1. DIC PUERPERRAL 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 ( neiseria gonorrhoea, 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 endometritis especialy 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 endometritis The 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 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,

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: ttt anaemia During labour: aseptic condition, VE 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 Clindamycingentamicin 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) ampicillin-sulbactam

15. Drug treatments reported to be equivalent to clindamycin plus gentamicin include cefotetan, cefoxitin, ceftizoxime, piperacillin with or without tazobactam, and ampicillin and sulbactam.clindamycin gentamicincefotetancefoxitinpiperacillinampicillin 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. Metronidazole

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