פוסט זה זמין גם ב:
עברית
Presentation of Case
Dr. Megan E. Bunnell (Obstetrics and Gynecology): A 31-year-old woman was admitted to this hospital 15 days after the birth of her first child because of abdominal pain and fever.
The patient had received routine prenatal care at this hospital. Serologic screening during the pregnancy showed immunity to rubella. Rectovaginal culture was positive for group B streptococcus. Tests for syphilis, hepatitis B virus surface antigen, gonorrhea, chlamydia, and human immunodeficiency virus were negative.
Sixteen days before this admission, the patient went into labor at 38 weeks 1 day of gestation. She was admitted to this hospital. The white-cell count was 13,800 per microliter (reference range, 4500 to 11,000), and the hemoglobin level was 14.0 g per deciliter (reference range, 12.0 to 16.0); treatment with intravenous penicillin was started. On hospital day 2, an epidural anesthetic agent was administered. Artificial rupture of the membranes revealed clear, odorless fluid, and infusion of oxytocin was started. Six hours after artificial rupture of the membranes, the patient gave birth to a healthy baby by vaginal delivery. Three minutes later, the placenta was delivered intact. Immediately after delivery, hemorrhage due to uterine atony occurred; there was an estimated blood loss of 500 ml. Bimanual massage of the uterus was performed, and oxytocin and methylergonovine were administered; hemostasis was subsequently achieved. A perineal laceration was repaired. The patient began breast-feeding, and on postpartum day 1, she was discharged.
Six days before the current admission, on postpartum day 9, pain in the left upper quadrant developed. The pain was dull, radiated to the left flank and back, and was worse with movement and deep breathing. The patient presented to a local urgent care clinic; urine was obtained for culture, and empirical treatment with amoxicillin–clavulanate was started.
Five days before this admission, on postpartum day 10, abdominal pain persisted, and a fever with a temporal temperature of 38.3°C developed. The patient sought evaluation in the emergency department of this hospital. She rated the abdominal pain at 10 on a scale of 0 to 10, with 10 indicating the most severe pain. A review of systems was notable for nausea and minimal lochia; there was no diarrhea, constipation, dysuria, hematuria, or breast tenderness.
Laboratory Data.
On examination, the abdomen was soft, and there was mild tenderness on palpation of the left upper quadrant, the uterine fundus, the suprapubic region, and the left costovertebral angle. Pelvic examination, including examination with the use of a speculum, revealed no dehiscence, drainage, or hematoma at the site of the perineal laceration repair and no discharge from the cervical os; there was mild cervical motion tenderness. The white-cell count was 20,700 per microliter. The level of hemoglobin was 11.4 g per deciliter. Blood cultures were obtained. The urine culture obtained at the urgent care clinic was positive for group B streptococcus. Other laboratory test results are shown in Table 1. Treatment with ceftriaxone was started, and the patient was admitted to the hospital for presumed pyelonephritis. On hospital day 3, when the fever and abdominal pain resolved, the patient was discharged home to complete a course of amoxicillin.
During the subsequent 2 days, the patient continued to take amoxicillin at home, but fever and abdominal and flank pain returned. On postpartum day 15, when the pain did not abate after she took acetaminophen, she returned to the emergency department of this hospital.
The patient’s medical history included high-grade cervical dysplasia that had led to a loop electrosurgical excision procedure 5 years earlier, as well as a ruptured ovarian cyst 3 years earlier and nephrolithiasis on the left side 5 months earlier. The patient had not been pregnant before the recent pregnancy; before this pregnancy, she had taken oral contraceptives for 12 years. She took prenatal vitamins, as well as polyethylene glycol, docusate, acetaminophen, and ibuprofen as needed. She had no known drug allergies. She lived with her husband and newborn infant in an urban area of New England and worked as an office manager. She did not smoke tobacco, drink alcohol, or use illicit drugs. Her mother had multiple sclerosis and her father had coronary artery disease; her brother was healthy.
On examination, the abdomen was soft, and there was mild tenderness in the left upper quadrant and at the left costovertebral angle. There was no tenderness on palpation of the uterine fundus or the suprapubic region and no cervical motion tenderness. The white-cell count was 10,330 per microliter. The hemoglobin level was 11.2 g per deciliter, the alanine aminotransferase (ALT) level 153 U per liter (reference range, 7 to 33), the aspartate aminotransferase (AST) level 44 U per liter (reference range, 9 to 32), and the alkaline phosphatase level 194 U per liter (reference range, 30 to 100). Other laboratory test results are shown in Table 1. The patient was admitted to this hospital. The next day, the hemoglobin level decreased to 9.7 g per deciliter.
Additional studies were performed, and a diagnosis was made.
