tommyk
04-10-2006, 11:00 AM
Hy 2124
22-year-old woman in labor named Gisele progresses to 7 cm dilation, and then has no further progress. Thus, you give her a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (103.9 F), blood pressure of 115/70 mm Hg, pulse of 90/min, and respirations of 14/min. She is having chills as well and vaginal discharge. PLEASE HELP HER!
(REMEMBER TO ALWAYS GO THROUGH REVIEW OF SYSTEMS): Her lungs are clear to auscultation bilaterally. Her abdomen with her navel ring is moderately tender. The incision for the C-section is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?
1-NSAIDS
2-Acetaminophen-oxycodone (T3)
3-Clindamycin
4-Gentamycin
5-Metronidazole
6-Clindamycin-Metronidazole
7-Clindamycin-Gentamycin
8-Reassurance
a) Answer is #7. This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin and ampicillin-gentamicin fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. BUT, Clindamycin-metronidazole and metronidazole have good activity against anaerobic organisms, but fail to cover gram-negative organisms. Therefore Clinda-Gentamycin will work here. Very tricky, but if you think it through slowly and carefully, it makes PERFECT SENSE. Revisit this concept later as it is so important.
22-year-old woman in labor named Gisele progresses to 7 cm dilation, and then has no further progress. Thus, you give her a primary cesarean section. Examination 2 days after the section shows a temperature of 39.1 C (103.9 F), blood pressure of 115/70 mm Hg, pulse of 90/min, and respirations of 14/min. She is having chills as well and vaginal discharge. PLEASE HELP HER!
(REMEMBER TO ALWAYS GO THROUGH REVIEW OF SYSTEMS): Her lungs are clear to auscultation bilaterally. Her abdomen with her navel ring is moderately tender. The incision for the C-section is clean, dry, and intact, with no evidence of erythema. Pelvic examination demonstrates uterine tenderness. Which of the following is the most appropriate pharmacotherapy?
1-NSAIDS
2-Acetaminophen-oxycodone (T3)
3-Clindamycin
4-Gentamycin
5-Metronidazole
6-Clindamycin-Metronidazole
7-Clindamycin-Gentamycin
8-Reassurance
a) Answer is #7. This patient has signs and symptoms that are most consistent with endometritis. Postpartum endometritis is believed to result from organisms ascending from the vagina and causing a polymicrobial infection of the endometrium. Infection may also involve the myometrium and parametrial tissues. Patients with endometritis typically present with fever and chills, lower abdominal pain, a foul-smelling vaginal discharge, and malaise. Examination is significant for fever, abdominal tenderness, and uterine tenderness. Cesarean section is the major risk factor for postpartum endometritis. Patients undergoing cesarean section have a several-fold higher risk of developing endometritis compared with those having a vaginal delivery. The treatment of choice for endometritis following a cesarean section must include anaerobic coverage, along with gram-positive and gram-negative coverage. Therefore, the treatment of choice is clindamycin and gentamicin. Ampicillin and ampicillin-gentamicin fail to cover the anaerobic organisms that play an important role in the pathophysiology of post-cesarean section endometritis. BUT, Clindamycin-metronidazole and metronidazole have good activity against anaerobic organisms, but fail to cover gram-negative organisms. Therefore Clinda-Gentamycin will work here. Very tricky, but if you think it through slowly and carefully, it makes PERFECT SENSE. Revisit this concept later as it is so important.