A 28-year-old nulliparous woman is evaluated in the hospital for persistent abdominal pain… — USMLE Step 2 CK

A 28-year-old nulliparous woman is evaluated in the hospital for persistent abdominal pain. Two days ago, she was admitted with severe bilateral lower abdominal pain, a temperature of $39.2^\circ\text{C}$ ( $102.6^\circ\text{F}$ ), and purulent cervical discharge. At that time, pelvic examination revealed extreme cervical motion tenderness and a palpable, tender fullness in the left adnexa. A transvaginal ultrasound demonstrated a $6\text{ cm}$ complex, multiloculated cystic mass in the left adnexa with thick walls and internal debris. She was diagnosed with a tubo-ovarian abscess and immediately started on intravenous cefoxitin and doxycycline.

Today ( $48\text{ hours}$ after admission), she reports her left lower quadrant pain has progressively worsened. Her temperature is $39.0^\circ\text{C}$ ( $102.2^\circ\text{F}$ ), blood pressure is $112/72\text{ mm Hg}$ , and pulse is $114\text{ /min}$ . Abdominal examination shows hypoactive bowel sounds and significant left lower quadrant tenderness with guarding, but no rebound tenderness. Her leukocyte count has increased from $16,500\text{ /mm}^3$ on admission to $21,000\text{ /mm}^3$ today. Which of the following is the most appropriate next step in management?

Ultrasound-guided percutaneous drainage of the adnexal massCevap
B
Exploratory laparotomy with left salpingo-oophorectomy
C
Broaden antibiotic coverage by switching to intravenous imipenem-cilastatin
D
Discontinue cefoxitin and initiate intravenous clindamycin and gentamicin
E
Continue the current antibiotic regimen and repeat pelvic ultrasound in 24 hours

Cevap

The most appropriate next step is ultrasound-guided percutaneous drainage of the adnexal mass.

The correct answer identifies that a tubo-ovarian abscess unresponsive to 48-72 hours of appropriate intravenous antibiotics requires minimally invasive drainage. The patient's worsening pain, persistent high fever, and rising leukocytosis clearly indicate medical failure, necessitating immediate source control to prevent frank rupture.

Adım Adım Çözüm

Evaluate the initial diagnosis and management.

The patient was correctly diagnosed with a tubo-ovarian abscess (TOA) and started on a guideline-concordant regimen of intravenous cefoxitin and doxycycline.

First-line management for a hemodynamically stable patient with an unruptured TOA less than 7-9 cm is hospitalization and intravenous broad-spectrum antibiotics.

Assess the patient's clinical trajectory over the standard observation period.

After 48 hours of medical therapy, the patient exhibits persistent high fever, worsening localized pain, and an increasing leukocyte count.

Patients receiving medical management for TOA must be closely monitored; lack of clinical improvement or frank deterioration within 48 to 72 hours defines medical failure.

Determine the appropriate intervention for a medically refractory TOA.

The patient requires physical source control of the abscess. Given her hemodynamic stability, minimally invasive drainage (ultrasound-guided percutaneous or laparoscopic) is preferred over exploratory laparotomy.

Drainage removes the infected fluid collection that antibiotics cannot fully penetrate, preventing life-threatening abscess rupture while preserving the adnexal structures in a nulliparous patient.

Anahtar Kavram

Management of a tubo-ovarian abscess (TOA) that fails to improve after 48-72 hours of broad-spectrum intravenous antibiotics requires prompt procedural intervention, ideally through minimally invasive image-guided or laparoscopic drainage.

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Cevap

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