241
MANAGEMENT OF OBSTETRIC AND GYNECOLOGIC INFECTIONS RESULTING FROM TRAUMA* WILLIAM J. LEDGER, M.D.t Professor of Obstetrics and Gynecology Director, Division of Maternal-Fetal Medicine Women's Hospital Los Angeles County-University of Southern California Medical Center Los Angeles, California
an rinll dille evice UR(( A l. proceduLr11eS. abortion, and pertforationI h iantt illnUries that (I Ut)) are the most prevalent obstetric and1 11e neclc1i'C C may result in soft-tissue infection. Diagnosis and treatment must be aggressive because the abundant bacterial flora of the lower genital tract can serve as the inoculum for serious soft-tissue pelvic infections. The large number of anaerobic organisms present contributes to the possibility of abscess formation if early antibiotic therapy is not appropriate and effective.
GENERAL CONSIDERATIONS Diagnosis. Infection should be suspected in any febrile patient with a history of surgery, of abortion, or of an IUD placement within the previous 10 to 14 days. Patients with infection caused from obstetricgynecologic injury frequently do not develop the dramatic, early spiking fever that we equate with serious infections. Such women may be asymptomatic for a week or 10 days after the abortion, IUD placement, or operation, and then develop a low-grade fever. Clear-cut signs of contamination are often not present. Had these women not been febrile, a discriminating examination, which mig ht have revealed a well-developed gynecologic infection or abscess, might not have been undertaken. On the other hand, early onset of high fever may sometimes develop within 48 hours of surgery or abortion. Possible causes are contaminated intravenous infusions, respiratory tract infections, or pelvic infections *Presented as part of a Symposium on Diagnosis and Management of Abdominal and Thoracic Trauma sponsored by the New York Hospital-Cornell Medical Center and the New York Academy of Medicine in cooperation with Science & Medicine Publishing Co., Inc., under a grant from Pfizer Laboratories, New York, N.Y., and held at the Cornell Medical Center on October 28,1978. tEffective January 1, 1979, Professor and Chairman, Department of Obstetrics and Gynecology,
The New York Hospital-Cornell Medical Center, New York, N.Y.
Vol. 55, No. 2, February 1979
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W.J. LEDGER
caused by either Group A or Group B ,-hemolytic Streptococcus. Fever that develops more than 48 hours after surgery is usually initiated by the procedure itself and, because most pathogens are endogenous, an appropriate incubation period is required before signs and symptoms of infection become evident. Treatmnenzt. In most obstetric-gynecologic infections, pathogens are usually mixed, and, in more than 70% of infections, anaerobes are involved. The most common organisms are Escherichia coli, enterococcus, the Group B f3-hemolytic and the anaerobic streptococci, and Bacteroides fragilis. Although a variety of antibiotics are available, none is a panacea effective against all organisms. Penicillin is effective against many infecting organisms, but it must be given in large intravenous doses for a long time to be effective against such pathogens as B. fragilis. Aminoglycosides, which are frequently administered along with penicillin, are not always effective in the acidic environment of pelvic infections. They have no effect on anaerobes and are not available in oral form. Clindamycin and chloramphenicol are effective against a broad spectrum of organisms, especially against the anaerobe B. fragilis, but potential toxicity limits their use to seriously ill patients. Chloramphenicol carries the risk of bone-marrow suppression, and clindamycin is associated with the hazard of pseudomembranous enterocolitis. The newer tetracyclines, such as doxycycline, are broad-spectrum antibiotics particularly effective against anaerobic organisms.1 These drugs are relatively safe and are especially recommended for patients who are not critically ill. Because doxycycline is excreted mainly by the gastrointestinal tract in patients with renal impairment, it is the only tetracycline that may also be administered to these patients without dosage adjustment. However, tetracyclines are not recommended for use during the last half of pregrilancy, infancy, and childhood to the age of eight years because there is a risk of enramel hypoplasia and permanent discoloration of the teeth. Further. tetracyclines are excreted in the milk of nursing mothers, and their slAety in breast-fed babies has not been established. Before antibiotic therapy is started, cultures should always be taken. If the patient does not respond to the initial treatment, culture and sensitivity test results will be available within two or three days, which allows more specific antibiotic therapy. Care must be taken in the collection of specimens, particularly when anaerobes are suspected, because the length of Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
243
their exposure to oxygen is critical to their growth. The use of oxygen-free gas tubes to transport the specimens to the laboratory will help in lengthening the amount of time in which the anaerobes remain viable. Another method to isolate anaerobic organisms utilizes a Gas Pak® to inoculate plates and initiate incubation at the bedside.2 In effect, the bedside use of an anaerobic jar brings the anaerobic laboratory to the patient. Immediate plating of specimens permits frequent recovery of anaerobes and quantitative isolation of organisms from the sites of infection. MANAGEMENT OF POSTOPERATIVE INFECTIONS
It is often difficult to evaluate a patient who becomes febrile within 48 hours of gynecologic surgery because diagnostic signs are often not evident in the early stage of infection. Physical examination may identify the origin of the infection, e.g., postoperative atelectasis may cause the fever, as in the patient just described. Early postoperative respiratory tract problems can usually be managed by deep breathing and coughing regimens and usually do not necessitate antibiotic therapy. But a patient may also become febrile within 48 hours of surgery because the operative site is infected. Patients who become febrile 48 hours or more after surgery may complain of fullness in the lower abdomen, and infected material may or may not be obtained from the vaginal cuff. Pelvic examination will often reveal marked induration, leading to the diagnosis of pelvic cellulitis (which is frequently caused by B. fragilis). Sometimes surgical intervention may become necessary to identify the site of infection, to establish drainage, or to remove infected tissue. The choice of an antibiotic depends on the severity of the illness and on the pathogens suspected of causing the infection. Patients undergoing either abdominal or vaginal hysterectomies are threatened with surface contamination by E. coli, B. fragilis, or the Group B f3-hemolytic streptococci. Because these operative procedures crush tissue, the drug selected should provide a high-tissue level of antibiotic. As already mentioned, cultures should be taken before antibiotic therapy is started so that results are available if the patient does not respond to the initial antibiotic selected. Patients who are not severely ill or those who are allergic to penicillin may be treated successfully with intravenous doxycycline. In a recent study comparing the efficacy of intravenous doxycycline with that of Vol. 55, No. 2, February 1979
244
244
W.J. LEDGER W.J.
LEDGER
intravenous cephalothin in patients with intra-abdominal and postoperative infections, good responses were seen in 74% of the patients treated with doxycycline, as compared to only 57% of those treated with cephalothin.' The usual regimen of doxycycline is 200 mg. intravenously in the first 12 hours and then 100 mg. intravenously every 12 hours. When the patient has been afebrile for 24 to 36 hours, she can be switched to oral doxycycline, 100 mg. twice a day for seven to 10 days. Case history of postoperative pelvic cellulitis. A 43-year-old white woman-5 ft. 3 in., 200 lb., gravida three, para four-underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy because of uterine leiomyomas (14 to 16 weeks in gestational size). At surgery fine adhesions were noted on both ovaries, and the left tube was clubbed. For the first 24 hours postoperatively the patient had a low-grade fever thought to be of respiratory origin. She was managed with deep breathing and coughing techniques. The patient became afebrile on the second postoperative day and remained so until the fourth postoperative day, when her temperature abruptly rose to 101.20F. and she also noted a loss of appetite. Results of a general physical examination were normal except for an elevated pulse rate commensurate with the temperature elevation. On pelvic examination there was no collection of fluid or blood in the vaginal cuff, but an indurated, tender area above the vaginal cuff was noted. Needle aspiration between the vaginal cuff and the peritoneal closure obtained less than I cc. of material, which was sent for culture. A tentative diagnosis of postoperative pelvic cellulitis was made. The patient was begun on 200 mg. of intravenous doxycycline for the first 12 hours, followed by 100 mg. every 12 hours.* The patient's response was dramatic, as she became afebrile within 24 hours of initiation of therapy. After 48 hours of intravenous administration the patient was switched to 100 mg. of oral doxycycline twice a day for the next seven days. She was discharged on her eighth postoperative day and was well at a follow-up examination four weeks later. The culture of the aspirate from the vaginal cuff had grown E. coli and B. fragilis, both of which were susceptible to doxycycline in the laboratory. SEPTIC ABORTION
Termination of pregnancy, whether induced or spontaneous, may be *Current maximum recommended dose: 200 mg. doxycycline on the first day, followed by 100 mg.
to 200 mg. daily.
Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
245
associated with infection. A septic abortion should be suspected in any pregnant woman who is febrile and bleeds during the first trimester. On pelvic examination the cervical os is open, and there may be evidence of passage of products of conception. High-spiking fevers and an unstable blood pressure are associated with a serious prognosis. Tenderness of the uterus, induration of extrauterine tissue, and evidence of peritoneal signs may indicate the need for abdominal exploration. Abdominal roentgenograms may reveal intraperitoneal or myometrial gas from either a perforated uterus or an extensive myometrial infection. If the abortion was performed in a hospital, operative intervention may not be necessary unless the uterine perforation was lateral rather than midline or a suction apparatus was involved in the perforation. However, when the abortion was performed under unknown circumstances, explorative laparotomy to assess the extent of uterine and possibly intraperitoneal damage may be indicated in a seriously ill patient. Incomplete abortion is always an indication for aggressive treatment because the threat of infection from retained tissue is always present. Although curettage will remove any remaining fetal tissue, this may introduce bacteria into the bloodstream. The resultant infections are therefore not always confined to the uterine lining and will often become systemic. Microbiologic studies by Rotheram and Schick have shown that in patients with septic abortion B. fragilis is one of the most commonly recovered anaerobes both in blood and in endocervical cultures.' Patients who are not critically ill from septic abortion do not require potent antibiotics, such as chloramphenicol or clindamycin, which are known to have toxic effects. Doxycycline, active against a wide range of Gram-positive and Gram-negative organisms, is usually effective in these patients, and its side effects are relatively milder. Case history of incomplete abortion. A 23-year-old woman-gravida two, para one-was in her 12th week of gestation when admitted to the emergency room because of the sudden onset of vaginal bleeding and cramping. Pelvic examination revealed a 3-cm. dilated endocervical os with products of conception present. Her uterus was tender, but no tenderness was present beyond the uterus. Her oral temperature was 1000F., her pulse was below 90 beats/min., and her blood pressure was within normal
limits. The products of conception were removed with ring forceps. The patient Vol. 55, No. 2, February 1979
246
24
LEDGER W.J. W.J LEGE
was treated with 200 mg. of intravenous doxycycline for the first 12 hours and followed by 100 mg. of intravenous doxycycline during the next 12 hours.* Curettage was performed two hours after initiation of antibiotic therapy. The patient was afebrile after the operative procedure and was switched to 100 mg. of oral doxycycline twice a day for seven days. Her recovery was uneventful, and she was discharged on the third hospital day.
IUD PERFORATION
Perforation by IUD may cause hematoma formation (either within the wall of the uterus or extrauterine), uterine infection, or an intraperitoneal infection, depending on the location and the extent of the perforation. If an infection has spread beyond the uterus, pelvic examination may reveal tenderness of the uterus and induration of extrauterine tissue. Management consists of removing the IUD, providing adequate drainage when necessary, and administering broad-spectrum antibiotics. As in all other infections, cultures should be taken before initial therapy is commenced. For the patient who fails to respond to systemic antibiotic therapy, as evidenced by continued spiking fevers, operative exploration is indicated to be certain that intraperitoneal abscess formation has not occurred. Case hiistory of IUD perforation. A 29-year-old woman had an IUD inserted six weeks after the birth of her second child. There was some difficulty with insertion: the uterus seemed deviated slightly to the left, and there was concern about the possibility of perforation because the strings had disappeared and could not be grasped by the snare forceps. The patient was immediately admitted to the hospital for observation. Because a mass on one side of the uterus, which was slightly tender on examination, was palpated, laparotomy was undertaken. Although the device and a small hematoma were found in the broad ligament, the threads were still inside the intrauterine cavity. However, the IUD was removed without difficulty. The patient developed a low-grade fever of 1000 to 1010F. about 48 hours after surgery. On examination some uterine tenderness was noted, but no masses were palpated. Because of the concern that there may have been an intraperitoneal infection and an endomyometritis associated with the insertion of and perforation by the IUD, the patient was started on intravenous doxycycline, 200 mg. for the first 12 hours, followed by 100 mg. every 12 hours intravenously.* The patient became afebrile within 36 *Current maximum recommended dose: 200 mg. to 200 mg. daily.
doxycytline on the first day, followed by
100 mg.
Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
247
hours and was switched to oral doxycycline 100 mg. twice a day for 12 days. The patient was discharged on the sixth postoperative day. Since there was no indication of an infection at the time of surgery, no cultures were obtained before the operation. However, once the patient became febrile and intraperitoneal infection was suspected, needle culdocentesis was performed prior to initiation of antibiotic therapy. No aerobes were recovered, but peptococci and peptostreptococci did grow; both were susceptible to doxycycline on tube-dilation analysis.
CONCLUSION Obstetric and gynecologic infections must be diagnosed and treated aggressively. Penicillin has probably been used by obstetricians and gynecologists most frequently because it is effective against many pathogens. But other broad-spectrum antibiotics, such as doxycycline, are also effective in treating patients with gynecologic infections who are not critically ill.
Discussion QUESTION: Dr. Ledger, do you use a gas antitoxin in peripferal sepsis? DR. LEDGER: We do not. Clostridial infections in obstetrics and gynecology have almost disappeared. Actually, the only situations in which we saw those problems in the past occurred beyond the 12th week of pregnancy in women with large pelvic organs, who used materials such as a soap solution-which cause tissue necrosis-to induce an abortion. Even in those situations-which we do not see anymore today-there was no good evidence that the antitoxins were of any benefit. The major objective is to remove the Mite of infection, and this can be done easily in female
patients. REFERENCES 1. Ledger, W. J.: Tetracyclines in gyneco- 4. Lazaro, E., Swaminathan, A. P., and logic infections. Bull. N. Y. Acad. Med. Louria, D.: Evaluation of intravenous 54:196-204, 1978. doxycycline in the treatment of intra2. Ledger, W. J., Norman, M., Gee, C., abdominal and post-surgical infections. J. and Lewis, W.: Bacteremia on an Abdom. Surg. /8:27, 1976. obstetric-gynecologic service. Am. J. 5. Rotheram, E. B. and Schick, S.F.: Obstet. Gynecol. 121:205, 1975. Nonclostridial anaerobic bacteria in septic 3. Ledger, W. J.:Infection in the Female. abortion. Am. J. Med. 46:80-89, 1969. Philadelphia, Lea & Febiger, 1977. *Current maximum recommended dose: 200 mg. doxycycline on the first day, followed by 100 mg. to 200 mg. daily.
Vol. 55, No. 2, February 1979
MANAGEMENT OF OBSTETRIC AND GYNECOLOGIC INFECTIONS RESULTING FROM TRAUMA* WILLIAM J. LEDGER, M.D.t Professor of Obstetrics and Gynecology Director, Division of Maternal-Fetal Medicine Women's Hospital Los Angeles County-University of Southern California Medical Center Los Angeles, California
an rinll dille evice UR(( A l. proceduLr11eS. abortion, and pertforationI h iantt illnUries that (I Ut)) are the most prevalent obstetric and1 11e neclc1i'C C may result in soft-tissue infection. Diagnosis and treatment must be aggressive because the abundant bacterial flora of the lower genital tract can serve as the inoculum for serious soft-tissue pelvic infections. The large number of anaerobic organisms present contributes to the possibility of abscess formation if early antibiotic therapy is not appropriate and effective.
GENERAL CONSIDERATIONS Diagnosis. Infection should be suspected in any febrile patient with a history of surgery, of abortion, or of an IUD placement within the previous 10 to 14 days. Patients with infection caused from obstetricgynecologic injury frequently do not develop the dramatic, early spiking fever that we equate with serious infections. Such women may be asymptomatic for a week or 10 days after the abortion, IUD placement, or operation, and then develop a low-grade fever. Clear-cut signs of contamination are often not present. Had these women not been febrile, a discriminating examination, which mig ht have revealed a well-developed gynecologic infection or abscess, might not have been undertaken. On the other hand, early onset of high fever may sometimes develop within 48 hours of surgery or abortion. Possible causes are contaminated intravenous infusions, respiratory tract infections, or pelvic infections *Presented as part of a Symposium on Diagnosis and Management of Abdominal and Thoracic Trauma sponsored by the New York Hospital-Cornell Medical Center and the New York Academy of Medicine in cooperation with Science & Medicine Publishing Co., Inc., under a grant from Pfizer Laboratories, New York, N.Y., and held at the Cornell Medical Center on October 28,1978. tEffective January 1, 1979, Professor and Chairman, Department of Obstetrics and Gynecology,
The New York Hospital-Cornell Medical Center, New York, N.Y.
Vol. 55, No. 2, February 1979
242
242
W.J. LEDGER
caused by either Group A or Group B ,-hemolytic Streptococcus. Fever that develops more than 48 hours after surgery is usually initiated by the procedure itself and, because most pathogens are endogenous, an appropriate incubation period is required before signs and symptoms of infection become evident. Treatmnenzt. In most obstetric-gynecologic infections, pathogens are usually mixed, and, in more than 70% of infections, anaerobes are involved. The most common organisms are Escherichia coli, enterococcus, the Group B f3-hemolytic and the anaerobic streptococci, and Bacteroides fragilis. Although a variety of antibiotics are available, none is a panacea effective against all organisms. Penicillin is effective against many infecting organisms, but it must be given in large intravenous doses for a long time to be effective against such pathogens as B. fragilis. Aminoglycosides, which are frequently administered along with penicillin, are not always effective in the acidic environment of pelvic infections. They have no effect on anaerobes and are not available in oral form. Clindamycin and chloramphenicol are effective against a broad spectrum of organisms, especially against the anaerobe B. fragilis, but potential toxicity limits their use to seriously ill patients. Chloramphenicol carries the risk of bone-marrow suppression, and clindamycin is associated with the hazard of pseudomembranous enterocolitis. The newer tetracyclines, such as doxycycline, are broad-spectrum antibiotics particularly effective against anaerobic organisms.1 These drugs are relatively safe and are especially recommended for patients who are not critically ill. Because doxycycline is excreted mainly by the gastrointestinal tract in patients with renal impairment, it is the only tetracycline that may also be administered to these patients without dosage adjustment. However, tetracyclines are not recommended for use during the last half of pregrilancy, infancy, and childhood to the age of eight years because there is a risk of enramel hypoplasia and permanent discoloration of the teeth. Further. tetracyclines are excreted in the milk of nursing mothers, and their slAety in breast-fed babies has not been established. Before antibiotic therapy is started, cultures should always be taken. If the patient does not respond to the initial treatment, culture and sensitivity test results will be available within two or three days, which allows more specific antibiotic therapy. Care must be taken in the collection of specimens, particularly when anaerobes are suspected, because the length of Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
243
their exposure to oxygen is critical to their growth. The use of oxygen-free gas tubes to transport the specimens to the laboratory will help in lengthening the amount of time in which the anaerobes remain viable. Another method to isolate anaerobic organisms utilizes a Gas Pak® to inoculate plates and initiate incubation at the bedside.2 In effect, the bedside use of an anaerobic jar brings the anaerobic laboratory to the patient. Immediate plating of specimens permits frequent recovery of anaerobes and quantitative isolation of organisms from the sites of infection. MANAGEMENT OF POSTOPERATIVE INFECTIONS
It is often difficult to evaluate a patient who becomes febrile within 48 hours of gynecologic surgery because diagnostic signs are often not evident in the early stage of infection. Physical examination may identify the origin of the infection, e.g., postoperative atelectasis may cause the fever, as in the patient just described. Early postoperative respiratory tract problems can usually be managed by deep breathing and coughing regimens and usually do not necessitate antibiotic therapy. But a patient may also become febrile within 48 hours of surgery because the operative site is infected. Patients who become febrile 48 hours or more after surgery may complain of fullness in the lower abdomen, and infected material may or may not be obtained from the vaginal cuff. Pelvic examination will often reveal marked induration, leading to the diagnosis of pelvic cellulitis (which is frequently caused by B. fragilis). Sometimes surgical intervention may become necessary to identify the site of infection, to establish drainage, or to remove infected tissue. The choice of an antibiotic depends on the severity of the illness and on the pathogens suspected of causing the infection. Patients undergoing either abdominal or vaginal hysterectomies are threatened with surface contamination by E. coli, B. fragilis, or the Group B f3-hemolytic streptococci. Because these operative procedures crush tissue, the drug selected should provide a high-tissue level of antibiotic. As already mentioned, cultures should be taken before antibiotic therapy is started so that results are available if the patient does not respond to the initial antibiotic selected. Patients who are not severely ill or those who are allergic to penicillin may be treated successfully with intravenous doxycycline. In a recent study comparing the efficacy of intravenous doxycycline with that of Vol. 55, No. 2, February 1979
244
244
W.J. LEDGER W.J.
LEDGER
intravenous cephalothin in patients with intra-abdominal and postoperative infections, good responses were seen in 74% of the patients treated with doxycycline, as compared to only 57% of those treated with cephalothin.' The usual regimen of doxycycline is 200 mg. intravenously in the first 12 hours and then 100 mg. intravenously every 12 hours. When the patient has been afebrile for 24 to 36 hours, she can be switched to oral doxycycline, 100 mg. twice a day for seven to 10 days. Case history of postoperative pelvic cellulitis. A 43-year-old white woman-5 ft. 3 in., 200 lb., gravida three, para four-underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy because of uterine leiomyomas (14 to 16 weeks in gestational size). At surgery fine adhesions were noted on both ovaries, and the left tube was clubbed. For the first 24 hours postoperatively the patient had a low-grade fever thought to be of respiratory origin. She was managed with deep breathing and coughing techniques. The patient became afebrile on the second postoperative day and remained so until the fourth postoperative day, when her temperature abruptly rose to 101.20F. and she also noted a loss of appetite. Results of a general physical examination were normal except for an elevated pulse rate commensurate with the temperature elevation. On pelvic examination there was no collection of fluid or blood in the vaginal cuff, but an indurated, tender area above the vaginal cuff was noted. Needle aspiration between the vaginal cuff and the peritoneal closure obtained less than I cc. of material, which was sent for culture. A tentative diagnosis of postoperative pelvic cellulitis was made. The patient was begun on 200 mg. of intravenous doxycycline for the first 12 hours, followed by 100 mg. every 12 hours.* The patient's response was dramatic, as she became afebrile within 24 hours of initiation of therapy. After 48 hours of intravenous administration the patient was switched to 100 mg. of oral doxycycline twice a day for the next seven days. She was discharged on her eighth postoperative day and was well at a follow-up examination four weeks later. The culture of the aspirate from the vaginal cuff had grown E. coli and B. fragilis, both of which were susceptible to doxycycline in the laboratory. SEPTIC ABORTION
Termination of pregnancy, whether induced or spontaneous, may be *Current maximum recommended dose: 200 mg. doxycycline on the first day, followed by 100 mg.
to 200 mg. daily.
Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
245
associated with infection. A septic abortion should be suspected in any pregnant woman who is febrile and bleeds during the first trimester. On pelvic examination the cervical os is open, and there may be evidence of passage of products of conception. High-spiking fevers and an unstable blood pressure are associated with a serious prognosis. Tenderness of the uterus, induration of extrauterine tissue, and evidence of peritoneal signs may indicate the need for abdominal exploration. Abdominal roentgenograms may reveal intraperitoneal or myometrial gas from either a perforated uterus or an extensive myometrial infection. If the abortion was performed in a hospital, operative intervention may not be necessary unless the uterine perforation was lateral rather than midline or a suction apparatus was involved in the perforation. However, when the abortion was performed under unknown circumstances, explorative laparotomy to assess the extent of uterine and possibly intraperitoneal damage may be indicated in a seriously ill patient. Incomplete abortion is always an indication for aggressive treatment because the threat of infection from retained tissue is always present. Although curettage will remove any remaining fetal tissue, this may introduce bacteria into the bloodstream. The resultant infections are therefore not always confined to the uterine lining and will often become systemic. Microbiologic studies by Rotheram and Schick have shown that in patients with septic abortion B. fragilis is one of the most commonly recovered anaerobes both in blood and in endocervical cultures.' Patients who are not critically ill from septic abortion do not require potent antibiotics, such as chloramphenicol or clindamycin, which are known to have toxic effects. Doxycycline, active against a wide range of Gram-positive and Gram-negative organisms, is usually effective in these patients, and its side effects are relatively milder. Case history of incomplete abortion. A 23-year-old woman-gravida two, para one-was in her 12th week of gestation when admitted to the emergency room because of the sudden onset of vaginal bleeding and cramping. Pelvic examination revealed a 3-cm. dilated endocervical os with products of conception present. Her uterus was tender, but no tenderness was present beyond the uterus. Her oral temperature was 1000F., her pulse was below 90 beats/min., and her blood pressure was within normal
limits. The products of conception were removed with ring forceps. The patient Vol. 55, No. 2, February 1979
246
24
LEDGER W.J. W.J LEGE
was treated with 200 mg. of intravenous doxycycline for the first 12 hours and followed by 100 mg. of intravenous doxycycline during the next 12 hours.* Curettage was performed two hours after initiation of antibiotic therapy. The patient was afebrile after the operative procedure and was switched to 100 mg. of oral doxycycline twice a day for seven days. Her recovery was uneventful, and she was discharged on the third hospital day.
IUD PERFORATION
Perforation by IUD may cause hematoma formation (either within the wall of the uterus or extrauterine), uterine infection, or an intraperitoneal infection, depending on the location and the extent of the perforation. If an infection has spread beyond the uterus, pelvic examination may reveal tenderness of the uterus and induration of extrauterine tissue. Management consists of removing the IUD, providing adequate drainage when necessary, and administering broad-spectrum antibiotics. As in all other infections, cultures should be taken before initial therapy is commenced. For the patient who fails to respond to systemic antibiotic therapy, as evidenced by continued spiking fevers, operative exploration is indicated to be certain that intraperitoneal abscess formation has not occurred. Case hiistory of IUD perforation. A 29-year-old woman had an IUD inserted six weeks after the birth of her second child. There was some difficulty with insertion: the uterus seemed deviated slightly to the left, and there was concern about the possibility of perforation because the strings had disappeared and could not be grasped by the snare forceps. The patient was immediately admitted to the hospital for observation. Because a mass on one side of the uterus, which was slightly tender on examination, was palpated, laparotomy was undertaken. Although the device and a small hematoma were found in the broad ligament, the threads were still inside the intrauterine cavity. However, the IUD was removed without difficulty. The patient developed a low-grade fever of 1000 to 1010F. about 48 hours after surgery. On examination some uterine tenderness was noted, but no masses were palpated. Because of the concern that there may have been an intraperitoneal infection and an endomyometritis associated with the insertion of and perforation by the IUD, the patient was started on intravenous doxycycline, 200 mg. for the first 12 hours, followed by 100 mg. every 12 hours intravenously.* The patient became afebrile within 36 *Current maximum recommended dose: 200 mg. to 200 mg. daily.
doxycytline on the first day, followed by
100 mg.
Bull. N.Y. Acad. Med.
OBSTETRIC AND GYNECOLOGIC INJURY
247
hours and was switched to oral doxycycline 100 mg. twice a day for 12 days. The patient was discharged on the sixth postoperative day. Since there was no indication of an infection at the time of surgery, no cultures were obtained before the operation. However, once the patient became febrile and intraperitoneal infection was suspected, needle culdocentesis was performed prior to initiation of antibiotic therapy. No aerobes were recovered, but peptococci and peptostreptococci did grow; both were susceptible to doxycycline on tube-dilation analysis.
CONCLUSION Obstetric and gynecologic infections must be diagnosed and treated aggressively. Penicillin has probably been used by obstetricians and gynecologists most frequently because it is effective against many pathogens. But other broad-spectrum antibiotics, such as doxycycline, are also effective in treating patients with gynecologic infections who are not critically ill.
Discussion QUESTION: Dr. Ledger, do you use a gas antitoxin in peripferal sepsis? DR. LEDGER: We do not. Clostridial infections in obstetrics and gynecology have almost disappeared. Actually, the only situations in which we saw those problems in the past occurred beyond the 12th week of pregnancy in women with large pelvic organs, who used materials such as a soap solution-which cause tissue necrosis-to induce an abortion. Even in those situations-which we do not see anymore today-there was no good evidence that the antitoxins were of any benefit. The major objective is to remove the Mite of infection, and this can be done easily in female
patients. REFERENCES 1. Ledger, W. J.: Tetracyclines in gyneco- 4. Lazaro, E., Swaminathan, A. P., and logic infections. Bull. N. Y. Acad. Med. Louria, D.: Evaluation of intravenous 54:196-204, 1978. doxycycline in the treatment of intra2. Ledger, W. J., Norman, M., Gee, C., abdominal and post-surgical infections. J. and Lewis, W.: Bacteremia on an Abdom. Surg. /8:27, 1976. obstetric-gynecologic service. Am. J. 5. Rotheram, E. B. and Schick, S.F.: Obstet. Gynecol. 121:205, 1975. Nonclostridial anaerobic bacteria in septic 3. Ledger, W. J.:Infection in the Female. abortion. Am. J. Med. 46:80-89, 1969. Philadelphia, Lea & Febiger, 1977. *Current maximum recommended dose: 200 mg. doxycycline on the first day, followed by 100 mg. to 200 mg. daily.
Vol. 55, No. 2, February 1979
