A 27-year-old woman admitted with a right tubo-ovarian abscess is on intravenous ceftriaxone, doxycycline and metronidazole. On day 3 she develops sudden worsening pain, hypotension with BP 80/50 mmHg, pulse 130/min, and board-like rigidity of the abdomen. What is the next BEST step in management?
- A Immediate laparotomy with drainage and excision of the abscess ✓
- B Add vancomycin and observe for 24 hours
- C Repeat transvaginal ultrasound to reassess abscess size
- D Ultrasound-guided percutaneous catheter drainage
Correct answer: A. Immediate laparotomy with drainage and excision of the abscess
Explanation
Rupture of a tubo-ovarian abscess with septic shock and generalized peritonitis is a surgical emergency requiring immediate laparotomy, drainage, and usually hysterectomy with bilateral salpingo-oophorectomy in completed families, since mortality approaches 10 percent even with surgery. Percutaneous drainage suits an intact abscess failing antibiotics, not free rupture. Repeating imaging or escalating antibiotics alone delays definitive source control and risks death from sepsis.
Reference: Williams Gynecology, 4th ed.
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Written and medically reviewed by the StethoPrep medical team.