REPORTING FROM THE PREGNANCY MEETING
DALLAS (FRONTLINE MEDICAL NEWS) – Abdominal CT scans changed therapeutic management in 39% of women being unsuccessfully treated for refractory puerperal fever, a retrospective study has determined.
The scans pinpointed a definite diagnosis in the majority of the cohort, allowing clinicians to reassess their treatment, Michal Fishel-Bartal, MD, said at the meeting sponsored by the Society for Maternal-Fetal Medicine.
“This study has important clinical implications for women with refractory puerperal fever,” said Dr. Fishel-Bartal of the Chaim Sheba Medical Center, Ramat Gan, Israel. “Our department now recommends that all women with refractory puerperal fever should undergo an assessment for risk factors, including urgent cesarean section, preterm delivery, and general anesthesia, and an evaluation to see if an abdominal CT may be appropriate to investigate the possibility of septic pelvic thrombophlebitis or the need for intra-abdominal drainage.”
She and her colleagues conducted a 10-year retrospective review of refractory puerperal fever cases at Chaim Sheba Medical Center. All of the patients had a CT scan within 7 days of their delivery. A radiologist reviewed each scan, looking for potential causes of the illness, including pelvic collection (a suspected pelvic abscess or collection of 4 cm or more) or signs of septic pelvic thrombophlebitis (enlargement of an involved vein, vessel wall enhancement, or a filling defect).
The primary outcome was a treatment change due to the CT results. These included switching antibiotics, starting therapeutic low-molecular-weight heparin, or a surgical intervention (intra-abdominal drainage or laparotomy).
The cohort comprised 238 women, who were a mean age of 33 years. In comparing them with the hospital’s background population, they were significantly more likely to have delivered at less than 37 weeks (25% vs. 7%), and to have had a cesarean delivery (80% vs. 25%). Dr. Fishel-Bartal also noted that 29% of the patients had experienced general anesthesia.
Most of the scans (144; 60%) were abnormal. Findings included septic pelvic thrombophlebitis (32) and pelvic collections (112). Treatment changed in 93 women (39% of the entire cohort). Changes included adding or switching antibiotics (24), adding low-molecular-weight heparin (28), laparotomy (11), and drainage insertion (30).
The investigators also performed a multivariate analysis to identify any risk factors that significantly predicted the need to change or add treatment. General anesthesia was the only factor significantly more common among those who needed a treatment switch (70% vs. 58%). This could have been a marker for an urgent C-section – something often associated with complications, Dr. Fishel-Bartal noted.
In the discussion period, Dr. Fishel-Bartal fielded a question about whether ultrasound would be a more logical and cost-effective method of assessing these patients.
“We actually do usually start with an ultrasound evaluation in our patients with refractory puerperal fever, and 68% of this group did have one,” Dr. Fishel-Bartal replied. “Findings were positive in 37%. The ultrasound actually was very good at predicting pelvic collections, but it only identified 5 of the 32 with septic thrombophlebitis. So it’s a good modality to start with, but if the patient still has fever or there is a concern for septic pelvic thrombosis, you really still need a CT.”
She had no financial disclosures.
SOURCE: Fishel-Bartal M et al. The Pregnancy Meeting. Am J Obstet Gynecol. 2018;218:S59 .
