When Antibiotics Were Not Enough
The following is a hypothetical situation designed to demonstrate a common form of medical error. It is not a real case, and no physician has reviewed it or offered an opinion about it.
Four days on the same plan
A woman of 29 came to an emergency department on a Monday at 9:20 in the morning. She had 5 days of pain in her lower pelvis and a fever. Her temperature was 101.4 and her pulse was 112. A pelvic examination was recorded as tender. An ultrasound performed on the outside of her abdomen, not internally, was read as normal. She was admitted at 2:40 that afternoon with pelvic inflammatory disease and started on I.V. antibiotics, with a white blood cell count of 18.6. On Tuesday morning her temperature was 99.8, she said the pain was better, and her count was 17.9. The plan was to continue the antibiotics. By Wednesday her temperature was back to 100.9, her pulse was 118, and her count was 18.4. On Thursday morning the pain was worse than on Tuesday, her pulse was 126, and her count was 19.6. Each morning the note said continue, and no imaging was repeated. At 9 that night her pulse was 138 and her blood pressure was 84 over 50. A scan showed a tubo-ovarian abscess that had ruptured, and surgery that night removed her right tube and ovary.
The short answer
A tubo-ovarian abscess is a pocket of pus involving a fallopian tube and an ovary. It usually starts as an infection that travels up from the cervix and walls itself off.
Antibiotics cure many of these. That is the part families are never told, and it is also why this condition is misdiagnosed. The common medical mistake in these cases is not a doctor choosing the wrong drug. It is a plan that never changed when the patient stopped getting better, and imaging that was never repeated to find out why.
There are two legal questions. Did the care fall below what a careful doctor, nurse, or hospital would have done? And would changing the plan when things turned have changed the outcome?
The rest of this page explains how to tell what happened in your case. Our guide to severe abdominal pain emergencies covers the other conditions that go wrong this way.
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Article written by Gregory Unatin, Esq. Greg is a managing partner in the law firm of Lupetin & Unatin, a medical malpractice law firm located in Pittsburgh and serving Western Pennsylvania.
Our practice is limited to high-value catastrophic cases because that is where we can do the most for our clients and for patient safety.
What a tubo-ovarian abscess actually is
Most of these begin as pelvic inflammatory disease, an infection that moves up from the cervix into the uterus, the tubes, and the ovaries. Antibiotics reach an infection spread through tissue reasonably well.
What changes the problem is walling off. The body contains the infection, and the result is a closed pocket of pus with a thick rim around it. Blood carries antibiotics to the rim of that pocket. It does not carry much into the center.
So a pocket can sit there while the patient looks like she is improving. The fever can come down because the infection in the surrounding tissue is responding while the pocket is not. That is not always what is happening, which is why the days that follow matter.
Two honest points. Not every one needs surgery, and many are cured with antibiotics alone. And not every one comes from a sexually transmitted infection. Some follow an infection next door, such as appendicitis, or a procedure.
Why a tubo-ovarian abscess gets missed
The mechanism of the miss here is unusual. The patient does get better. Then she stops, and the plan does not notice.
Pain low in the pelvis with a fever gets treated as pelvic inflammatory disease, and antibiotics are the treatment. Both of those are often correct. Then the temperature falls a degree, the patient says the pain is easier, and that is read as a positive response. That reading is fair on the first morning. What goes wrong is that it carries forward. The next note says continue the current treatment plan, and so does the one after that. Nobody asks whether something inside her cannot be reached by what she is getting.
Imaging gets misread in a specific way here. A pocket sitting deep in the pelvis can be missed by an ultrasound done only from the outside of the abdomen.
Then there are the tests for sexually transmitted infection. A negative result gets treated as ruling the infection out, when those tests look for only some of the organisms involved.
That mistake is understandable. Pelvic inflammatory disease is meant to be treated with antibiotics, and most patients who get them get well.
What is harder to defend is a chart where the numbers stopped supporting the story. A white count that rises. A pulse that climbs. A fever that comes back. And a plan that reads the same on day four as on day one.
The test that should have been done
A pregnancy test, first. A pregnancy outside the womb can look similar, and it is the more immediate danger. That test belongs at the front of every one of these.
The right kind of ultrasound. A complete pelvic ultrasound is normally done two ways. The probe on the outside gives the wide view and can show a large mass. The probe placed internally sits close to the tubes and the ovaries and shows them in far better detail. That is the study of choice here. A scan done only from the outside is incomplete rather than worthless. Where it shows nothing and the concern is still there, the internal study should follow. If the report does not say the study was done internally, that is worth asking about.
A scan with contrast dye. Ultrasound comes first for the pelvis. A scan with dye is generally used when appendicitis or another bowel condition is also possible, or when the ultrasound is unclear. It can find the pocket and show whether it has burst.
No blood test rules out a tubo-ovarian abscess, and the white count is useful as a trend rather than as a single number.
Whether the pocket needed draining from the start. Size drives this decision, which is why the measurement in a radiology report is worth finding. Small pockets are the ones most often cured by antibiotics alone. Large ones are where waiting tends to fail. In those, draining early is often the better first move. It is usually done with a needle guided by imaging rather than by an operation. The sizes commonly described are under about 5 centimeters for the first group, and 7 to 8 centimeters or more for the second. In a case like this one, if the abscess is never found, nobody measures it, and the decision about draining it never gets made.
What should have happened next. Once this diagnosis is suspected or made, the patient belongs in the hospital on antibiotics by vein. For many patients that is the only treatment needed. What comes with it is a scheduled reckoning, which the next section explains.
The clock
This condition runs on two clocks, and confusing them is why these cases get argued poorly.
Before the pocket bursts, the clock runs in days. That is the window where this is a manageable problem, and where the decision gets made.
The recognized point for judging that is usually described as 48 to 72 hours of antibiotics by vein. Somebody has to decide, against the examination and the laboratory trend, whether the treatment is working. That is why a single good morning does not end the inquiry. A plan never reassessed by the fourth day is hard to explain. The window is not a shield either, because a patient who is getting worse does not wait for it to close.
When the abscess bursts, the clock changes. Pus spills into the abdomen. That causes peritonitis, meaning infection of the lining of the belly, and it can cause septic shock within hours. At that point the treatment is emergency surgery.
Nobody can put a reliable number of hours or days on when one bursts. It depends on the wall, the pressure inside, and the organisms. The goal is to find it and drain it first.
In this case, the plan should have changed on Wednesday morning, when the fever returned, the pulse climbed, and the white count rose. Imaging and a drainage decision then would likely have found the abscess intact.
Who is at highest risk
- Prior pelvic inflammatory disease, the most relevant piece of history, and often sitting in an old chart.
- A recent procedure inside the uterus, including insertion of an intrauterine device, or a recent childbirth, miscarriage, or gynecologic surgery.
- A prior sexually transmitted infection.
- Diabetes or a weakened immune system, which can blunt the fever and the laboratory changes that would raise the alarm.
- Being past menopause. This is uncommon, and when it happens it calls for a look for an underlying gynecologic cancer.
This article on severe abdominal pain covers the broader risk factors across these emergencies.
What to look for in the records
These are things you can check or ask a lawyer to check.
- Whether a pelvic examination was performed, and what it recorded.
- The ultrasound report, and whether it says the study was performed internally or only on the abdomen.
- Whether anyone documented a decision at the 48 to 72 hour mark about whether the antibiotics were working, and whether imaging was repeated.
- The measured size of the pocket on any imaging, which is what the decision about draining should have turned on.
- The antibiotic record, showing what was given, by which route, and whether it was ever changed.
- The white count, the inflammatory markers, and the vital signs with their times, read as a trend.
- The daily progress notes, and whether the plan changed at any point or the same sentence was carried forward.
- The operative report, the cultures, and the pathology, which describe what the pocket had become.
The central question: should the plan have changed?
Admission with antibiotics by vein is the right first treatment, and most patients who get it do well. Draining a pocket carries its own risks, so waiting is not laziness. Accepted practice allows a stable patient 48 to 72 hours before the antibiotics are called a failure. A falling fever is the main way response gets judged. A defense expert will say the team followed accepted treatment and that hindsight turns a reasonable course into a negligent one. Sometimes that is right.
The two central questions remain. Did the care fall below what a careful doctor, nurse, or hospital would have done in the same situation? And would changing the plan when things turned have changed the outcome?
The argument here is not that this diagnosis is easy, or that antibiotics were the wrong idea. It is narrower. It is that the improvement stopped, the numbers turned, the window came and went, and the plan stayed the same. The medical evidence must then show that looking again would have found the pocket in time to drain it.
How people die from this, and what happens to those who survive
Most patients with a tubo-ovarian abscess who are found and treated in time recover, and many are cured with antibiotics alone.
When it goes the other way, it usually goes one of two ways. The more common is rupture leading to septic shock. Pus spreads through the abdomen, blood pressure stops responding, and organs fail. The other is death in the days after surgery, in a patient already in shock when it started. Death from this condition is uncommon, and it happens after rupture.
Among those who survive, the injuries that permanently change a life are these, most common first.
- Loss of the fallopian tube and the ovary on that side. An abscess that has destroyed those structures cannot be repaired. Many women conceive afterward with the other side. Some do not.
- Scarring that causes lasting pelvic pain and infertility, even where the organs were preserved. Infection damages the inside of a tube in ways no operation puts back.
- A later pregnancy that implants outside the womb, because a scarred tube is where those tend to implant. Our page on a ruptured ectopic pregnancy explains it.
- Removal of the uterus with both tubes and ovaries. This is uncommon, and happens where the disease is on both sides or cannot be controlled otherwise.
How we prove a case like this
A handful of records decide this condition.
The pelvic examination note and the ultrasound report establish what was looked at and how. Whether the ultrasound was done internally is often the first fact that changes a case. The antibiotic record shows what she was receiving, by which route, and whether anyone changed it. The vital signs and laboratory values show when the improvement stopped. The operative report and the pathology describe what the pocket had already done, which is how we work backward.
These cases usually need emergency medicine, obstetrics and gynecology, radiology, and infectious disease.
Pennsylvania also requires a licensed professional to certify that the care fell below the accepted standard before a case can move forward. This article on severe abdominal pain walks through the full investigation process.
Frequently Asked Questions
Because improving is not the same as improved. A falling fever is real evidence, and it is the main way doctors judge whether antibiotics are working. What it cannot do is settle the question. A walled off pocket of pus sits behind a rim that antibiotics do not cross well. The infection around it can respond while the pocket does not. The question is not whether she looked better on Tuesday. It is what happened when she stopped looking better, and whether anybody went back and checked.
Neither. How an infection started is not the question, and the standard of care does not change with the answer. A patient with an infection is owed the same attention wherever it came from. Not all of these come from a sexually transmitted infection. Families are often told this part first, and it is what keeps them from calling a lawyer.
No. The records that matter here, including nursing notes, laboratory logs with times, and imaging reports, are among the harder ones to get. We request the complete record ourselves.
No. An initial conversation is free, and so is our review of the case. We work on a contingency basis, which means a fee only if we recover money.
In Pennsylvania, a medical malpractice lawsuit must be filed in a proper court within two years of the date of death or in the absence of death, the date when the patient knew or should have known they suffered an injury which may have been related to health care. The practical point is that these cases turn on the times attached to laboratory values and imaging orders. Those details get harder to reconstruct over time.
What to do now
Gather what you have: discharge paperwork, any operative report, and the hospital name and dates. Then write down what you watched happen, day by day, while it is fresh. When she seemed better, and when she stopped. Families are usually the only source for the day the improvement stopped, and that day is the case. Then call us, or start with our guide to severe abdominal pain.