion; it presents with fever, heavy vaginal bleeding, purulent discharge, and uterine tenderness. Septic abortion is a medical emergency that requires prompt treatment with broad-spectrum antibiotics and surgical evacuation of the uterus (eg, suction curettage). References: Induced septic abortion: a major factor in maternal mortality and morbidity. (http://www.ncbi.nlm.nih.gov/pubmed/14718012) Treating spontaneous and induced septic abortions. (http://www.ncbi.nlm.nih.gov/pubmed/25932831)

A 39-Year-Old Woman, Gravida 4 Para 3, Comes to the Emergency