Abdominal computed tomography (CT) scan in the evaluation of refractory puerperal fever: impact on management.

Introduction: Computed tomography (CT) imaging should be employed judiciously, given its cost, use of intravenous contrast, and ionizing radiation. The aim of this study was to determine the clinical benefit of a CT scan in the evaluation of refractory puerperal fever and to identify the appropriate candidates for its use.Methods: This was a retrospective cohort study conducted in a single tertiary care center between January 2007 to April 2017. Indications for CT scan were refractory postpartum fever of ≥3 days and/or ultrasound findings suggesting complex abdominal fluid collection. Primary outcome was defined as a change in the mode of treatment due to the CT findings. In addition, a multivariate analysis of risk factors for puerperal fever was performed to identify patients who would benefit from the CT scan evaluation.Results: There were 520 women that underwent an abdominal and pelvic CT scan during the study period, 238 (45.7%) met inclusion criteria, 94 (39.5%) had a normal CT scan, and 144 (60.5%) had abnormal findings including 32 (13.4%) cases with pelvic thrombophlebitis and 112 (47%) cases with pelvic fluid collections. Results of the CT changed clinical management in 93 (39.0%) patients, including: switching antibiotics in 24 (10%) patients, adding low molecular weight heparin for 28 (11.8%) patients, and surgical intervention (laparotomy or drainage insertion) in 41 (17.2%) patients. In the regression model, we didn't find any significant risk factors associated with treatment change following the CT scan.Conclusions: Abdominal and pelvic CT scan in women with refractory puerperal fever has a high clinical yield and lead to a change in management in a substantial number of patients.

Disseminated tuberculosis after pregnancy progressed to paradoxical response to the treatment: report of two cases.

BACKGROUND: Early postpartum women are more likely to develop tuberculosis than nonpregnant women mainly due to immune reconstitution after delivery. Paradoxical response (PR) during antituberculosis treatment also arises via recovery from immunosuppression. However, no study focused on PR during antituberculosis treatment in a postpartum patient has been reported. CASE PRESENTATION: We present two sequential cases (Patient 1: 26-year-old; Patient 2: 29-year-old) of postpartum tuberculosis with pulmonary and extrapulmonary lesions (Patient 1: peritonitis; Patient 2: psoas abscess secondary to spondylitis). Both cases progressed to PR (worsening of pre-existing lung infiltrations (Patients 1, 2) and new contralateral effusion (Patient 2)) in a relatively short time after initiation of treatment (Patient 1: 1 week; Patient 2: 3 weeks), suggesting that immune modulations during pregnancy and delivery may contribute to the pathogenesis of both disseminated tuberculosis and its PR. The pulmonary lesions and effusion of both cases gradually improved without change of chemotherapy regimen. CONCLUSION: Physicians should recognize PR in tuberculosis patients with postpartum and then evaluate treatment efficacy.

Methicillin-resistant Staphylococcus aureus infections may not impede the success of ultrasound-guided drainage of puerperal breast abscesses.

BACKGROUND: Ultrasound-guided percutaneous drainage has been suggested in recent years to be the treatment of choice for breast abscesses. Although MRSA has recently been observed to be a significant causative pathogen in mastitis, reports dealing with ultrasound-guided drainage of breast abscess did not address the bacteriology of these infections. STUDY DESIGN: Between January 1 and December 31, 2007, 129 women were diagnosed with puerperal mastitis at Taipei City Hospital. Data were collected by retrospective chart review. Charts were surveyed for mastitis recurrence for at least 1 year after the initial infection treatment, through December 31, 2008. RESULTS: The most commonly identified organism was Staphylococcus aureus, present in 69 of 78 of bacterial isolates (88%). There were 52 of 78 (66%) bacterial isolates that were MRSA. Forty-seven of 52 (90%) women infected by MRSA underwent initial ultrasound-guided percutaneous abscess drainage. Among them, 11 (23%) women underwent subsequent conversion to surgical incision and drainage. Comparing women infected with MRSA and women infected with other pathogens, there was no statistical difference in the duration of treatment, number of outpatient follow-up visits, duration of antibiotics use, or abscess recurrence rates. CONCLUSIONS: MRSA is the most common bacteria in puerperal breast abscess in our population. When these patients are treated initially by percutaneous abscess drainage followed by repeated ultrasound-guided drainage or surgical incision and drainage, the presence of MRSA may not adversely affect treatment outcomes.

Postpartum appendicitis manifesting as umbilical purulence.

The diagnosis of abdominal pain is often difficult in the intrapartum and postpartum states. We describe an unusual case of postpartum appendicitis complicated by appendiceal rupture, abscess formation, and enterocutaneous umbilical drainage.

Donovanosis presenting as a pelvic mass mimicking ovarian cancer.

A 29-year-old female presented with chronic postpartum abdominal pain. Computerized tomography scan was consistent with ovarian carcinoma, and biopsy yielded macrophages laden with eosinophilic bodies. Cultures, histoplasma serologies, and taxoplasma serologies were negative. A diagnosis of pelvic donovanosis was reached; the patient was treated with azithromycin resulting in clinical and radiographic resolution.

Postpartum uterine arteriovenous fistula.

BACKGROUND: Uterine arteriovenous communications are uncommon lesions that may be associated with life-threatening postpartum and postinstrumentation hemorrhage. CASE: A primigravida presented with infected retained products of conception. Excessive hemorrhage of unclear etiology occurred at dilation and curettage. After a second episode of bleeding, the patient received a diagnosis of uterine arteriovenous fistula. CONCLUSION: Uterine arteriovenous communications should be included in the differential diagnosis in patients with excessive postpartum or postinstrumentation bleeding. Color and spectral flow Doppler can aid diagnosis and clinical management.

[Pain in the symphyseal region after parturition: possibly osteomyelitis]. / Pijnklachten in de symfyseregio na een bevalling: mogelijk osteomyelitis.

A 29-year-old woman 3 weeks after her first childbirth suffered from atypical and progressive pain in the pelvis, which turned out to be a symptom of osteomyelitis of the pubic bone. She recovered after treatment with antibiotics and 6 weeks' stabilization of the pelvis. Symptoms of osteomyelitis resemble those of pubic osteitis, symphyseal rupture and symphysiolysis. Radiologically, osteomyelitis is characterized by development of infiltrates, cortical involvement and local osteopenia. Isolation of micro-organisms in a bone culture after puncture is regarded as proof of the diagnosis. The treatment is primarily with antibiotics, if abscesses or sequestra develop these should be relieved and/or removed.

Non-surgical management of post-cesarean endomyometritis associated with myometrial gas formation.

We present a case of post-cesarean delivery, nonclostridial endomyometritis in which uterine (myometrial) gas formation raised concern for myonecrosis and need for hysterectomy. The patient fully recovered without surgery. Myometrial gas formation in this setting and in an otherwise stable patient may be an insufficient reason for hysterectomy.

Role of duplex color Doppler ultrasound, computed tomography, and MR angiography in the diagnosis of septic puerperal ovarian vein thrombosis.

BACKGROUND: Septic puerperal ovarian vein thrombosis (SPOVT) is one of the underlying etiologies of puerperal fever. A correct diagnosis of this condition is important because adequate treatment requires additional administration of anticoagulants. The purpose of this study was to evaluate the role of duplex color Doppler ultrasound (CDUS), computed tomography (CT), and magnetic resonance angiography (MRA) in the detection of SPOVT. METHODS: Twenty-six patients with puerperal fever suspected to be due to SPOVT and unresponsive to broad antibiotic treatment for at least 48 h were included in a prospective study using CDUS, CT, and MR imaging including MRA. Examinations were analyzed and then correlated to a standard of reference gathered from surgical and clinical follow-up data and from results of imaging. RESULTS: SPOVT was present in nine patients (right side n = 8, bilateral n = 1). CDUS was inconclusive due to gaseous distention of the bowel or obesity in 13 of 26 cases. After counting inconclusive findings as wrong results for statistical purposes, sensitivity, specificity, and accuracy for CDUS were 55.6%, 41.2%, and 46.2%, respectively. CT had a sensitivity of 77.8% with a specificity of 62.5%; accuracy was 68.0%. MRA rendered conclusive results in all evaluated patients, resulting in a sensitivity and specificity of 100%. CONCLUSION: MRA is recommended in all patients with inconclusive CDUS findings and persistent suspicion for SPOVT. CT has the advantage of more rapid access and lower cost and thus will probably remain a sufficiently accurate alternative. Septic puerperal ovarian vein thrombosis (SPOVT)-Computed tomography-Magnetic resonance angiography-Ultrasound.

Ross operation and mitral homograft for aortic and tricuspid valve endocarditis.

We report here a case of concomitant aortic and tricuspid valve endocarditis occurring in a 26-year-old woman 2 weeks after she had given birth by cesarean delivery. Preoperative transthoracic echocardiography revealed a previously undetected aorta-right atrium fistula, which at operation appeared to be congenital in origin. Surgical treatment consisted of aortic valve replacement with a pulmonary autograft, tricuspid valve replacement with a cryopreserved mitral homograft, and closure of the fistulous communication. The postoperative recovery was uneventful.

[Septic ovarian vein thrombosis. Conservative management with CT-controlled follow-up]. / Die septische Ovarialvenenthrombose (POVT). Konservatives Management mit CT-geführter Verlaufskontrolle.

Puerperal ovarian vein thrombophlebitis (POVT) is a rare complication during the puerperal period. A late diagnosis can lead to a high rate of morbidity and even mortality. By CT the POVT can be diagnosed early. This enables initiation of an adequate therapy with broad-spectrum antibiotics and i.v. anticoagulation well in time. In this way the disease can often be managed conservatively. CT controls can confirm the effectiveness of the therapy and are helpful in determining the duration of the i.v. anticoagulation.

Acute puerperal breast abscesses: US-guided drainage.

Breast abscesses typically develop in lactating women. The recommended treatment is surgical incision and drainage with the patient under general anesthesia. Ultrasonically guided percutaneous drainage with local anesthesia was performed in 19 consecutive patients referred for treatment because of clinical signs of acute puerperal breast abscess. Eighteen of the 19 patients (95%) were successfully treated. Long-term follow-up (median, 12 months) did not show any recurrences, and the cosmetic results were excellent. Eight of the 19 patients (42%) continued nursing during and after treatment. Ten of the 19 (53%) were treated on an outpatient basis. On the basis of these results, the authors recommend ultrasonically guided percutaneous treatment for use in patients with acute puerperal breast abscesses.