A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor for fever. The patient awoke this morning with fever, chills, and increasing abdominal pain. She is passing flatus and has no nausea. Two days ago, the patient was in active labor, developed prolonged fetal bradycardia, and was rushed to the operating room for an emergency cesarean delivery under general anesthesia. The fetus was delivered with Apgar scores of 6 and 8 at 1 and 5 minutes, respectively. The patient was unable to void on the first postoperative day, so the Foley catheter was replaced and is continuing to drain. The patient developed a fever this morning, and now her temperature is 38.4 C (101.1 F). Bilateral breasts are engorged, tender, and have no erythema. The uterine fundus is nontender and palpable at the umbilicus. The skin overlying the incision is intact and has induration and erythema extending to the mons pubis. There are no palpable abdominal masses, rebound, or guarding. A Foley catheter is draining blood-tinged urine. Urinalysis shows trace blood, negative leukocyte esterase, and negative nitrites. Which of the following is the most likely underlying cause of this patient's presentation?

Question

A 23-year-old woman, gravida 1 para 1, is evaluated on the postpartum floor for fever.  The patient awoke this morning with fever, chills, and increasing abdominal pain.  She is passing flatus and has no nausea.  Two days ago, the patient was in active labor, developed prolonged fetal bradycardia, and was rushed to the operating room for an emergency cesarean delivery under general anesthesia.  The fetus was delivered with Apgar scores of 6 and 8 at 1 and 5 minutes, respectively.  The patient was unable to void on the first postoperative day, so the Foley catheter was replaced and is continuing to drain.  The patient developed a fever this morning, and now her temperature is 38.4 C (101.1 F).  Bilateral breasts are engorged, tender, and have no erythema.  The uterine fundus is nontender and palpable at the umbilicus.  The skin overlying the incision is intact and has induration and erythema extending to the mons pubis.  There are no palpable abdominal masses, rebound, or guarding.  A Foley catheter is draining blood-tinged urine.  Urinalysis shows trace blood, negative leukocyte esterase, and negative nitrites.  Which of the following is the most likely underlying cause of this patient's presentation?

Quizplus · Accepted Answer

This patient with postpartum fever (≥38 C more than 24 hours after delivery), wound induration, and incisional erythema most likely has cellulitis, a superficial surgical site infection due to incisional bacterial contamination during her cesarean delivery. Risk factors for wound infection include obesity and emergency surgery (eg, inadequate skin antisepsis or antibiotic prophylaxis). Patients typically develop superficial surgical site infection within days to weeks after surgery. Typical signs include wound induration and erythema, which begins at the incision site at the level of the dermis but may also spread to surrounding subcutaneous tissue, resulting in edema, subcutaneous fluid accumulation, and increased peri-incisional pain. Treatment of nonpurulent cellulitis is with first-generation cephalosporins (eg, cephalexin) because they cover common skin pathogens (eg, beta-hemolytic streptococci, methicillin-susceptible Staphylococcus aureus [MSSA]). (Choice B) This patient's hematuria and urinary retention are likely due to bladder and urethra trauma during labor and general anesthesia. Urinary retention is managed with Foley catheter replacement, which can cause catheter-introduced bacteriuria and cystitis. This patient's urinalysis is normal (eg, negative leukocyte esterase and nitrites), making this diagnosis unlikely. (Choice C) Septic pelvic thrombophlebitis can cause postpartum fever due to injury, thrombus, and hematogenous spread of infection to the pelvic veins (eg, ovarian veins). Patients are typically initially treated for suspected endometritis but have relapsing-remitting fevers and persistent abdominal pain despite antibiotics. Septic pelvic thrombophlebitis is not associated with incisional induration or erythema. (Choice D) Breast tenderness and engorgement can be due to normal postpartum milk letdown or signs of developing mastitis, which is caused by obstruction, inflammation, and infection of the breast ducts. However, patients with mastitis typically have high fevers, malaise, and unilateral breast erythema (not seen in this patient). (Choice E) Patients who undergo cesarean delivery are at risk for endometritis, a polymicrobial infection of the intrauterine cavity and common cause of postpartum fever. Patients with endometritis typically have uterine fundal tenderness, which is not seen in this patient. Educational objective: Superficial surgical site infection (ie, cellulitis) can occur after cesarean delivery and present with postpartum fever (≥38 C more than 24 hours after delivery) as well as incisional induration and erythema. Risk factors include obesity and emergency surgery (eg, inadequate skin antisepsis or antibiotic prophylaxis). References: Surgical site infections after cesarean delivery: epidemiology, prevention and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/28690864) Effects of postoperative analgesia on postpartum urinary retention in women undergoing cesarean delivery. (http://www.ncbi.nlm.nih.gov/pubmed/20846254)

A 23-Year-Old Woman, Gravida 1 Para 1, Is Evaluated on the Postpartum