1. DIC PUERPERRAL SEPSIS

2. Puerperal sepsis Bacterial infection of genital tract after delivery. Organism :polymicrobial 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 Local causes: ROM, laceration, retained placenta Site of infection: Primary: laceration, placental bed, retained tissue Secondary: tubes, ovaries, peritonium, parametrium, pelvic veins

4. pathology Localized= putrid endometritis= mild form Infection is limited to the superficial layer of endometrium Spreading=septic endometritis= severe form The endometrium is the commonest site of puerperal sepsis

5. Clinical picture Infected tears: local pain, mild fever, dysuria Endometritis: fever in the 3 rd day, lower abdominal pain, tender uterus, offensive excessive lochia Septicaemia: 3 rd or 4 th day, high temp, pulse rapid, lochi is scanty and not offensive Salpingooophoritis: Parametritis: 2 nd week Peritonitis Pelvic thrombophlebitis: 2 nd week, mild fever,

6. Investigation CBC+ Diff WCC Blood culture MSU, culture sensitivity Cervicovaginal swab Ultrasound ? X ray chest, widal test, blood film for malaria

7. ttt Prophylactic: During pregnancy: ttt anaemia During labour: aseptic condition, VE 18H, complete delivery of placenta, Puerperium:avoid hospital acquired infection,

8. ttt General measures Antibiotic Drainage : fowler, semisitting, Heparin for pelvic vein thrombosis

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

10. 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

11. 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

12. 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

13. 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

14. 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