From the Guidelines
This patient is experiencing post-abortion sepsis, a serious infection following her dilation and curettage procedure, and requires immediate management with broad-spectrum antibiotics and suction uterine curettage to prevent severe morbidity and mortality. The diagnosis is based on her fever, hypotension, tachycardia, purulent cervical discharge, cervical motion tenderness, and positive pregnancy test suggesting retained products of conception 1. Management should include immediate fluid resuscitation with crystalloids (normal saline or lactated Ringer's) at 30 mL/kg within the first hour to address her septic shock. Broad-spectrum antibiotics should be administered promptly, typically a combination of ampicillin 2g IV q6h, gentamicin 5mg/kg IV daily, and metronidazole 500mg IV q8h to cover gram-positive, gram-negative, and anaerobic organisms. Some key points to consider in the management of this patient include:
- The importance of prompt antibiotic administration to prevent the progression of sepsis to severe sepsis and septic shock 1
- The need for suction curettage to remove retained products of conception, which serve as a nidus for infection 1
- The importance of close monitoring in an inpatient setting with frequent vital sign checks
- The need for blood cultures, complete blood count, comprehensive metabolic panel, and coagulation studies to guide management and monitor for complications
- The requirement for antibiotics to continue until the patient is afebrile for 24-48 hours, then transition to oral antibiotics to complete a 14-day course. The patient's condition, as described, is consistent with the diagnosis of postpartum hemorrhage (PPH) due to retained products of conception (RPOC) with superimposed infection, as outlined in the ACR Appropriateness Criteria® for postpartum hemorrhage 1.
From the Research
Patient Presentation and Diagnosis
- The patient presents with fever, chills, and lower abdominal pain after undergoing dilation and curettage for a 9-week missed abortion.
- The patient's symptoms, including heavy and malodorous bleeding, increasing abdominal pain, and fever, suggest a possible infection.
- The physical examination and transvaginal ultrasound reveal a thickened endometrial stripe, purulent discharge, and cervical motion tenderness, consistent with pelvic inflammatory disease (PID) or endometritis.
Treatment Options
- Broad-spectrum intravenous antibiotics are prescribed, which is consistent with the treatment of PID or endometritis 2, 3, 4.
- The use of broad-spectrum antibiotics is supported by studies that demonstrate their efficacy in treating PID and endometritis, including those caused by polymicrobial infections 2, 3, 4.
- The patient undergoes a suction uterine curettage, which may be necessary to remove any retained products of conception or infected tissue.
Antibiotic Regimens
- The choice of antibiotic regimen may depend on various factors, including the suspected causative organisms, patient allergies, and local resistance patterns.
- Studies have compared the efficacy of different antibiotic regimens, including cefotetan plus doxycycline, cefoxitin plus doxycycline, and clindamycin-containing regimens 3, 4, 5.
- The use of broad-spectrum beta-lactam agents, such as cefoxitin, has been shown to be effective in treating PID and endometritis, including cases with tubo-ovarian abscesses 5.
Appropriate Use of Antibiotics
- The use of broad-spectrum antibiotics should be guided by clinical judgment and suspicion of bacterial infection, rather than solely on the presence of systemic inflammatory response syndrome (SIRS) criteria or Quick Sequential Organ Failure Assessment (qSOFA) score 6.
- The patient's clinical presentation and diagnostic findings should be carefully evaluated to determine the need for antibiotics and to guide the choice of antibiotic regimen.