--
Richard Chudacoff, MD
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From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Gordon M.
Goldman
Sent: Tuesday, May 31, 2005 4:54 PM
To: Multiple recipients of list OB-GYN-L
Subject: Re: baffling case
Rick,
Don't know how useful this might be, but an old surgical saying is, pus
everywhere, pus nowhere, equals pus under the diaphragm. CT worthwhile?
Gordon
_____
From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of Richard
Chudacoff, MD
Sent: Tuesday, May 31, 2005 9:14 AM
To: Multiple recipients of list OB-GYN-L
Subject: baffling case
21 yo G1, GBS negative, admitted through the midwife service 12 days ago.
She arrested in dilation, after IUPC and FSE, and underwent an unremarkable
low transverse c-section via Pfannenstiel skin incision 10 days ago. 36
hours post-op she spike to 103 degrees F and hand a tender uterus, and was
started on Ampicillin, gentamycin and clindamycin (by the resident on call)
for post partum endomyometritis. 48 hours post op she was still febrile. ID
was consulted, after another exam which noted a still tender uterus and she
was switched to vancomycin and meropenem to cover MRSA as well as the
usually culprits. She has a history of IBD and grew out C. diff on stool
culture and was started on Flagyl. She also started taking scheduled Motrin
and Tylenol. She defervesced for 36 hours and the antibiotics were stopped,
except for the Flagyl, as were the anti-pyretics. 4 hours later she spiked
to 103. Antibiotics and anti-pyrectis were restarted. Pelvic U/S was
negative. KUB to r/o foreign body was negative. CT of pelvis was negative,
as was chest x-ray, blood cultures and urine culture (from the original
workup) and all subsequent cultures have been negative. She defervesed, and
was stable for 24 hours. Anti-pyrectics were stopped 48 hours ago, and she
then spiked again, despite being on anti-biotics. Repeat CT is negative, as
is repeat CXR. Doppler studies of the lower extremities are negative, with
great flow bilaterally. GI consults negative. No evidence of cardiac valve
abnormalities ruling out SBE.
I'm thinking that the only thing left to try is heparin for septic pelvic
thrombophelbitis or septic gonadal thrombophelbitis. I thought she might
have a drug fever, however she did spike after discontinuation of the wonder
drugs.
Any thoughts, pearls, questions, and acceptance of transfer to your service
would be appreciated.
Richard Chudacoff, MD, FACOG
Women's Specialists of Houston
6624 Fannin Suite 1800
Houston, TX, 77030
713-797-1144
713-425-3071
Email: Richard.Chudacoff@obgyn.net
rchudacoff.md@womenspecialists.com
This message is confidential, intended only for the named recipient(s) and
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