DIC PUERPERRAL SEPSIS

1. DICPUERPERRAL SEPSIS Prof. Mohamed Khalil, MD, MRCOG. Security Forces Hospital

2. Puerperal sepsis • Bacterial infection of genital tract after delivery. • Fibrile morbidity: is an oral temp of >=38degrees on any 2 of the first 10 days postpartum , exclusive of the first 24h • Organism : polymicrobial 60% facultative gram +ve and gram –ve bacteria 40% anaerobes 30% mycoplasmas Chlamydia trachomatis is associated with late onset of symptoms (2 or more weeks after delivery) Sexually transmitted ( neiseriagonorrhoea , chlamydia) are uncommon causes of postpartum endometritis • Mode of infection: Exogenous: external sources Endogenous: organism already present in genital tract-anaerobic streptococci. Autogenous: from septic focus in the patient

3. Puerperal sepsis • Predisposing factors General causes: anaemia, diabetes, repeated vaginal examination Local causes: ROM, laceration, retained placenta Cesarean section is the most important risk factor for postpartum endometritisespecialy if performed after the onset of labor Endometritis after emergency CS =11% VS 1.7% after elective CS with prophylactic antibiotic Endometritis after emergency CS =28% VS 3.5% after elective CS without prophylactic antibiotic Endometritis after vaginal birth=3% • Site of infection: Primary: laceration, placental bed, retained tissue Secondary: tubes, ovaries, peritonium, parametrium, pelvic veins

4. Risk factors for postpartum endometritisThe endometrium is the commonest site of puerperal sepsis ●Chorioamnionitis ●Prolonged labor ●Prolonged rupture of membranes ●Multiple cervical examinations ●Internal fetal or uterine monitoring ●Large amount of meconium in amniotic fluid ●Manual removal of the placenta ●Low socioeconomic status ●Maternal diabetes mellitus or severe anemia ●Preterm birth ●Operative vaginal delivery ●Postterm pregnancy ●HIV infection ●Colonization with group B streptococcus

5. pathology • Localized= putrid endometritis= mild form Infection is limited to the superficial layer of endometrium • Spreading=septic endometritis= severe form

6. Clinical picture • The diagnosis of postpartum endometritis is clinical and largely based upon the presence of postpartum fever that cannot be attributed to another etiology after a thorough history and physical examination • Infected tears: local pain , mild fever, dysuria • Endometritis: fever in the 3rd day, lower abdominal pain , tender uterus, offensive excessive lochia • Septicaemia: 3rd or 4th day, high temp, pulse rapid, lochi is scanty and not offensive • Salpingooophoritis: • Parametritis: 2nd week • Peritonitis • Pelvic thrombophlebitis: 2nd week, mild fever,

7. Endometritis with toxic shock syndrome •  It is rare, • Clostridia, streptococci, and staphylococci can lead to endometritis with toxic shock syndrome and other serious complications (eg, necrotizing myometritis, necrotizing fasciitis) • Group A streptococcus (GAS) (eg, Streptococcus pyogenes) infection should be suspected in patients with early onset, high fever. • High fever with hypotension and involvement of at least two other organ systems (eg, renal, liver, or pulmonary insufficiency; coagulopathy; soft tissue necrosis; erythematous macular rash with desquamation) suggests toxic shock syndrome. • With necrotizing myometritis, the uterus may be boggy and non tender due to diminished innervation

8. Differential diagnosis — In women with postpartum fever, but no or minimal uterine tenderness or purulent vaginal discharge, other sources of postpartum fever should be considered • Some of these disorders can be diagnosed or excluded by history and physical examination alone; in the remainder, laboratory and/or imaging studies will clarify the diagnosis. • Surgical site infection • Mastitis or breast abscess • Pyelonephritis • Aspiration pneumonia • Unexplained fever with significant back pain after a neuraxial anesthetic • Pseudomembranous colitis due to Clostridium difficile • Any disorder associated with fever, such as appendicitis or viral syndrome,

9. Differential diagnosis — In women with postpartum fever, but no or minimal uterine tenderness or purulent vaginal discharge, other sources of postpartum fever should be considered • Some of these disorders can be diagnosed or excluded by history and physical examination alone; in the remainder, laboratory and/or imaging studies will clarify the diagnosis. • Surgical site infection (cesarean delivery incision, episiotomy incision, perineal lacerations) is typically evident on physical examination of the surgical site (eg, local erythema, edema, and/or tenderness). • Mastitis or breast abscess is typically evident on physical examination of the breast (eg, local erythema, edema, and/or tenderness) • Pyelonephritis is characterized by fever (>38ºC), chills, flank pain, costovertebral angle tenderness, and possibly lower urinary tract symptoms. Pyuria and/or a positive urine culture support the diagnosis.

10. Differential diagnosis — In women with postpartum fever, but no or minimal uterine tenderness or purulent vaginal discharge, other sources of postpartum fever should be considered • Aspiration pneumonia presents with fever, dyspnea, and possibly hypoxemia. Lung auscultation may reveal diffuse crackles and a chest radiograph will show infiltrates. • Unexplained fever with significant back pain after a neuraxial anesthetic, especially when accompanied by neurologic symptoms, may be due to infection or inflammation of the spinal cord. Consultation with the anesthesia and neurology services is indicated • Pseudomembranous colitis due to Clostridium difficile is a rare, but potentially serious, cause of postpartum fever. It should be considered in postpartum women who have low-grade fever, abdominal and gastrointestinal symptoms, and recent antibiotic exposure • Any disorder associated with fever, such as appendicitis or viral syndrome, can present with fever in the postpartum period. Clinical findings guide the diagnostic evaluation and differential diagnosis.

11. Investigation • Laboratory studies are of limited value: • CBC+ Diff WCC: A rising neutrophil count associated with elevated numbers of bands is suggestive of infection. • Cervicovaginal swab: • Endometrial cultures are not useful. • Blood cultures can be useful in guiding antimicrobial treatment if the patient fails to respond to empiric therapy • MSU , culture sensitivity • Ultrasound • ? X ray chest, widal test, blood film for malaria

12. Treatment • Prophylactic: During pregnancy: tttanaemia During labour: aseptic condition, VE <, antibiotic if SROM > 18H, complete delivery of placenta, Puerperium: avoid hospital acquired infection,

13. Treatment • General measures • Antibiotic • Drainage : fowler, semi sitting, or underguide of ultrasound • Heparin for pelvic vein thrombosis

14. Treatment • Broad spectrum parenteral antibiotics that include coverage for beta-lactamase producing anaerobes. • Oral antibiotics are an option for mild endometritis diagnosed after the woman has been discharged, especially those post vaginal birth • Clindamycin (900 mg intravenously every eight hours) plus gentamicin is a commonly used, effective regimen: cure rates are 90 to 97 percent • The gentamicin dose is (5 mg/kg every 24 hours) is more convenient and cost-effective and as efficacious and safe as three daily dosing (1.5 mg/kg intravenously every eight hours) for patients with normal renal function • For patients with renal dysfunction, reasonable alternatives to gentamicin include ampicillin-sulbactam (1.5 g every six hours)

15. Drug treatments reported to be equivalent to clindamycin plus gentamicin include cefotetan, cefoxitin, ceftizoxime, piperacillin with or without tazobactam, and ampicillin and sulbactam. • Sulbactam inhibit beta bacteria lactamase • Lactamase enzyme breaks down ampicillin • These drugs, particularly ampicillin and sulbactam, are used as the initial antibiotic choice in some hospitals. • Metronidazole provides good activity against most anaerobes and can be useful with ampicillin and gentamicin, but is not the preferred choice for breastfeeding women if a drug with a better safety profile is available.

16. Duration of treatment • Continue treatment until the patient is clinically improved (no fundal tenderness) and afebrile for at least 24 hours. • Oral antibiotic therapy after successful parenteral treatment is not required, as randomized trials have shown that it does not improve outcome. • However, if bacteremia was present as indicated by a positive blood culture, we suggest oral antibiotic therapy after discontinuation of parenteral antibiotics to complete a seven-day total course of antibiotic therapy

17. Causes of persistent postpartum fever  • A response to the initial antibiotic regimen should be evident within 48 to 72 hours. • Resistant organisms • Infected hematoma, • Pelvic cellulitis or abscess, • Surgical site infection, • Septic pelvic thrombophlebitis, • Ovarian vein thrombosis, • Myometrial necrosis

18. DIC • Normal fibrinogen 400-600mg% • Bleeding from DIC –fibrinogen <=100mg%

19. Causes of DIC • Abruptio placenta 60-70% • Missed miscarriage • IUFD • Sepsis • AF embolism • Severe preeclampsia and eclampsia • Massive bleeding • Massive blood transfusion • Incompatable blood transfusion • Acute fatty liver of pregnancy

20. Diagnosis of DIC • Bleeding per nose , haematuria • Bleeding from puncture sites • PPH • Clot observation test= Weiner test =bed sit test Failure of any clots in 5ml tube blood within 10 minutes indicate fibrinogen <100mg% If a clot forms the tube incubated at 37c . If clot dissolves after 30 minutes it means excessive fibrinolytic activity

21. Diagnosis of DIC • Low fibrinogen • FDP > 40 micrograms/ml • Platelet < 100,000/cumm • Prothrombin time is increased ( N 10-15 second) • Thrombin time is increased ( N 25-35 second) • PTT is increased ( N 25-35 Second) • Antithrombin 111 deficiency • D-Dimers is increased > 0.5 microgram/ml is abnormal

22. Treatment of DIC • Treat the cause: infection-antibiotic • Fresh blood • Fresh FP • Cryoprecipitate • Give platelet if Platelets <50,000 • Antithrombin 111 adminstration • Heparin to increase fibrinogen

23. Treatment of DIC Remember • Dextran more than one liter may cause DIC • Dextran interferes with cross matching • One unit platelets raises the platelet count by 10,000/mm3 • Each unit cryoprecipitate raise the fibrinogen level by 10mg/dl • One liter of FFP Supplies 3 gm fibrinogen and all clotting factors