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. POBH: gestational HTN in previous pregnancy.
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 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 Bakry balloon.

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 sonography suggestive 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˟17mm collection 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:
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. therapy and after radiologic consult
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 8th day ,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,staphylococcus areus.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,purulent luchia,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 po QID+ 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 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