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Septic abortion and death (long case)From: Ricardo Savaris (rsavaris@hcpa.ufrgs.br)Fri Dec 12 14:26:22 2003
Dear all, I got a case at the ER last week. I would like to share with you, because of the bad outcome. 3:10 pm A 21 years old black patient arrived at the ER complaining of vaginal bleeding. LMP: 10/24/2003. She had used Cytotec 1 week ago (2 tb PO and 2 tb PV, and repeated once again). Story details were very few. Physical exam, was quite normal, except for light vaginal bleeding, enlarged uterus (+/- 8 weeks), painless. Cervix was closed We ordered a US, CBC, Blood type At 10:46 pm (patient run away from the ER and returned)Nobody knows what happened in the mean time. Patient arrived confused, not connected, seems that she had use some drug. We sent her to pelvic US, which had the following result: Dismorphic fetus, uterus about 10cm. No free fluid in the peritoneal cavity,ovaries normal CBC: Hb: 8,9 g/dL Leucocytes: 6900 rods6% 9:00am next day Sent to D&C, light bleeding after the procedure. She started with hipotension. Started IV fluids, oxytocin, ergotics. After that she was stable. 1:30pm Started with septic shock, IVCD. We prescribed gentamicin + Clindamicin + Penicilin IV, measure supports and sent to Intensive unit care. 4:00 pm IUC Patient with pulmonary failure, cardiac disfunction, hemodinamic unstable. IVCD. The IUC decided to use Cipro and Clindamicine. 9pm Sent to Operating Theather TAH + bilateral ooforectomy. Extense necrosis. Left a sponge inside the cavity because of the bleeding. Cardiac arrest during the surgery, reverted with standard measures. 5:45 am New cardiac arrest, reverted with life support measures 9 am High intrabdominal pressure,causing compartimental syndrome. Decided to reopen the patient. Unstable to surgery. 11 am Patient died Blood culture: Streptococcus mirelli. Send to the forensic medic for necropsy. No result yet. QUESTIONS Quite fast case. Any idea to clear our minds. I started to believe that s. mirelli was the problem, and the sepsis started after D&C. Nevertheless, I dont believe that using antibiotics before, although we had no indication to do so, would help. Here to know more from you Tour humble brazilian doctor
-- Ricardo Savaris, MD Back after a long period of silence
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