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Abstract: The patient was overworked and had premature sexual intercourse after performing painless abortion and uterine removal surgery, which led to the patient’s symptoms of fever and pelvic pain, and the examination of routine blood leukocytes was significantly increased, which confirmed the diagnosis of pelvic inflammatory disease.
Basic information】Female, 23 years old
Type of disease】Pelvic pain
Hospital】Jiangbin Hospital of Guangxi Zhuang Autonomous Region
Time of consultation】May 2022
Treatment plan】Medication (Ceftriaxone sodium for injection + 0.9% sodium chloride injection + metronidazole injection)
Treatment period】7 days of inpatient treatment, 1 week of outpatient review
Treatment effect】The condition has been controlled after treatment, pelvic pain symptoms have been relieved, and all indicators have improved
I. Initial consultation
The patient reported that she had a painless abortion on April 14, 2022, and her vaginal bleeding was not cleared for 7 days after the operation. On May 10, she started to have mild lower abdominal pain, which was persistent, and on May 11, she had her menstrual period and the pain increased. She was diagnosed with pelvic inflammatory disease and was admitted to the hospital.
II. Treatment history
After admission, the temperature was measured at 38.3℃, and a gynecological examination was performed after sterilization. The pain of cervical elevation was obvious, and there was pressure pain in the uterus and both adnexal areas. It was explained to the patient that the patient’s body resistance and immunity are reduced after abortion and uterine removal surgery, which can easily lead to infection, while the patient did not take a good rest after surgery, went to work and had sex too early, which can lead to the proliferation of vaginal pathogenic bacteria, plus the opening of the uterus during menstruation, which can easily travel up to the uterus and pelvis, causing endometritis, adnexitis, pelvic inflammatory disease, resulting in pelvic pain, fever and other symptoms of infection. In severe cases, it can also lead to chronic pelvic pain and infertility, etc. The patient agreed to actively cooperate with the treatment. Immediately after admission, the patient was given intravenous infusion of antibiotics (ceftriaxone sodium for injection, 0.9% sodium chloride injection, metronidazole injection) and an ice pack to cool her down due to her high fever.
III. Treatment effect
After 3 days of treatment, the patient’s body temperature was 37.7℃, the abdominal pressure symptoms were reduced, the routine blood count was 14.65×10^9/L and the percentage of neutrophils was 85.1%, indicating that the treatment was effective, and the antibiotic treatment was continued. After 7 days of treatment, the patient’s body temperature was completely normalized, the routine blood count was 8.95×10^9/L and the percentage of neutrophils was 80.2%, and the painful cervical lifting and pressure pain in the uterus and adnexal area on gynecological examination were significantly reduced.
IV. Notes
My heart is still very relieved to see the patient normally discharged from the hospital. The patient was advised to strengthen nutrition, mainly with light and nutritious easy-to-digest food, more high-calorie, high-protein and high-vitamin food, and drink more water. Patients are advised to take more rest, not to work too hard, avoid sexual intercourse for 1 month and pay attention to personal hygiene, otherwise the infection will easily recur. Patients are advised to develop good living habits, ensure sufficient sleep, do not stay up late, combine work and rest, and appropriate exercise is recommended during the recovery period. Patients are advised to relax and not to be overly worried and anxious. Pelvic inflammatory disease, when adequately treated in time, usually does not produce significant sequelae.
V. Personal Insights
Women’s body resistance and immunity tend to decline after surgical operations such as abortion and uterine removal. At this time, they should take more rest, avoid straining, prohibit sexual intercourse, and pay attention to personal hygiene to prevent the occurrence of infections. After gynecological surgery, if the infection appears vaginitis, endometritis and other gynecological inflammatory diseases, you should actively seek medical treatment, early treatment is good, if you do not give attention to it, to the aggravation of the disease before considering medical treatment, prone to a series of complications, such as pelvic inflammatory disease, infertility, etc., to the female body and psychological will bring adverse effects.