What is the likely diagnosis for a woman with post-procedure fever, chills, and abdominal pain after a dilation and curettage (D&C) procedure for a missed abortion, presenting with heavy and malodorous bleeding, severe abdominal pain, hypotension, tachycardia, and a positive urine pregnancy test?

From the Guidelines

This patient requires immediate and aggressive management for septic abortion, including broad-spectrum intravenous antibiotics and prompt evacuation of retained products of conception through suction curettage, as already initiated, to prevent progression to septic shock and improve outcomes in terms of morbidity, mortality, and quality of life. The patient's clinical presentation, including fever, hypotension, tachycardia, purulent cervical discharge, and cervical motion tenderness, is consistent with septic abortion, a serious complication following her dilation and curettage procedure for a missed abortion 1. The positive pregnancy test and thickened endometrial stripe on transvaginal ultrasound further support the diagnosis of retained products of conception.

Key aspects of management include:

• Hemodynamic stabilization with IV fluids to address hypotension and prevent shock
• Broad-spectrum antibiotics, such as a combination of ampicillin, gentamicin, and metronidazole or clindamycin, to cover polymicrobial infections with aerobic and anaerobic bacteria
• Prompt evacuation of retained products through suction curettage, which has already been initiated
• Blood cultures should be obtained before starting antibiotics to guide targeted therapy
• Close monitoring in a hospital setting with vital sign checks, input/output measurements, and laboratory tests including complete blood count, comprehensive metabolic panel, coagulation studies, and C-reactive protein to assess response to treatment and detect potential complications early.

The infection typically results from ascending bacteria from the vagina into the uterus, facilitated by retained products of conception providing an excellent medium for bacterial growth 1. Common pathogens include polymicrobial infections with aerobic and anaerobic bacteria. Antibiotics should continue until the patient is afebrile for at least 24-48 hours with clinical improvement. Septic abortion can rapidly progress to septic shock, disseminated intravascular coagulation, and multi-organ failure if not treated promptly, emphasizing the need for aggressive and timely management to improve outcomes in terms of morbidity, mortality, and quality of life.

From the Research

Patient Presentation and Treatment

The patient presents with fever, chills, and lower abdominal pain after undergoing dilation and curettage for a 9-week missed abortion. The symptoms have worsened over time, with increasing heavy and malodorous bleeding, abdominal pain, and fever. The patient's condition is suggestive of an acute pelvic infection, likely caused by bacterial contamination during the procedure.

Diagnosis and Management

The diagnosis is supported by the presence of purulent discharge at the os, cervical motion tenderness, and a thickened endometrial stripe on transvaginal ultrasound. The patient is prescribed broad-spectrum intravenous antibiotics and undergoes a suction uterine curettage. This approach is consistent with the management of acute pelvic infections, as seen in studies comparing different antibiotic regimens for the treatment of pelvic inflammatory disease (PID) 2, 3, 4.

Antibiotic Regimens

The studies suggest that various antibiotic regimens, including cefoxitin plus doxycycline, cefotetan plus doxycycline, and clindamycin-containing regimens, are effective in treating PID and tuboovarian abscesses 2, 3, 4, 5. The choice of antibiotic regimen may depend on the specific clinical presentation, the presence of comorbidities, and the suspected causative organisms.

Key Findings

• Broad-spectrum antibiotic coverage, including single-agent broad-spectrum antibiotics such as cefoxitin, in conjunction with doxycycline, has efficacy equivalent to that of clindamycin-containing regimens in treating tuboovarian abscesses 5.
• Cefoxitin has a broad spectrum of activity, including activity against Bacteroides fragilis, making it suitable for prevention and treatment of intraabdominal and pelvic infections 6.
• The combination of cefoxitin and doxycycline has been shown to be effective in eradicating Chlamydia trachomatis, Neisseria gonorrhoeae, and anaerobic and aerobic bacteria in patients with PID 2, 3, 4.