A 31-year-old woman, gravida 1 para 1, is seen in the hospital on postoperative day 2 due to lower abdominal pain, chills, and pain with sitting. The patient initially planned to have a home delivery but came to the hospital when she had no contractions a day after spontaneous rupture of membranes. After a 26-hour induction of labor, she had a primary cesarean delivery for arrest of descent. The patient has asthma controlled with a rescue inhaler. She does not use tobacco, alcohol, or illicit drugs. Temperature is 38.3 C (100.9 F), blood pressure is 100/60 mm Hg, and pulse is 96/min. Cardiopulmonary examination is normal. The breasts are full but have no erythema or fluctuant masses. The uterine fundus is firm and tender to palpation. There is scant serosanguineous drainage from the lower aspect of the incision. Pelvic examination shows a small amount of blood on the perineal pad with mildly malodorous discharge. Bilateral lower extremities are symmetric with minimal pedal edema. Which of the following is the best regimen for treating this patient's condition?

Question

A 31-year-old woman, gravida 1 para 1, is seen in the hospital on postoperative day 2 due to lower abdominal pain, chills, and pain with sitting.  The patient initially planned to have a home delivery but came to the hospital when she had no contractions a day after spontaneous rupture of membranes.  After a 26-hour induction of labor, she had a primary cesarean delivery for arrest of descent.  The patient has asthma controlled with a rescue inhaler.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.3 C (100.9 F), blood pressure is 100/60 mm Hg, and pulse is 96/min.  Cardiopulmonary examination is normal.  The breasts are full but have no erythema or fluctuant masses.  The uterine fundus is firm and tender to palpation.  There is scant serosanguineous drainage from the lower aspect of the incision.  Pelvic examination shows a small amount of blood on the perineal pad with mildly malodorous discharge.  Bilateral lower extremities are symmetric with minimal pedal edema.  Which of the following is the best regimen for treating this patient's condition?

Quizplus · Accepted Answer

11ec25c8_da60_8c1e_bc81_3f64ad738661_MD0003_00 This patient has postpartum endometritis, an infection of the uterine decidua and the most common etiology of puerperal fever. Patients typically develop a fever >24 hours following delivery and have purulent lochia and uterine tenderness. Risk factors include prolonged rupture of membranes, operative vaginal delivery, prolonged labor, and cesarean delivery. Postpartum endometritis is the result of inoculation of the uterine cavity by vaginal flora during labor or delivery and is a polymicrobial infection. Normal vaginal flora includes a mix of gram-positive cocci (eg, group B Streptococcus [GBS]), gram-negative bacilli (eg, Escherichia coli), and anaerobes (eg, Gardnerella vaginalis); therefore, treatment requires broad-spectrum antibiotic therapy with coverage for all potential bacterial types. A common regimen is clindamycin plus gentamicin; clindamycin covers gram-positives and anaerobes, and gentamicin covers gram-negative bacilli. Treatment is continued until the patient is afebrile for >24 hours. Neither blood nor endometrial cultures are required for diagnosis, but further evaluation is indicated if there is no clinical improvement after 48 hours of antibiotic therapy. (Choice A) Ceftriaxone is the treatment of choice for pyelonephritis during pregnancy. It is a third-generation cephalosporin that covers the most common cause of pyelonephritis, gram-negative E coli. (Choice B) Ceftriaxone plus doxycycline is a dual-therapy regimen that covers the most common bacterial causes of acute cervicitis, Neisseria gonorrhoeae (gram-negative cocci) and Chlamydia trachomatis (atypical organism). Although ceftriaxone also covers gram-negative bacilli (eg, E coli) and doxycycline covers gram-positives (eg, Streptococcus), this regimen lacks sufficient anaerobic coverage for the treatment of postpartum endometritis. (Choice D) Dicloxacillin is used in the treatment of lactational mastitis. This narrow-spectrum penicillin covers the 2 most frequent pathogens, methicillin-sensitive Staphylococcus aureus and group A Streptococcus (gram-positives). (Choice E) Penicillin, a beta-lactam, is the antibiotic of choice for the treatment of syphilis or GBS prophylaxis during labor to prevent neonatal GBS infection. It is not used for postpartum endometritis because it has narrow coverage and many bacteria are penicillin resistant. (Choice F) Vancomycin is used for the treatment of breast abscesses due to its coverage against methicillin-resistant S aureus; however, it has no activity against gram-negative or anaerobic bacteria. Educational objective: Postpartum endometritis is a polymicrobial infection characterized by fever >24 hours postpartum, purulent lochia, and uterine tenderness. The antibiotic regimen is clindamycin plus gentamicin due to its broad-spectrum coverage. References: Antibiotic regimens for postpartum endometritis. (http://www.ncbi.nlm.nih.gov/pubmed/25922861)

A 31-Year-Old Woman, Gravida 1 Para 1, Is Seen in the Hospital