A 29-year-old woman, G1P1, is evaluated on postpartum day 3 for a new-onset fever, chills,… — USMLE Step 2 CK

A $29$ -year-old woman, G1P1, is evaluated on postpartum day $3$ for a new-onset fever, chills, and lower abdominal pain. Three days ago, she underwent a primary low transverse cesarean delivery due to active phase arrest. Her membranes had been ruptured for $22$ hours prior to delivery. Her temperature is $39.0^\circ\text{C}$ ( $102.2^\circ\text{F}$ ), blood pressure is $112/72\text{ mmHg}$ , pulse is $112/\text{min}$ , and respirations are $18/\text{min}$ . Physical examination reveals soft, non-tender breasts without erythema. Her abdomen is soft. The cesarean incision is clean, dry, and intact, with no erythema, induration, or purulent drainage. Palpation of the uterine fundus elicits severe tenderness. Pelvic examination reveals a normal-appearing cervix with moderate, foul-smelling lochia. Which of the following is the most appropriate next step in the management of this patient?

Intravenous clindamycin and gentamicinAnswer
B
Intravenous ampicillin and gentamicin
C
Chest radiograph
D
Lower extremity venous Doppler ultrasound
E
Reassurance and observation

Answer

Intravenous clindamycin and gentamicin

This patient's clinical presentation of fever, uterine tenderness, and foul-smelling lochia on postpartum day

3

following a cesarean delivery is classic for postpartum endometritis. The primary risk factor is the cesarean delivery itself, compounded by her prolonged rupture of membranes and arrest of labor. The infection is typically polymicrobial, involving both aerobes and anaerobes. The gold-standard treatment for post-cesarean endometritis is broad-spectrum intravenous antibiotic therapy with clindamycin (covering anaerobes and Gram-positive cocci) and gentamicin (covering Gram-negative bacilli). Treatment is continued until the patient has been afebrile for

24

48

hours.

Step-by-Step Solution

Analyze the clinical presentation.

The patient is on postpartum day 3 after a cesarean delivery (with prolonged rupture of membranes) and presents with high fever, marked uterine tenderness, and foul-smelling lochia.

Identifying the timing of the fever and localizing signs is crucial for diagnosing the source of postpartum fever.

Determine the diagnosis.

The combination of fever, uterine fundal tenderness, and purulent lochia establishes the clinical diagnosis of postpartum endometritis.

Cesarean delivery, especially after prolonged membrane rupture and labor, is the most significant risk factor for polymicrobial endometritis.

Select the appropriate management.

Initiate empiric intravenous clindamycin and gentamicin.

Post-cesarean endometritis requires broad-spectrum coverage, including against anaerobes (e.g., Bacteroides species), which is provided by clindamycin, while gentamicin covers Gram-negative aerobes.

Key Concept

Postpartum endometritis is the most common cause of puerperal fever, presenting with uterine tenderness and foul lochia. It is treated with intravenous clindamycin and gentamicin.

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