Rosh Women’s EOR (Answered) 125
Questions and Correct Answers, 100%
Correct. Fall 2024/2025.
30-year-old woman presents with pelvic pain and fever. She had a cesarean section 3 days prior to
presentation at 36 weeks gestation due to arrest of labor and prelabor rupture of
membranes. Her incision is clean and dry. She is tender in the lower abdomen, and foul-smelling
lochia is noted during pelvic examination.
Which of the following is the most important risk factor in the development of this condition?
A Cesarean section
B Maternal age
C Multiple internal examinations
D Prelabor rupture of membranes
E Preterm labor
Cesarean section
The patient has postpartum endometritis, for which a history of cesarean section is the most
important risk factor. This is an acute bacterial infection of the endometrium commonly caused by
group B Streptococcus, Staphylococcus aureus, Escherichia coli, and Enterococcus faecalis.
Endometritis classically occurs 2–3 days postpartum and is characterized by fever, foul-
smelling lochia, abdominal and pelvic pain, abnormal vaginal bleeding, uterine tenderness, and
leukocytosis.
The patient should have an ultrasound to rule out retained products of conception. They should be
started on intravenous broad-spectrum antibiotics and admitted to the hospital.
Most common postpartum infection
Risk factors: C-section, prolonged labor, prolonged ROM, chorioamnionitis, meconium-stained
amniotic fluid, maternal DM, GBS colonization
Etiology: polymicrobial (usually two to three aerobic and anaerobic species)
Early-onset disease (< 48 hours after delivery) or fever > 101.3°F
- Suspect Streptococcus pyogenes
Sx: fever, abdominal pain, foul-smelling lochia
PE: uterine tenderness and purulent drainage from the uterus
Labs: leukocytosis
Treatment is clindamycin + gentamicin
- GBS colonized: add ampicillin or use ampicillin-sulbactam
,Postpartum Endometritis
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What is the first-line intravenous antibiotic therapy for postpartum patients with endometritis?
Clindamycin and gentamicin.
21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and
fever. She estimates that she is approximately 7.5 months pregnant. On questioning,
she acknowledges intermittent pain for 2 days and a gush of fluid shortly after the pain
began. Her temperature is 101.8°F (38.8ºC). Physical examination is notable for purulent material in
the vaginal vault. Which of the following is the most likely diagnosis?
A Chorioamnionitis
B Endometritis
C Pelvic inflammatory disease
D Urinary tract infection
Chorioamnionitis
- Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are
at risk for infection.
Chorioamnionitis is an intraamniotic infection of the chorion and amniotic layers of the amniotic
sac.
The placenta and fetal membranes may also be involved. It is caused by an ascending infection of
normal vaginal flora.
Risk factors include premature rupture of membranes, preterm labor, prolonged rupture of
membranes, multiple vaginal examinations, and genital tract infections.
Clinical findings include fever, uterine tenderness, and maternal and fetal tachycardia.
,Women may also have purulent vaginal discharge on examination. This is a clinical diagnosis and
patients require intravenous antibiotics, most commonly ampicillin and gentamicin.
Infection, inflammation, or both of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
Previously known as chorioamnionitis
Risk factors: nulliparity, prolonged rupture of membranes, meconium-stained amniotic fluid, internal
fetal or uterine contraction monitoring
Most common cause is ascending genital tract infectionUsual pathogens: Mycoplasma
hominis, Ureaplasma urealyticum, E. coli, Gardnerella vaginalis, group B Streptococcus
Tx: ampicillin + gentamicin
Intraamniotic Infection or Triple I
What is the definition of preterm or premature labor?
Labor before 37 weeks. A delivery before 20 weeks is considered a miscarriage.
21-year-old woman presents to the ED with pelvic pain that has been worsening over the last 2 days.
She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin,
copious vaginal discharge, cervical motion tenderness, and a mass palpated in the left adnexa.
Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass.
Which of the following antibiotic regimens represents the most appropriate pharmacotherapy?
A Intravenous azithromycin and ceftriaxone
B Intravenous cefoxitin and doxycycline
C Intravenous vancomycin
D Oral ampicillin and clindamycin
E Oral ciprofloxacin and metronidazole
Intravenous cefoxitin and doxycycline
Intravenous cefoxitin and doxycycline are an appropriate antibiotic regimen for a patient with
a tubo-ovarian abscess (TOA). A TOA usually follows pelvic inflammatory disease (PID) and
infection with sexually transmitted infections, particularly Neisseria gonorrhoeae and Chlamydia
trachomatis. Antibiotic choices should target these organisms.
Recurrent pelvic infections and damaged adnexal tissue can predispose individuals to the formation
of a TOA. Pain may be accompanied by nausea, vomiting, or fever.
A pelvic ultrasound is the radiographic imaging study of choice and can show a complex
multiloculated fluid collection or mass. A CT scan may be preferred in some patients to rule out
other causes of a surgical or acute abdomen.
Antibiotics are the initial treatment for TOA in stable, premenopausal patients.
Treatment should also include gynecologic consultation, hospital admission, and intravenous
antibiotics. Patients with a large or ruptured abscess require urgent surgical intervention.
Most commonly caused by a complication of pelvic inflammatory disease
, Sx: lower abdominal pain, fever, vaginal discharge
PE: unilateral adnexal tenderness
Dx: pelvic ultrasound (complex, heterogenous adnexal mass with septations and thickened walls)
Tx: intravenous antibiotics, surgical drainage, or both
Tubo-Ovarian Abscess
What is an acceptable alternative regimen to treat PID in those with a severe allergic reaction to
penicillin?
Clindamycin and gentamicin.
64-year-old woman presents to the clinic for evaluation of pelvic pressure. She reports a sensation of
feeling like she is sitting on something, which improves when she lies down. Her medical history
includes hyperlipidemia treated with atorvastatin and hypertension treated with valsartan. Vital
signs are a blood pressure of 136/84 mm Hg, heart rate of 80 beats/minute, respiratory rate of 18
breaths/minute, oxygen saturation of 96% on room air, and a temperature of 98.8°F. On physical
exam, there is a palpable bulge in the posterior vaginal wall with the Valsalva maneuver. Which of
the following represents a common risk factor for the development of the suspected condition?
A Cesarean section delivery
B Current smoking
C Estrogen use
D Nulliparity
E Obesity
E Obesity
A rectocele is the anterior protrusion of the rectum secondary to a posterior vaginal wall
defect. Obesity is a common risk factor for the development of a rectocele. The most common
symptom of a rectocele is the need to manually splint the vagina, perineum, or rectum to have a
bowel movement. Other common symptoms include a sensation that something is falling out of the
rectum, which may be worsening with increased intra-abdominal pressure and relieved by lying
down, sexual dysfunction, pelvic pressure, and fecal incontinence.
Additional risk factors for development of a rectocele include vaginal childbirth, pelvic surgery,
collagen disorders, and advanced age.
Chronic constipation is associated with rectocele development because it is thought to increase the
intra-abdominal pressure and stretch the pudendal nerve. The diagnosis can typically be made on
physical exam by palpation of a posterior vaginal bulge with straining.
Imaging is not usually required for diagnosis. Management can be divided into nonsurgical and
surgical options.
The most effective nonsurgical option is the use of a pessary. Medications to address constipation
should also be used if this is a clinical feature of the patient’s disorder.
Questions and Correct Answers, 100%
Correct. Fall 2024/2025.
30-year-old woman presents with pelvic pain and fever. She had a cesarean section 3 days prior to
presentation at 36 weeks gestation due to arrest of labor and prelabor rupture of
membranes. Her incision is clean and dry. She is tender in the lower abdomen, and foul-smelling
lochia is noted during pelvic examination.
Which of the following is the most important risk factor in the development of this condition?
A Cesarean section
B Maternal age
C Multiple internal examinations
D Prelabor rupture of membranes
E Preterm labor
Cesarean section
The patient has postpartum endometritis, for which a history of cesarean section is the most
important risk factor. This is an acute bacterial infection of the endometrium commonly caused by
group B Streptococcus, Staphylococcus aureus, Escherichia coli, and Enterococcus faecalis.
Endometritis classically occurs 2–3 days postpartum and is characterized by fever, foul-
smelling lochia, abdominal and pelvic pain, abnormal vaginal bleeding, uterine tenderness, and
leukocytosis.
The patient should have an ultrasound to rule out retained products of conception. They should be
started on intravenous broad-spectrum antibiotics and admitted to the hospital.
Most common postpartum infection
Risk factors: C-section, prolonged labor, prolonged ROM, chorioamnionitis, meconium-stained
amniotic fluid, maternal DM, GBS colonization
Etiology: polymicrobial (usually two to three aerobic and anaerobic species)
Early-onset disease (< 48 hours after delivery) or fever > 101.3°F
- Suspect Streptococcus pyogenes
Sx: fever, abdominal pain, foul-smelling lochia
PE: uterine tenderness and purulent drainage from the uterus
Labs: leukocytosis
Treatment is clindamycin + gentamicin
- GBS colonized: add ampicillin or use ampicillin-sulbactam
,Postpartum Endometritis
Previous
Play
Next
Rewind 10 seconds
Move forward 10 seconds
Unmute
0:00
/
0:15
Full screen
Brainpower
Read More
What is the first-line intravenous antibiotic therapy for postpartum patients with endometritis?
Clindamycin and gentamicin.
21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and
fever. She estimates that she is approximately 7.5 months pregnant. On questioning,
she acknowledges intermittent pain for 2 days and a gush of fluid shortly after the pain
began. Her temperature is 101.8°F (38.8ºC). Physical examination is notable for purulent material in
the vaginal vault. Which of the following is the most likely diagnosis?
A Chorioamnionitis
B Endometritis
C Pelvic inflammatory disease
D Urinary tract infection
Chorioamnionitis
- Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are
at risk for infection.
Chorioamnionitis is an intraamniotic infection of the chorion and amniotic layers of the amniotic
sac.
The placenta and fetal membranes may also be involved. It is caused by an ascending infection of
normal vaginal flora.
Risk factors include premature rupture of membranes, preterm labor, prolonged rupture of
membranes, multiple vaginal examinations, and genital tract infections.
Clinical findings include fever, uterine tenderness, and maternal and fetal tachycardia.
,Women may also have purulent vaginal discharge on examination. This is a clinical diagnosis and
patients require intravenous antibiotics, most commonly ampicillin and gentamicin.
Infection, inflammation, or both of the amniotic fluid, placenta, fetus, fetal membranes, or decidua
Previously known as chorioamnionitis
Risk factors: nulliparity, prolonged rupture of membranes, meconium-stained amniotic fluid, internal
fetal or uterine contraction monitoring
Most common cause is ascending genital tract infectionUsual pathogens: Mycoplasma
hominis, Ureaplasma urealyticum, E. coli, Gardnerella vaginalis, group B Streptococcus
Tx: ampicillin + gentamicin
Intraamniotic Infection or Triple I
What is the definition of preterm or premature labor?
Labor before 37 weeks. A delivery before 20 weeks is considered a miscarriage.
21-year-old woman presents to the ED with pelvic pain that has been worsening over the last 2 days.
She reports vaginal discharge, nausea, and chills for the last week. Physical exam reveals thin,
copious vaginal discharge, cervical motion tenderness, and a mass palpated in the left adnexa.
Pregnancy test is negative. A pelvic ultrasound reveals a complex multiloculated left adnexal mass.
Which of the following antibiotic regimens represents the most appropriate pharmacotherapy?
A Intravenous azithromycin and ceftriaxone
B Intravenous cefoxitin and doxycycline
C Intravenous vancomycin
D Oral ampicillin and clindamycin
E Oral ciprofloxacin and metronidazole
Intravenous cefoxitin and doxycycline
Intravenous cefoxitin and doxycycline are an appropriate antibiotic regimen for a patient with
a tubo-ovarian abscess (TOA). A TOA usually follows pelvic inflammatory disease (PID) and
infection with sexually transmitted infections, particularly Neisseria gonorrhoeae and Chlamydia
trachomatis. Antibiotic choices should target these organisms.
Recurrent pelvic infections and damaged adnexal tissue can predispose individuals to the formation
of a TOA. Pain may be accompanied by nausea, vomiting, or fever.
A pelvic ultrasound is the radiographic imaging study of choice and can show a complex
multiloculated fluid collection or mass. A CT scan may be preferred in some patients to rule out
other causes of a surgical or acute abdomen.
Antibiotics are the initial treatment for TOA in stable, premenopausal patients.
Treatment should also include gynecologic consultation, hospital admission, and intravenous
antibiotics. Patients with a large or ruptured abscess require urgent surgical intervention.
Most commonly caused by a complication of pelvic inflammatory disease
, Sx: lower abdominal pain, fever, vaginal discharge
PE: unilateral adnexal tenderness
Dx: pelvic ultrasound (complex, heterogenous adnexal mass with septations and thickened walls)
Tx: intravenous antibiotics, surgical drainage, or both
Tubo-Ovarian Abscess
What is an acceptable alternative regimen to treat PID in those with a severe allergic reaction to
penicillin?
Clindamycin and gentamicin.
64-year-old woman presents to the clinic for evaluation of pelvic pressure. She reports a sensation of
feeling like she is sitting on something, which improves when she lies down. Her medical history
includes hyperlipidemia treated with atorvastatin and hypertension treated with valsartan. Vital
signs are a blood pressure of 136/84 mm Hg, heart rate of 80 beats/minute, respiratory rate of 18
breaths/minute, oxygen saturation of 96% on room air, and a temperature of 98.8°F. On physical
exam, there is a palpable bulge in the posterior vaginal wall with the Valsalva maneuver. Which of
the following represents a common risk factor for the development of the suspected condition?
A Cesarean section delivery
B Current smoking
C Estrogen use
D Nulliparity
E Obesity
E Obesity
A rectocele is the anterior protrusion of the rectum secondary to a posterior vaginal wall
defect. Obesity is a common risk factor for the development of a rectocele. The most common
symptom of a rectocele is the need to manually splint the vagina, perineum, or rectum to have a
bowel movement. Other common symptoms include a sensation that something is falling out of the
rectum, which may be worsening with increased intra-abdominal pressure and relieved by lying
down, sexual dysfunction, pelvic pressure, and fecal incontinence.
Additional risk factors for development of a rectocele include vaginal childbirth, pelvic surgery,
collagen disorders, and advanced age.
Chronic constipation is associated with rectocele development because it is thought to increase the
intra-abdominal pressure and stretch the pudendal nerve. The diagnosis can typically be made on
physical exam by palpation of a posterior vaginal bulge with straining.
Imaging is not usually required for diagnosis. Management can be divided into nonsurgical and
surgical options.
The most effective nonsurgical option is the use of a pessary. Medications to address constipation
should also be used if this is a clinical feature of the patient’s disorder.
