A 28-year-old G2P2 presents to the hospital 2 weeks after vaginal delivery with a chief complaint of sudden onset heavy vaginal bleeding that soaks a sanitary napkin every hour. Her pregnancy was complicated by preterm labor, and she delivered precipitously at 26 weeks’ gestation. Her pulse is 89 beats per minute, blood pressure 120/76 mm Hg, and temperature 37.1°C (98.9°F). Her abdomen is nontender and her fundus is located above the symphysis pubis. On physical examination, you note active bleeding from the uterus, and you estimate a blood loss of 500 cc during the examination. Her uterus is about 12 to 14 weeks size and nontender. Her cervix is closed. An ultrasound reveals an irregularly thickened endometrial stripe. Her hemoglobin is 10.9 g/dL, unchanged from the one at her vaginal delivery. β-HCG is negative.
Which of the following is the most appropriate treatment for the cause of her vaginal bleeding?
Uterine hemorrhage after the first postpartum week is most often the result of retained placental fragments or subinvolution of the placental site. Risk factors for retained placenta include extreme prematurity, precipitous delivery, succenturiate lobe of the placenta, placenta accreta, and manual extraction of the placenta. Ultrasound can aid in the diagnosis, and when retained products of conception are present, the endometrial stripe may appear thickened and/or irregular. In some cases, if the cervix is open, this tissue may spontaneously expel. Surgery is required if the cervix is closed. The standard of treatment is dilation and curettage.
A 22-year-old G1P0 has just undergone a spontaneous vaginal delivery. As the placenta is being delivered, a red fleshy mass is noted to be protruding out from behind the placenta.
Which of the following is the best next step in management of this patient?
This patient has a uterine inversion. The most important first step is to summon assistance immediately, including an anesthesiologist. Next, discontinue any uterotonic agents, and ensure that the patient has adequate IV access and blood available if needed. The placenta should not be removed, as this may cause profound hemorrhage. Instead, attempts should be made to manually replace the inverted uterus into its normal position. Uterine relaxants such as nitroglycerine, terbutaline, or inhaled anesthetic agents may need to be given in order to aid attempts at manual replacement. Once the uterus is restored to its normal configuration, the placenta may be removed by waiting for spontaneous separation or by manual removal if indicated. After the placenta delivers, uterotonic agents should be given to enhance myometrial contraction and decrease the risk of uterine atony.
Three days ago you delivered a 40-year-old G1P1 by cesarean following arrest of descent after 2 hours of pushing. Labor was also significant for prolonged rupture of membranes. The patient had an epidural, which was removed the day following delivery. The nurse calls you to come to see the patient on the postpartum floor because she has a fever of 38.8°C (102°F) and is experiencing shaking chills. Her blood pressure is 120/70 mm Hg and her pulse is 120 beats per minute. She has been eating a regular diet without difficulty and had a normal bowel movement this morning. She is attempting to breastfeed, but says her milk has not come in yet. On physical examination, her breasts are mildly engorged and tender bilaterally. Her lungs are clear. Her abdomen is tender over the fundus, but no rebound is present. Her incision has some serous drainage at the right apex, but no erythema is noted.
Which of the following is the most likely diagnosis?
Endometritis, or infection of the uterus, is the most common infection that occurs after a cesarean delivery. A long labor and prolonged rupture of membranes are predisposing factors for endometritis. Other risk factors include chorioamnionitis, group b streptococcus colonization, manual removal of the placenta, and diabetes mellitus. In the presence of a pelvic abscess, usually signs of peritoneal irritation such as rebound tenderness, ileus, and decreased bowel sounds are present. Wound infections occur with an incidence of about 6% following cesarean deliveries. Fever usually begins on the fourth or fifth POD, and erythema around the incision along with purulent drainage is often present. Atelectasis can be a cause of postoperative fever, but the fever occurs generally in the first 24 hours. In addition, on physical examination, atelectasis is generally accompanied by decreased breath sounds at the lung bases on auscultation. It more commonly occurs in women who have had general anesthesia, not an epidural like the patient described here. SPT occurs uncommonly as a sequela of pelvic infection. Venous stasis occurs in dilated pelvic veins; in the presence of bacteria, it can lead to septic thromboses. Diagnosis is usually made when persistent fever spikes occur after treatment for endometritis. The patient usually has no uterine tenderness, and bowel function tends to be normal.
Which of the following is the most appropriate antibiotic to treat this patient with initially?
The etiology of endometritis, like that of all pelvic infections, is polymicrobial. Therefore, the antibiotic coverage selected should treat aerobic and anaerobic organisms. Common aerobes associated with metritis are staphylococci, streptococci, enterococci, Escherichia coli, Proteus, and Klebsiella. The anaerobic organisms associated with pelvic infections are most commonly Bacteroides, Peptococcus, Peptostreptococcus, and Clostridium. Generally, endometritis should be treated with intravenous broad-spectrum antibiotic coverage. Intravenous clindamycin (900 mg/8 h) plus gentamicin (1.5 mg/kg/8 h OR 5 mg/kg/24 h) is a commonly used effective therapy. The antibiotic therapy is generally continued until the patient has been afebrile for at least 24 hours. Oral therapy is not as effective as intravenous therapy, and is therefore not the most appropriate choice for treatment. Bactrim is a sulfa drug that is commonly given orally to treat uncomplicated urinary tract infections. Dicloxacillin is commonly used orally to treat women with mastitis because it has good coverage against S aureus, which is the most common organism responsible for this infection. Ciprofloxacin, a quinolone, is useful in the treatment of complicated urinary tract infections. This medication is not recommended for pregnant or lactating women because animal studies show an association of fluoroquinolones with cartilage damage and/or arthropathy.
After 48 hours of treatment, the patient remains febrile. What is the most appropriate next step in management?
Most patients should respond to intravenous antibiotic treatment for endometritis within 48 hours. If no improvement is noted, further investigation is warranted. Approximately 20% of treatment failures are due to resistant organisms such as enterococcus. Therefore, a reasonable next step in management is to add ampicillin to extend her antibiotic coverage. If she continues to remain febrile after adding ampicillin, it may be appropriate to evaluate for SPT ore pelvic abscess with CT or MRI.
Click to expand