A 29-year-old woman, gravida 1 para 1, is evaluated due to recurrent fevers on day 5 after a cesarean delivery for arrest of descent after a prolonged induction of labor. Gentamicin and clindamycin were administered for fever on postoperative day 1. Ampicillin was added on postoperative day 3 as the patient continued to be intermittently febrile. She has had no nausea, vomiting, hemoptysis, dyspnea, hematuria, dysuria, or diarrhea. Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, and pulse is 108/min. Oxygen saturation is 98% on room air. The lungs are clear to auscultation bilaterally. Breast examination shows full, slightly tender breasts with no erythema. Abdominal examination shows mild bilateral lower quadrant tenderness to deep palpation and an incision with minimal serosanguineous drainage but no erythema or induration. Pelvic examination reveals a nontender uterine fundus that is below the umbilicus. Examination of the lower extremities shows no swelling, tenderness, or erythema. Hemoglobin is 10.8 g/dL. Urinalysis is normal. Which of the following is the most likely diagnosis in this patient?

Question

A 29-year-old woman, gravida 1 para 1, is evaluated due to recurrent fevers on day 5 after a cesarean delivery for arrest of descent after a prolonged induction of labor.  Gentamicin and clindamycin were administered for fever on postoperative day 1.  Ampicillin was added on postoperative day 3 as the patient continued to be intermittently febrile.  She has had no nausea, vomiting, hemoptysis, dyspnea, hematuria, dysuria, or diarrhea.  Temperature is 39 C (102.2 F), blood pressure is 120/80 mm Hg, and pulse is 108/min.  Oxygen saturation is 98% on room air.  The lungs are clear to auscultation bilaterally.  Breast examination shows full, slightly tender breasts with no erythema.  Abdominal examination shows mild bilateral lower quadrant tenderness to deep palpation and an incision with minimal serosanguineous drainage but no erythema or induration.  Pelvic examination reveals a nontender uterine fundus that is below the umbilicus.  Examination of the lower extremities shows no swelling, tenderness, or erythema.  Hemoglobin is 10.8 g/dL.  Urinalysis is normal.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_da8c_3053_bc81_b5287bf6c3ab_MD0003_00 This patient's presentation is consistent with septic pelvic thrombophlebitis (SPT), a complication associated with either pelvic surgery or the postpartum period. SPT is a thrombosis of the deep pelvic or ovarian veins (as seen in this patient's bilateral lower quadrant tenderness) that becomes infected. Several factors predispose postpartum patients to thrombosis: Hypercoagulable state of pregnancy Pelvic venous stasis and dilation Endothelial damage from infection and/or trauma during delivery Because the most common etiology for postpartum fever is endometritis, patients are initially treated empirically with antibiotics. Persistent fever unresponsive to broad-spectrum antibiotic therapy and a negative infectious evaluation (eg, blood and urine cultures, urinalysis) suggest SPT, which is a diagnosis of exclusion. Risk factors include cesarean delivery and chorioamnionitis/endometritis. Treatment is with anticoagulation and broad-spectrum antibiotics. (Choice A) Acute pyelonephritis presents with costovertebral angle pain and dysuria, neither of which is seen in this patient. In addition, this patient has a normal urinalysis. (Choice B) In addition to fever, aspiration pneumonia typically presents with dyspnea, low oxygen saturation, and crackles in the lower lobes on pulmonary examination. (Choice C) Incisional infections can cause puerperal fever but present with incisional pain, erythema, and induration. The serosanguineous discharge from this patient's incision is normal. (Choice D) Although pulmonary embolism can present with fever, patients typically also have dyspnea, hemoptysis, pleuritic chest pain, and low oxygen saturation, none of which are seen in this patient. Educational objective: Septic pelvic thrombophlebitis refers to a postoperative or postpartum infected thrombosis of the deep pelvic or ovarian veins. Patients have persistent fever unresponsive to antibiotics. Treatment includes anticoagulation and broad-spectrum antibiotics. References: Postpartum ovarian vein thrombosis: two cases and review of literature. (http://www.ncbi.nlm.nih.gov/pubmed/19809519)

A 29-Year-Old Woman, Gravida 1 Para 1, Is Evaluated Due