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In The Name Of God

A case presentation of a 37-year-old woman who experienced maternal morbidity following a cesarean section, including chorioamnionitis, placenta accreta, and pelvic abscess.

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In The Name Of God

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  1. In The Name Of God

  2. Maternal Morbidity

  3. Case Presentation A 37 years old woman,G3 L2 (PC/S), GA : 29w+6d LMP 30W+2d Sonogrophy CC: vaginal leakage from 1 day ago.

  4. PMH: Seasonal allergy. • PSH: C/S , cerclage. • POBH: gestational HTN in previous pregnancy. • Drug history: ferrous sulfate, calcium, multivitamin, serotide and rhinocort spray, prolotone,cetirizine ,

  5. Physical Examination • Vital sign: BP=120/60 PR=86 RR=18 T=37c • Other findings were normal. • Vaginal exam: 1 finger, 30%, -3, breech , vaginal leakage +

  6. Management • .Lab data: CBC/diff, U/A, ESR , CRP, 24 hour urine. • Antibiotics: Azithromycin 1 gram single dose+ ampicillin 2 gr QID. • Corticosteroid Magnesium sulfate • Hydration • Cerclage removal • Biometry and Doppler sonography for acreta.

  7. Lab data • WBC: 10400 (neutrophil 67%) • Hb: 11.4 • Plt: 214000 • CRP: negative • ESR : 30

  8. Sonography • single , breech, GA 28-29w • Placenta anterior • AFI 57mm • Normal Doppler of acreta.

  9. In third day of admission due to : PR 110 T 37.9 C FHR 160 and diagnosis of chorioamnionitis she was terminated by C/S • 2 gr cefazolin before C/S was injected.

  10. Operation note • Pfannenstiel incision • Pack of long gaze before uterine incision. • Severe bladder to uterine adhesion. • Male breech neonate with Apguar score 6/10& 8/10 was borned. • Placenta was separated hardly and sequestrated,(focal acreta). • Placental site suturing. Ligation of uterine arteries and uterine packing by Bakryballoon.

  11. Operation note Placenta was sent to pathology . Estimations of intra-operation bleeding 2500cc (2 units of P.C & 2 units of FFP).

  12. Post operation events • Post 0: ampicillin+gentamicin+clindamycin, ICU admission, removal of Bakery balloon before 24 hr. • Post 1:ampicillin+clindamycin, NPO due to nausea. No defecation. • Post 2: continue AB,PO nutrition , bisacodyl supp, nausea and vomiting after nutrition, internal medicine consult( check off LFT,amylase,lipase and liver sonography , No defecation • Sono: diffuse intestinal dilatation and airfullness,mild free fluid in pelvic and abdominal cavity.

  13. Post 3:continue nausea and vomiting, No defecation • Post 4:surgery consult(abdominal X-ray ). • Post 5: fever 38.5 c, positive defecation, gentamicin is added to ampicillin+clindamycin , start per oral nutrition. • Post 6: venofer vial is ordered because of Hb 8.5 but she leaves hospital with her personal satisfaction.

  14. Readmission • 26 days after C/S she admitted with complain of fever and chills, malodorous vaginal discharge and a sonographysuggestive of pelvic abscess. • Sonography 1 day before readmission: normal size uterus, an echogenic mass with size 133mm˟ 78mm ˟97mm in volume of 530cc behind the uterus suggestive of pelvic abscess.

  15. Physical exam in readmission time • BP =120/60 , PR=120, T=38.2 C. • Abdominal exam: soft , tenderness on deep palpation on low midline abdomen, uterine size 20w. • Vaginal exam: numerous greenish no odorless vaginal discharge. Fullness in cul-de-sac.

  16. Management Lab data: CBC/diff, ESR, CRP, blood, urine and vaginal discharge cultures, LFT Antibiotics: ampicillin+gentamicin+clindamycin Abdominal and pelvic CT

  17. Abdominal and pelvic CT report A large fluid collection in size of 160˟ 100˟92 mm in pelvic cavity in favor of abscess, also a 122˟17mmcollection is seen anterior to the above mentioned collection.

  18. Lab data • WBC: 9800(neut 66.5%) • Hb: 7.3 (2 units of packed cell was prescribed). • Plt: 529000 • ESR: 112 • CRP: 3+ • Blood culture : negative • Urine culture: negative

  19. 72 hours after antibiotic therapy and continuation of fever and the vaginal culture result antibiotics were changed to meropenem+ vancomycin . • Vaginal discharge culture result: E.Coli Resistant to: cefepime,ciprofloxacin,gentamicin Sensitive to: imipenem Intermediate to: pipracillin-tazobactam

  20. 2 days after antibiotic change because of fever continuation interventional radiology consult was made for abscess drainage. Radiology consult: because the abscess is located in cul-de-sac, it is better to be treated by laparoscopy or laparotomy.

  21. with continuous fever in spite of antibiotic therapy and after radiologic consult the decision was made to do laparotomy for abscess treatment

  22. Laparotomy note sheet • severe intestinal adhesions to abdominal wall and uterus, enterolysis, TAH and sigmoid repair due to its damage during adhesiolysis. A penrose drain was embedded.

  23. Post operation management After surgery she was sent to ICU , She was NPO for 7 days because of enteral injury and she received serum and electrolytes according to internal medicine consult. meropenem –vancomycin were continued for 8 days after operation.

  24. The fever stopped one day after surgery. • On 3th day after surgery bloody discharge came out of abdominal incision so some sutures were removed and incisional washing and antibiotics continued until complete healing. • On 5th day after surgery she defecated.

  25. On 7th day after surgery drain was removed. • On 8thday ,she was let to have PO nutrition. • On 9th day after surgery injecting antibiotics were removed and oral antibiotics were prescribed. • 0n 13th day, sutures were removed and the patient was discharged without any fever and in good health condition.

  26. Post surgical infection • Febrile morbidity: T≥ 38 c(100/4 F) in 2 or more times at least 6 hours apart,but not in first 24 hours after surgery (more acceptable). • one episode of T≥39c at any time after surgery (within first 24 hours may be due to GAS).

  27. differential diagnosis for puerperal fever • Pelvic infection(metritis with pelvic cellulitis) • Breast engorgement and infection • UTI • Pneumonia • SSI (episiotomy ,C/S incision) • DVT/PTE • Drug fever • Intravenous catheter infection

  28. Risk factors for uterine infection • Route of delivery: the single most significant risk factor. • Chorioamnionitis and prolonged ROM. • Multiple cervical examination. • Prolonged labor. • General anesthesia. • Young maternal age. • Nulliparity. • Obesity • Meconium stained. • Manual removal of the placenta • Preterm and post term pregnancy. • Heavy vaginal colonization: E.coli,staphylococcusareus.GBS • Internal fetal monitoring • Low socioeconomic

  29. Frequency of post partum endometritis • Normal vaginal delivery :< 3% • NVD after prolong PROM and labor, multiple vaginal examination: 5-6% • NVD after chorioamnionitis: 13% • Elective cesarean delivery: 6% • Cesarean during labor: 11%

  30. Microbiology Most of uterine infections are polymicrobial. • Aerobes gram positive: group A,B stereptococci, staphylococcus. • Aerobes gram negative: E.coli, klebsiella • Aerobes gram variable: Gardnerella vaginalis • Anaerobes : Clostridium, Bacteroides, peptostreptococcus

  31. Endometritis with toxic shock syndrome • Group A stereptococci. • Staphylococci • Clostridium sordellii, perfringens

  32. Diagnosis • Diagnosis is clinical based upon the presence of post partum fever that can not be attributed to another etiology after a through history and physical examination. • Fever,tachycardia,midline lower abdominal pain, uterine tenderness,purulentluchia,chills,anorexia, leukocytosis

  33. The WBC is elevated but this can be normal in post partum women, but a left shift and a rising rather than falling neutrophil count postpartum is suggestive of an infectious process.

  34. Role of culture • Blood culture: is not recommended routinely(bacteremia occurs in 5-20% of patients) Indication for blood culture: immunocompromised patients ,septic patients and failure to respond to empirical therapy. • Cervical culture: is not recommended routinely.

  35. treatment Non severe metritis following vaginal delivery: • Clindamycin 600 poQID+ Gentamicin 4.5mg/kg IM daily. • Amoxicillin –clavulanic acid 875mg po BID. • Cefotetan 2g IM TDS. • Amoxicillin 500 mg+Metronidazole 500 mg po TDS. • Meropenem or imipenem-cilastatin 500 mg IM TDS.

  36. Moderate to severe infection treatment • Vaginal delivery: Ampicillin+ gentamicin • Cesarean section: Clindamycin 900 mg TDS +gentamicin 1.5mg/kg TDS or 5mg/kg single dose daily (ampicillin can be added in sepsis or suspected entrococcal infections) • Metronidazole +ampicillin+gentamicin • Ampcillin+sulbactam 1.5 g QID.

  37. Antibiotic treatment for renal insufficiency • Ampicillin sulbactam 1.5 g QID. • Clindamycin+second generation cephalosporin • Clindamycin+aztereonam. • Vancomycin added to other regimens for suspected staphylococcus aureus,C difficile infections and also inpatients with type 1 allergic reaction to penicillin.

  38. Duration of treatment • Continue IV treatment until the patient is clinically improved and afebrile for 24 to 48 hours.Oral antibiotic therapy after successful parenteral treatment is not required. • If an oral antibiotic regimen is administered Up ToDate suggests 14 day course. • If an IM antibiotic regimen is used up ToDate suggests 48-72 h of IM therapy and then switch to oral antibiotics to complete a 7 day course.

  39. If fever continues 48-72 hour after antibiotic therapy we should search for: • Phlegmon • Incisional or pelvic abscess • Infected hematoma • Septic pelvic thrombophlebitis • Wound infection

  40. Prevention of post surgical infection • Single dose prophylaxis with 2 g ampicillin or a first generation cephalosporin before C/S. • For obese women →3 g cefazolin. • Prophylaxis with azithromycin added to standard single dose prophylaxis further reduced postcesarean metritis rate. • Preoperative skin preparation with chlorhexidine-alcohol is superior to povidone iodine .

  41. Prevention of post surgical infection • Preoperative vaginl cleansing with povidone iodine or metronidazole gel in high risk women.. • Don’t remove placenta manually. • Exteriorizing the uterus to close the hysterotomy. • Changing gloves dose not decrease infection rate. l

  42. Prevention of post surgical infection • Closure of subcutaneous tissue in obese women dose not lower wound infection rate but decreases wound separation. • Skin closure with staples versus sutures has a higher incidence of non infected skin separation.

  43. Thanks Your Attention

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