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Zorluk: OrtaLabor, Delivery, and Puerperium

A 31-year-old woman is evaluated on the maternity ward on postpartum day 2 for new-onset fever and pelvic pain. She delivered a full-term neonate via low transverse cesarean delivery following a diagnosis of active phase arrest. Her membranes were ruptured for 18 hours prior to the procedure. Over the last few hours, she has developed chills and worsening lower abdominal discomfort. Vital signs show a temperature of 39.2°C (102.6°F), blood pressure of 115/72 mm Hg, and heart rate of 110/min. Physical examination reveals clear lungs and soft, non-tender breasts. Abdominal examination demonstrates a soft abdomen with a well-approximated surgical incision that is free of erythema or induration. Deep palpation of the suprapubic region elicits marked uterine tenderness. The perineal pad contains a moderate amount of malodorous, purulent lochia. Urinalysis is unremarkable. Which of the following is the most appropriate next step in management?

  1. A
    Initiate intravenous ampicillin and gentamicin
  2. B
    Obtain a computed tomography scan of the abdomen and pelvis
  3. Initiate intravenous clindamycin and gentamicinCevap
  4. D
    Administer oral acetaminophen and continue routine postpartum care
  5. E
    Perform a lower extremity venous duplex ultrasound

Cevap

Initiate intravenous clindamycin and gentamicin
The correct answer is to initiate intravenous clindamycin and gentamicin. This patient has classic signs of postpartum endometritis: fever, uterine fundal tenderness, and purulent lochia on postoperative day 2 following a cesarean delivery. Postpartum endometritis is a polymicrobial infection. The combination of clindamycin and gentamicin provides the necessary broad-spectrum coverage, particularly against anaerobic organisms and gram-negative aerobes, which are the primary culprits.

Adım Adım Çözüm

1
Analyze the patient's clinical presentation and timing.
The patient is on postpartum day 2 with a high fever, marked uterine tenderness, and foul-smelling lochia following a cesarean delivery with prolonged rupture of membranes.
Identifying the timing and specific physical exam findings localizes the source of the postoperative fever.
2
Establish the most likely diagnosis.
The clinical picture is diagnostic for postpartum endometritis, the most common cause of puerperal fever.
Cesarean delivery and prolonged membrane rupture are major risk factors, and marked uterine tenderness is the hallmark clinical sign.
3
Determine the most appropriate pharmacologic intervention.
Select intravenous clindamycin and gentamicin.
This regimen provides the necessary broad-spectrum coverage for the polymicrobial (aerobic and anaerobic) etiology of the infection.

Anahtar Kavram

Postpartum endometritis diagnosis and management with broad-spectrum antibiotics covering aerobes and anaerobes.
Tahmini Süre:1m 15s
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Konular

Labor, Delivery, and Puerperium

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