-case presentation -chorioamnionitis.definition,incidence,risk factors,pathophysiology,treatment and complications. -postpartum pulmonary embolism,rate,risk factors,diagnoses and treatment.
18/12/2012 11:50 a.m. In ER: G3 P2+0,unbooked,Saudi lady GA : term c/o labor pain started the day before +ve hx of gush of fluid 3 days ago,not sure of color nor the odour. No hx of decrease fm Systemic symtoms :unremarkable. Hx of this pregnancy: totally unbooked Past ob hx: All previous svd >>>uneventful Medical hx: k/c asthma,frank dm not on medication Surgical hx:free
On Examination: Vitals in triage: BP 90/68 HR 139 T 38 C O2 % = 100 % RR 24 Pt was distressed in pain,uncooperative. PA: S,C,LL,T FHR 177 b/min PV: 7 cm fully effaced Vx 0 MA Offensive discharge
Impression: Active labor+/-chorioamnionitis until proven otherwise. Plan: Transfer pt to L&D unit.
18/12/2012 12:15 p.m. IN L&D: Pt stared ampicillin loading dose 2 g iv then 1 g iv q 6hrs,clindamycin 600 mg q8hrs,gentamicyn 80 mg q8hrs,perfalgan 1g q6hrs. Vitals : BP:111/59 HR: 135 T: 38.6C RR:24 O2 sat= 100% CTG applied: Fhr baseline 180 bpm Minmal variability Variable deceleration No acceleration Ctegory II
Senior on call informed Pt observed and he contacted consultant on call and plan for er cs Blood gp O+ hb=8.5 ceasearn section done. Baby girl deleverd at 13:41 w/ apgar scor of 2@1, 6@5 Baby transferred to NICU and intubated. EBL 600 cc.
In Recovery: Pt seen,no SOB,no chest pain Pa: uterus is contracted Soft,lax Minimal lochia Vitals: BP 138/37 HR 123 T 37.1 RR 20 O2 sat 99% Transfer to PNW 18/12/2012 6:50 p.m.
19/12/2012 Day 1 post op In PNW: She was afebrile BP ranged but within normal range HR ranged between 117-137 bpm RR 20 O2 sat 100% Lab results: hb 6.8 Wbc15.11 Platelates: 292 Pt transfused 1 Unit PRBC She was on:ampicillin,clindamycin,gentamicyn,prophylactic clexan,ISS,ferrous sulphate and calcium.
Patient was asymptomatic for 24 hrs Active issue: tachycardia
20/12/2012 Day 2 post op In PNW: Pt seen C/O Shortness of breath Chest pain No plapitation No dizziness No cough No hymoptysis on EX: Vitals: HR 114,BP 127/80,T36.8,O2 sat 100%,RR20 Chest is clear No murmers Pa:soft and lax,contracted and tender uterus above the umbilicus No LL edema or tenderness Plan: Spiral ct Cardiac enzyme ECG Medical referral
20/12/2012 Day 2 post op In PNW: Seen by medical: Summary: Anemia with microcytosis Signficant leukocytosi with left shift Fever along w/ tachycardia and tachpnea Normal arterial blood gases Pulmonary angio: Ruled out major pulmonary embolisim but coul not rule out subsegmental ones,bilateral basal atelectic bands seen. Impreassion:chorioamnionitis seems plausable,tachypnea related to atelectasis Plan: Full septic screen Mycobacterium studies Anemia workup Inflammatory markers Echo Dc current antibiotics and start Tazocin Start nebulization sessions.
21/12/2012 Day 3 post op 9:50 a.m. In PNW: Pt seen,still c/o SOB and chest pain Vitals: Bp 143/66,HR 119, RR 51,O2 sat 97 % Pt is unstabal and critical Medical contacted and asked for ICU referral and change heparin to theraputic dose. ICU contacted:orderd CXR,ABG, will send the BiPAP After ICU evaluation ordered to transfer pt to MICU.
21/12/2012 Day 3 post op 14:50 p.m. In ICU: Assessment: Consious,on face mask O2 rate 45,O2 sat99% Hemodynamically stabel Urine adequte Temp 38, wbc15,81 decreasing on Tazocin Cultures sent On clexan 70 mg subQ BID Lab results: Hb 8 Platelates 364 ESR 123 d dimer2 fibrinogen900 Pt is in distress Plan apply bipap Cbc Chemistry Echo bedside normal Diagnoses: chest infection +/- PE
Mobile CXR: In comparison to a previous radiograph there is anew left lower lobe opacity has developed,consistant with atelectic changes.
22/12/2012 Day 4 post op 1:36 p.m. In ICU: GCS 15/15 Off inotrps Bp 129/70 On BIPAP 16/7 FIO2 30%,o2 sat 100% Taking orally UOP 200 cc,normal renal function Spiking fever,w/leukocytosis (improving) On tazocin,no +ve cultures Hb 7.6 Normal coagulation Plan: Doppler ll>>> no signs of DVT
23/12/2012 Day 5 post op 11:30 a.m. In ICU: GCS 15/15 Vitals: HR 100 137/101 Rr 26 O2 sat 100% on 2 NC Afebrile Chest is clear CXR showed air bronchogram suggested for consolidation. Histopathology released:third trimester placenta with funisitis and chorioamnionitis Plan: discharge from ICU Con t Abx and trace culutures Cont theraputic clexan and repeat ct chest after 1 week.
25/12/2012 Day 7 post op 4:20 p.m. In PNW: Vitally stabel Uterus well contracted Pv minimal lochia Pt is for discharge Instructed for clexan dose injection regularly Opd in 2 weeks
Chorioamnionitis Definition: an acute inflammation of the membranes and chorion of the placenta, typically due to ascending polymicrobial bacterial infection in the setting of membrane rupture. -can occur with intact membranes, especially common for the very small fastidious genital mycoplasmas such as Ureaplasma species and Mycoplasma hominis, found in the lower genital tract of over 70% of women -rarely is hematogeneous spread implicated in chorioamnionitis, as occurs with Listeria monocytogenes -varies according to key diagnostic criteria, which can be clinical (presence of typical clinical findings), microbiologic (culture of microbes from appropriately collected amniotic fluid or chorioamnion) or histopathologic (microscopic evidence of infection or inflammation on examination of the placenta or chorioamnionic specimens
-polymicrobial infection most often due to ascending genital microbes. -over 65% of positive amniotic fluid cultures involve two or more organisms. The genital mycoplasmas, Ureaplasma urealyticum and Mycoplasma hominis (genital mycoplasmas). -These provoke a robust inflammatory reaction affecting both maternal and fetal compartments, particularly in preterm gestations. They are commonly isolated from amniotic fluid in the setting of preterm birth or premature membrane rupture with or without clinical chorioamnionitis. Chorioamnionitis
Risk factor of chorioamnionitis Relative riskReference(s) Prolonged membrane rupture (including PPROM) ≥ 12 hours5.813 > 18 hours6.915 Prolonged labor S econd stage > 2 hours3.715 Active labor > 12 hours4.014 Multiple digital exams with membrane rupture ≥ 3 exams2 to 51313–1414 Nulliparity1.814 Group B streptococcus colonization1.7 to 7.21414, 16, 191619 Bacterial vaginosis1.717 Alcohol and tobacco use7.915 Meconium-stained amniotic fluid1.4–2.377, 1414 Internal monitoring2.013 Epidural anesthesia4.115 Selected risk factors and their relative risks for chorioamnionitis,
-1–4% of all births in the US are complicated by chorioamnionitis. – -Chorioamnionitis (clinical and histologic combined), complicates as many as 40–70% of preterm births with premature membrane rupture or spontaneous labor. -1–13% of term births. -Twelve percent of primary cesarean births at term involve clinical chorioamnionitis, with the most common indication for cesarean in these cases being failure to progress usually after membrane rupture. Incidence: Chorioamnionitis
Clinical signs and symptoms: Maternal fever(>/=37.8C) Fetal tachycardia(>160bpm) Uterine tenderness maternal tachycardia (>100/min) purulent or foul amniotic fluid Chorioamnionitis
Diagnoses of chorioamnionitis CBC Other blood tests Amniotic fluid testing Placental and umbilical cord pathology
Complications of chorioamnionitis increased risk for cesarean delivery Endomyometritis wound infection pelvic abscess bacteremia postpartum hemorrhage PE maternal fetal death neonatal sepsis cp fetal
Antibiotics -randomized trials and observational studies demonstrate that immediate intrapartum use of broad-spectrum antibiotics significantly reduces maternal and fetal complications of chorioamnionitis. -neonatal sepsis is reduced by up to 80% -optimal antibiotic regimen for treatment of clinical chorioamnionitis has not been well-studied and current recommendations are based largely on clinical consensus -Intravenous administration of ampicillin every 6 hours and gentamicin every 8–24 hours until delivery is the typical regimen - --cesarean delivery is performed, clindamycin every 8 hours (or metronidazole) is often added for anaerobic coverage -Optimal treatment should also include administration of a single intravenous additional dose of antibiotics after delivery Chorioamnionitis
-although genital mycoplasmas are the most commonly isolated organisms associated with chorioamnionitis, the standard antibiotic regimens used for clinical chorioamnionitis do not provide optimal coverage against these organisms -The standard regimen effectively treats maternal infection (>95% success rate) and reduces neonatal sepsis, and there are currently no published trials suggesting that specific coverage against ureaplasma (with macrolide antibiotics) provides additional benefits Chorioamnionitis Antibiotics
For the mother with chorioamnionitis, serious infectious complications include endometritis, l ocalized pelvic infections requiring drainage, and intra-abdominal infections. Maternal chorioamnionitis or other secondary infectious complications may cause thrombosis of pelvic vessels and the potential for pulmonary emboli. Author Michael P Sherman, MD Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Director, Fellowship Training Program in Neonatal-Perinatal Medicine, NICU, Columbia Regional Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine
-Pulmonary embolism is the leading cause of maternal death in the UK and Norway. And amongst the leading causes in Australia and the US. -The rate of venous thromboembolism was 1.72 per 1000 deliveries with 1.1 deaths per 100,000. -rate of pulmonary embolism following birth is 0.45 per 1000 deliveries and this rate was relatively stable over a 6- year period despite a rise in the Caesarean section rate. -Pregnancy itself is a risk factor for pulmonary embolism, and increases the incidence by a factor of five because of the normal physiologic changes of pregnancy (decreased fibrinolytic activity and effects of estrogen on the coagulation system and vessels) increase the risk of thromboembolism. -Also, cesarean delivery increases the risk of pulmonary embolism 9-fold compared to vaginal delivery.6,7 Postpartum Pulmonary embolism
Risk factors: -38% higher for women ages 35 and older -64% higher for black women. -Thrombophilia, lupus, heart disease, sickle cell disease, obesity, fluid and electrolyte imbalance, postpartum infection, and transfusion. -The risk factor with the highest odds ratio, 51.8 (38.7-69.2) was thrombophilia. -Maternal transfusion of all types was crudely associated with an increased risk of postpartum pulmonary embolism (RR = 8.90; 95% CI, 5.74, 13.8). For women whose transfusions included fresh frozen plasma, cryoprecipitate, platelets or coagulation factor in addition to packed cells or whole blood, compared with women who did not received any blood transfusion Postpartum Pulmonary embolism
Pre exisitingPrevious VTE Thrombophilia Heritable: Antithrombin deficiency Protein C deficiency Protein S deficiency Factor V Leiden Prothrombin gene G20210 A Acquired (antiphospholipid syndrome) Persistent lupus anticoagulant Persistent moderate/high-titre anticardiolipin antibodies or beta 2 glycoprotein 1 antibodies Medical comorbidities (e.g., heart or lung disease, SLE, cancer, inflammatory conditions (inflammatory bowel disease or inflammatory polyarthropathy), nephrotic syndrome (proteinuria >3 g/day), sickle cell disease, intravenous drug user Age >35 years Obesity (BMI >30 kg/m 2 ) either prepregnancy or in early pregnancy Parity ≥3 Smoking Gross varicose veins (symptomatic or above knee or with associated phlebitis, oedema/skin changes) Paraplegia ObstetricMultiple pregnancy, assisted reproductive therapy Pre-eclampsia Caesarean section PPH (>1 litre) requiring transfusion Prolonged labour, mid-cavity rotational operative delivery New onset/transientSurgical procedure in pregnancy or puerperium (e.g., ERPC, appendicectomy, postpartum sterilisation) Potentially reversible a Hyperemesis, dehydration Ovarian hyperstimulation syndrome Admission or immobility (≥ 3 days' bed rest) (e.g., symphysis pubis dysfunction restricting mobility) Systemic infection (requiring antibiotics or admission to hospital) (e.g., pneumonia, pyelonephritis, postpartum wound infection) Long-distance travel (> 4 hours)
Treatment : Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis, and to discontinue UFH, LMWH, or fondaparinux only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation). [ Women experiencing a thromboembolic event during pregnancy should receive therapeutic treatment with unfractionated heparin or LMWH during pregnancy, with anticoagulation continuing for 4-6 weeks postpartum and for a total of at least 6 months Postpartum Pulmonary embolism
Chorioamnionitis: -identify signs and symtoms. -start antibiotics immediately. -it is not an indication for ceasearn delivery. -treatment of BV may decease risk. Pulmonary embolisim: -Pregnancy and postpartum period is a hypercoagulabe state. - identify risk factors to start prophylactic anticoagulant.