A 22-year-old woman comes to the emergency department with fever and abdominal pain. A week ago, the patient had an elective termination of pregnancy at an outside facility. For the last 3 days, she has had increasingly purulent vaginal discharge, bleeding, and intermittent headaches. She has no nausea, vomiting, or diarrhea. The patient takes valacyclovir daily for recurrent herpes simplex. She has no other chronic medical problems or previous surgeries. The patient drinks alcohol once or twice a week and smokes 1 or 2 cigarettes daily. Temperature is 39 C (102.2 F), blood pressure is 93/52 mm Hg, pulse is 120/min, and respirations are 18/min. Neurologic examination is grossly normal. Lungs are clear to auscultation bilaterally. Abdominal palpation shows bilateral lower quadrant tenderness but no masses, rebound, or guarding. Purulent cervical discharge is noted on speculum examination. Bimanual pelvic examination reveals an 8-week-sized tender uterus with cervical motion tenderness; no adnexal masses are palpated. Bedside ultrasound reveals a 2×2 cm (0.8×0.8 in) echogenic mass in the endometrial cavity near the uterine fundus. A urine pregnancy test is positive. Intravenous fluid and antibiotics are administered. Which of the following is the best next step in management of this patient?

Question

A 22-year-old woman comes to the emergency department with fever and abdominal pain.  A week ago, the patient had an elective termination of pregnancy at an outside facility.  For the last 3 days, she has had increasingly purulent vaginal discharge, bleeding, and intermittent headaches.  She has no nausea, vomiting, or diarrhea.  The patient takes valacyclovir daily for recurrent herpes simplex.  She has no other chronic medical problems or previous surgeries.  The patient drinks alcohol once or twice a week and smokes 1 or 2 cigarettes daily.  Temperature is 39 C (102.2 F), blood pressure is 93/52 mm Hg, pulse is 120/min, and respirations are 18/min.  Neurologic examination is grossly normal.  Lungs are clear to auscultation bilaterally.  Abdominal palpation shows bilateral lower quadrant tenderness but no masses, rebound, or guarding.  Purulent cervical discharge is noted on speculum examination.  Bimanual pelvic examination reveals an 8-week-sized tender uterus with cervical motion tenderness; no adnexal masses are palpated.  Bedside ultrasound reveals a 2×2 cm (0.8×0.8 in) echogenic mass in the endometrial cavity near the uterine fundus.  A urine pregnancy test is positive.  Intravenous fluid and antibiotics are administered.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c01c_196e_8f63_2d32e75bee67_MD0005_00 This patient has fever, tachycardia, hypotension, lower abdominal pain, and purulent vaginal discharge, a presentation consistent with a septic abortion. Other presenting features include a dilated cervix and a tender, boggy uterus. Although septic abortions can occur spontaneously, they usually present as a complication of an elective termination procedure, particularly one that was performed using unsterile technique. Septic abortions occur when retained products of conception become infected by ascending vaginal flora (eg, anaerobes, gram-negative bacilli, gram-positive cocci) in the context of prolonged bleeding or recent instrumentation (eg, from a termination procedure). A septic abortion is a medical emergency; a delay in treatment can lead to the spread of infection from the fetus and placenta to the myometrium, which can lead to sepsis, acute respiratory distress syndrome, disseminated intravascular coagulation, and death. Management includes starting intravenous fluids, collecting blood and cervical cultures, and initiating broad-spectrum parenteral antibiotics (eg, gentamicin plus clindamycin) (Choice C). After initial stabilization, the next step is uterine evacuation via suction curettage. suction curettage (Choice A) Methotrexate, a dihydrofolate reductase inhibitor, is used in the management of an ectopic pregnancy in hemodynamically stable patients. Methotrexate is not used in abortion management and does not treat this patient's infection. ectopic pregnancy (Choice B) Misoprostol, a synthetic prostaglandin, causes uterine contractions and expulsion of retained products of conception. It is used in the medical management of spontaneous abortion, but the onset of action is too slow for the treatment of a septic abortion, which requires prompt uterine evacuation to minimize the risk of sepsis. (Choice D) A hysterectomy may be indicated if the patient's condition does not improve with antibiotics and suction curettage. Other indications include the development of a pelvic abscess and clostridial myonecrosis (eg, pelvic tissue crepitus, radiographic evidence of air within the uterine wall). Educational objective: Patients with septic abortion have fever, tachycardia, hypotension, lower abdominal pain, and mucopurulent cervical discharge. A septic abortion is a medical emergency managed with broad-spectrum intravenous antibiotics and surgical evacuation of the uterine contents via suction curettage. References: Treating spontaneous and induced septic abortions. (http://www.ncbi.nlm.nih.gov/pubmed/25932831)

A 22-Year-Old Woman Comes to the Emergency Department with Fever