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MRCOG PART 2 SBAs and EMQs

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Essay 312 - Sepsis

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		Posted by H H. Sat Jan 16, 2010 03:11 am
This is a high risk condition as the findings point to septic shock. Patient level of consciousness is noted. Resuscitation should be considered (airway,breathing,circulation) first if in shock. History is taken from patient if she can or from the notes regarding her pregnancy and labour ,whether she had a medical condition like diabetes and how controlled and whether she had an episiotomy. I will ask if she is breast feeding and if she has pain in breast, ask if has burning micturition and loin pain, ask if she has cough with expectoration, ask if she has abdominal pain with foul vaginal discharge, ask if has infected episiotomy scar and also if she has lower limb pain. Will ask if has any chest pain or shortness of breath. I will examine her chest for reduced air entery and crepitations, examine the breast for tenderness and reddness, abdomen for tenderness and rigidity ,check lower limbs for tenderness or unilateral swelling. I will do local examination to see infected episiotomy scar or fowel smelling vaginal discharge, and do a local examination as I might find a missed swab that might be a cause. Will do FBC for increased WBC, will do CRP denoting infection, Blood culture for proper antibiotic to be given . Will do urine dipstix for nitrites,protein,glucose,ketones and blood. If nitrites positive will do culture and sensitivity.Urea and electrolytes for renal function .Will do HINI virus detection test. Will take swabs from vaginal discharge, or infected episiotomy or from breast discharge if any is proposed cause. Will do chest Xray if has chest symptoms. Will consider doing duplex compression scan if lower limb signs and if suspecting pulmonary embolism will do objective tests(V/Q scan and CTPA) Resuscitation and correction of shock in a multidisciplinary team work(obstetrician,midwives, anesthetist, porters, bacterioogist )should be done. Airway , give oxygen and notice her breathing. She is fitted with 2 wide bore IV canulaes.The anesthetist will fit a CVP and a urinary catheter is put and a fluid chart is monitored.Patient will need proper monitoring so she is transferred to high dependency unit but should be isolated so as not to transfere infection to other patients. Puerperal sepsis is managed IV fluids, antipyretics and antibiotics(cephalosporins). Temperature is taken every 15 minutes with automated monitoring of pule, BP ,respiratory rate and pulse oxymetry for O2 saturation. The amount of lochia noted daily. Urinary tract infection is treated by antipyretics, analgesics, IV fluids and anti biotics. Breast abscess will need surgical input for incision drainage. Chest infection will be treated by chest exercises,antibiotics and chest physician input. Swine flu is treated conservatively by antipyretics and giving Tamiflu. It is characterized by persistant high fever for 7 days and chest symptoms. If suspect pulmonary embolism, I will commence therapeutic heparin (LMWH) while awaiting the results of objective tests. I will inform her GP of her condition. Will do an incident report.I will see the patient when she is ok and inform her of her condition and give written information regarding high fever after delivery and swine flu if proved to have it.
		Posted by Ida I. Sat Jan 16, 2010 06:02 am
a) She is in septic shock, thus her assessment should begin with her GCS, as well as her airway, breathing and circulation. Previous notes from her antenatal check ups and delivery has to be obtained, to see if she previously had a premature rupture of membranes or any antenatal infections like chicken pox or Group B Streptococcus antenatally or any retained placenta which required an MRP after her delivery. Full examination should include the breasts to look for any mastitis, assessment of her uterus size per abdomen and her perineum to look at her episiotomy wound, presence of foul smelling discharge lochia or any vaginal hematoma. b) She would need a full blood count, to look at her hemoglobin level to look for any anaemia, and her white cell count which increases with infection. A coagulation profile is useful to look for any signs of DIVC. She also needs a high vaginal swab to look for any vaginal infection, especially if she presents with foul smelling lochia. Blood cultures for aerobes and anaerobes to look for bacteremia. A Urine FEME and urine culture would be useful to look for any evidence of urinary tract infection. She would also need an ultrasound to look for any retained placental tissue. c) She requires inpatient management in the high dependency unit with a multidisciplinary team, that consist of the senior obstetrician, anaesthesiologist and microbiologist. She needs to be resuscitated with colloids in view of her hypotension. She needs empirical antibiotic treatment with intravenous wide spectrum antibiotics, preferably second generation cephalosporins and metronidazole. Her antibiotics can be changed according to the culture sensitivity once its available. If she is found to have retained placenta, an emergency evacuation has to be done by the senior obstetrician. Similarly, if there is a presence of a vaginal hematoma, she needs an examination under anaesthesia and hematoma evacuation as soon as possible. Any mastitis with suspicion of a breast abscess needs to be referred to the surgical team for possible drainage. She needs an hourly BP, PR and temperature monitoring, including hourly urine output via CBD. If her blood pressure does not respond to colloid resuscitation, she may require inotrope support. Any anaemia has to be corrected by means of transfusion. Similarly, if her fever does not respond to antibiotics, even with the sensitivity available, she may need to be referred to the physician or infectious diseases team to further investigate the cause of her fever. Any vaginal bleeding should be assessed by pad chart If there is presence of excessive vaginal bleeding that is not arrested by medical therapy , she may need to undergo a hysterectomy.
		Posted by SYAMALRANJAN S. Sat Jan 16, 2010 07:23 am
a) I will review the delivery records and treatment notes thoroughly . Presence of prolonged labour with ruptured membranes may be related to fever. Urinary catheterization, urinary retention was the other points which must be enquired. Dysuria , burning sensation, urinary frequency are related to urinary tract infection (UTI). Fever with chill , rigor may be associated with UTI. Nature, amount, smell of lochial dischagre would be enquired. Chest and leg symptoms ( pain , cough , sortness of breadth, leg swelling) should asked for. Breast feeding, problems, swelling are important for fever related to breasts. Carefull physical examination which should include general examination and other relevant examinations. Chest examination to exclude infection. Breast examination to see presence of milk engorgement, cellulitis, abscess. Abdominal examination of uterine tenderness and involution is to be assessed. Perineal wounds, lochial discharged to be examined.Retained vaginal tampons or foreign body may be present b) FBC is an important investigation and presence of increased WCC would indicate infection. Clean catch urine for Dipsticks and microscopy , cultre to exclude a UTI. High vaginal and endocervical swabs for culture, sensitivity testing for infection. Other investigations if clinical conditions demand then chest radiograph , blood cultures, Doppler study leg veins to exclude chest infection , septicemia, rare possibility of DVT. c) Here inpatient treatment is required for proper monitoring , appropriate treatment and progress. I will start intravenous broad spectrum antibiotics . Blood will be sent for FBC, culture. I will give antipyretic (paracetamol) for her comfort from fever. Antibiotics will be changed after having culture reports. Adequate hydration is to be maintained( if oral intake is considered inadequate then IV fluid). Monitoring is to be done by the parameters of pulse, BP, temperature, urine, feeling of wellbeing, appetite, Input, output chart. If specific cause is detected such as breast infection or engorgement, UTI, endometritis, Chest infection then I will treat according to guidelines and unit protocol. If DVT is strongly suspected then I will start LMWH in therapeutic doses and objective tests are to be arranged promptly and advices from expert is to be sought for. If septicemia is diagnosed then patient is to be transferred in high dependency unit and multidisciplinary input ( such as critical care specialist, renal physician, hamatologist , cardiologist). Patient may need ionotropic support for septicemia.
		Posted by L S. Sat Jan 16, 2010 07:26 am
LS: (a) Discuss your initial clinical assessment [5 marks]. I will first assess to see if her conscious level is deteriorating and initiate acute resuscitation first by securing airway, breathing and circulation if not. If she is alert and able to communicate, history taken regarding her symptoms in detail on specific site of infective cause like symptoms of urinary tract infection (dysuria, hesitancy, had catheterization during her labour). Symptoms of endometritis with foul smelling lochia and associated increased lower abdominal pain, vomiting and diarrhoea enquired. Details regarding her delivery on duration of labour, water delivery, instrumental delivery needed, type of perineal trauma sustained if any or had epidural as analgesia enquired. History of chorioamnionitis or prolonged rupture of membrane asked. Other systemic review history enquired on lower limb swelling and tenderness, breast engorgement and respiratory tract infective symptoms. Examination carried out to check size of uterus and tenderness. Her lungs auscultated and lower limb examined for signs of localized inflammation or tenderness. Her perineum inspected for signs of hematoma over wound or has inflammation with pus discharge. Her breast inspected if she complaints of tenderness for signs of localized inflammation. If she had an epidural, the injection site inspected for inflammation. (b) Discuss the investigations that you will perform [3 marks]. I will perform a full blood picture to see her total white count together with C-reactive protein. I will take her blood cultures for infection and sensitivity. Perineal wound and vaginal (lochia) swabs taken and sent for culture and sentivity. Two samples of mid stream urine should be sent. I will also check her urea and electrolytes, liver function test, clotting screen, lactate and blood group and save. (c) Justify your initial treatment and subsequent monitoring [12 marks]. I will take blood cultures and commence intravenous (IV) broad spectrum antibiotics immediately to cover Streptococcal and anaerobs which are common causes of pelvic sepsis. IV fluids (1000ml crystalloid and 500ml colloid) over the first 30 minutes should be given as she is hypovolaemic. Oxygen under high flow 15l/min given. She should be admitted into high dependency unit or labour ward as per local protocol for management of post partum sepsis. Senior staff (consultant), anaesthetist and microbiologist should be informed to help in multidisciplinary team approach to optimize her care. Her vital signs, fluid balance and intensive care charts should be monitored for signs of improvement or deterioration. Any imbalances should be corrected accordingly. Her response to antibiotic monitored and changed if culture results are different from current antibiotic cover. If she response well and is apyrexial for 48 hours IV antibiotics can be coverted to oral to complete for a duration of 10 days. If retained products of conception or pelvic collection is suspected, ultrasonography should be carried out by someone experience in post partum uterine sonography as it can be misleading. If sonography is suggestive of suspicion, exploratory laparotomy and evacuation might be needed and should be performed under general anaesthesia for seriously unwell woman.
		Posted by Taghrid B. Sat Jan 16, 2010 08:26 am
initial treatment and subsequent monitoring.this is most probably septic shock. Initial resusitation can be managed in ward. Intravenous fluid crystalloid or colloid to correct hypovolumia and prevent end organ failure.Intravenous Broad spectrum antibiotics till the the results of culture and sensitivit available.If patient does not response on initial therapy she should be trasfer to ICU . invesive monitoring by central venouse and arteial catheter.CVP to be maintain 8-12 mm Hg. Urine out put initial assesment. are there any other associated symptoms eg cough , chest pain . abdominal pain ,any lower limb swellings and pain to rule out DVT any canula site pain , any offensive vaginal discharge , any breast related problems to rule out breast abcess. any assoociated urinary or bowel related complaint, diarrhoea and vomiting. any h/o of infection in antenatl period eg urinary tract infection. h/o PROM.h.o episiotomy or perineal tear.was there prolong immobilisation . is there any abdominal pain or swelling. any offensive vaginal discharge. clinical examination of the patient.during history taking I will rule out altered mental status. after vital signs her lower limb examination to rule out DVT . cannula site if one she had, for phlebitis, chest examination.I will alo examne the breast to rule out mastitis and breast abscess. abdominal examination for tenderness and any mass.tenerness over uteru will indicate endometritis . per speculum and vaginal examination if there is any offensive discharge any infected wound secondary to episiotomy or perineal tears.Tenderness during vaginal examination (endometritis). Investigation.complete blood film, blood culture. blood glucose. serum urea and electrolyte .coagulation sreen.urine analyis and culture and sensitivity . throat swab. vaginal and wound swab .culture and sensitivty should be before starting any antibiotics. during the treatment period further investigation needed are arterial blood gases, serum lactate if no response to hypotension. U/S abdomen and Pelvis chest xray and ECG. should be0.5ml/hour . if not responding to iv fluids then inotropics drug to be used. oxygen saturation to be maintained as lactate acidemia wil hamper it in septic shock.insuline therapy can be started Low dose steroids can be given as in septic patient there is adrenal insuffciency and Actvated protein c adminisrtation will decrease end organ damage . These are sepsis management bundle recomendation in accordance with standarised ICU policy. T.B
		Posted by Harry B. Sat Jan 16, 2010 09:11 am
HB A healthy 30 year old woman is referred to the maternity assessment unit 4 days after spontaneous vaginal delivery because she is feeling generally unwell. Her pulse is 120 / minute, BP = 90/50 mmHg and her temperature is 39 C. (a) Discuss your initial clinical assessment [5 marks]. (b) Discuss the investigations that you will perform [3 marks]. (c) Justify your initial treatment and subsequent monitoring [12 marks]. A. The initial assessment of this lady should include assessment of airway, breathing and circulation if any evidence of altered level of consciousness. I would go through the antenatal, intrapartum and postnatal notes to look for any risk factors for sepsis as the initial observation is suggestive of septic shock. History of smoking, diabetes mellitus, prolonged SROM, prolonged labour, intrapartum pyrexia, estimated blood loss, comments about placenta and membranes, perineal tears and episiotomy and suturing and about the initial postnatal period. I would ask for associated symptoms such as chest pain, shortness of breath and cough, pain in the breasts, abdominal pain, nausea, vomiting, colour and nature of the lochia, urinary symptoms such as frequency and dysuria, pain and swelling in the lower limbs. I would do a thorough examination of the respiratory and cardiovascular system for any signs of chest infection and evidence of endocarditis respectively. The breasts will be examined for signs of mastitis or breast abscess such as redness, swelling, engorgement and tenderness. I would examine her abdomen to establish the uterine size and tenderness and a speculum examination to look for signs of endometritis. I would look for any evidence of infection in the perineaum if there were any perineal tears or episiotomy suturing. The lower limbs will be examined for signs of DVT. B. The urinalysis will be performed on a catheter specimen of urine and a sample will be sent for culture and sensitivity. The blood tests would include full blood count for haemoglobin and WBC levels, serum C-reactive protein for inflammatory markers. The baseline serum urea, electrolytes, creatinine, liver function tests and clotting profile would be useful. A blood group and save will be done if not already done at the time of delivery. Blood cultures to look for septicaemia and sensitivity to antibiotics. A high vaginal swab for culture and sensitivity to look for vaginal infections. Further investigations such as sputum culture, nasal swabs, wound swabs from the perineum, chest X-ray, abdominal and pelvic ultrasound scan and Doppler ultrasound of the lower limbs based on the clinical pictures. C. The initial treatment includes oxygen supplementation via face mask at 15 L/min to improve tissue oxygenation, insertion of two large bore cannulae and fluid resuscitation for hydration and broad spectrum antibiotics to treat infection. The aggressive fluid resuscitation has shown reduction in morbidity and mortality in these patients and should include 500 ml of iv fluids in 20 minutes and then to continue at a rate of 1 L of fluid in 2h, 4h and then 6-8hourly. Broad spectrum intravenous antibiotics of choice will be Cefuroxime 1.5g TDS and Metronidazole 500mg TDS. A urinary catheter will be used to monitor the urine output. Paracetamol 1g will be given orally or per-rectally or intravenous depending on the clinical situation and other physical methods of reducing the temperature such as tepid sponging and fan air. The consultant obstetrician and anaesthetist would be informed. Continuous monitoring in a high dependency unit will be done using a modified early warning obstetric chart as this would improve the outcome and necessary early interventions if any deterioration. Further management will depend on the cause. IV antibiotics will be continued or changed to specific antibiotics based on the culture and sensitivity results of the urine, blood and the high vaginal swab, till apyrexial for at least 24 hours and then oral antibiotics for 5-10 days depending on the cause. If there is no initial improvement with 24 hours of IV antibiotics, further advice will be taken from microbiologists on further antibiotics. Breast support, strong analgesia, expression of the breasts will be considered for mastitis and incision and drainage for breast abscess. Evacuation of retained products of conception will be undertaken for retained products after 24 hours of IV antibiotics. Chest infections and UTIs will be treated with appropriate antibiotics. Low molecular weight heparin prophylaxis and TEDS for the duration of hospital stay will be considered to decrease the risks of thromboembolism and therapeutic LMWH or warfarin for confirmed thromboembolism. Perineal infections will be allowed to heal with secondary intention if there is improvement with antibiotics
		Posted by Naheed M. Sat Jan 16, 2010 11:27 am
n.m Puerperal sepsis is the most likely cause of this woman’s fever as benign postpartum fever usually occurs within 24 hours of delivery. Patient should be asked about onset time, pattern, severity and associated complains along with fever. History about the delivery may give leading clues: including place of delivery to ensure aseptic measures, time taken (prolonged labour is associated with high risk of infection) membrane rupture before labour or during labour ( Pre-labour rupture may be assocaied with infection). Episiotomy was given or not? was there any tear and lacerations which was stitched? If yes, is the wound unhealthy, swollen and painful? Was there any heavy blood loss after delivery (postpartum hemorrhage) adding anemia factor to other infectious illness. She should be asked about urinary complains such as frequency, dysuria and lumbar region pain. Any history of nausea vomiting and rigors should be asked. Lower abdominal pain and excessive or offensive vaginal discharge may indicate endometritis and genital tract infection. Woman should be asked about difficulty is breast feeding due to painful breasts or any swelling (abscess) in breast. History of sore throat, cough and difficuly in breathing shows possibility of respiratory tract t infection and chest pain or pain in legs may direct attention to pulmonary or venous thromboembolism (VTE). Patient should be examined, Conjunctiva, skin and palms for pallor (anemia) should be checked. Any skin rash would warn about viral infections. BMI should be checked. If BMI>30kg/m2 with other high risk factors( postpartum period and infection) increases her risk of VTE and may indicate the need for thromboprophylaxis. Perineal wounds or episiotomy she should be checked for the signs of infection. Perspeculum examination would give clue for cervicitis or abnormal discharge. Bimanual vaginal examination would explore uterine tenderness boggy un-involuted condition of uterus. Examination of breast may show tenderness and redness of mastitis or swelling for breast abscess. Inspection of throat congestion for throat infection or chest auscultation for the presence of rhonchi suggest chest infection. Lumbar region tenderness (for pyelonephritis) should be checked. B. Full blood count (FBC) for leucocytosis, C-reactive protein, urine dipstick test and blood culture/ sensitivity. The other investigations would be according to suspicious site of infection. urine culture and sensitivity (C/S), High vaginal and/or wound swabs for C/S are the investigation for genitourinary infections. Throat swab C/S for sore throat and serology for viral infections. Other investigations may be chest X-ray, sputum C/S for complains of cough or chest pain. Calf muscle tenderness would indicate ultrasound Doppler. C. Patient should be counselled about her condition and the diagnostic and treatment process. She can be treated admitted for close monitoring and efficient treatment. Patient should be provided psychological support as this illness after delivery and during the risk of postpartum blues put additional psychological stress on patient. Investigations (FBC, CXR, Urinalysis and C/S, blood culture and the swabs for C/S from suspicious infection sites)should be collected and sent before starting any antibiotic therapy. She should be given antipyretics and additional symptomatic treatment such as analgesics (for any pain)and antiemetics for nausea and vomiting (if present). Broad spectrum intravenous antibiotics should be started after the collection of investigations samples. Antibiotics can be changed after receiving culture and sensitivity reports to replace with specific suggested antibiotics. Depending upon the severity of condition and patient’s progress antibiotics are continued for 7-10 days (sometimes 14 days). If there is evidence of anemia iron rich diet and oral hematinics should be advised. Patient is monitored (6 hourly) for pulse, temp. blood pressure, urine output and improvement or deterioration of symptoms. It should be ensured that she takes adequate fluids and healthy diet if orally tolerated. Multidiscilplinary team should be involved according to the patient’s need, example urophysician, chest physician, gastroenterologist or hematologist. As she is at higher risk of VTE (postpartum period, infection and hospitalization ) thromboprophylaxis, mobilization and adequate hydration should be in treatment priorites. In case of postpartum depressive illness psychological support from family, clinical staff and counsellor should be provided and in severe cases psychiatrist involvement and drug therapy may be needed. If she has perineal or episiotomy infectious wound she should be advised warm saline soothing baths 2-3 times a day. Perineal heamtomas are incised and drained. Breast feeding is encouraced and is not contraindicated even in the presence of mastitis. Flucloxacillin is the antibiotic of choice for mastitis (due to staph aureus) while breast abscess need incision and drainage. Patient is updated with verbal and written (leaflets) information about her illness, medication benefits and side effects throughout her treatment. After fever subsides and patient’s condition (symptoms) improve drugs can be switiched to oral medication (if on I/V medication) and monitoring (pulse, temperature, B.P, respiration and urinary output) should be continued. After ensuring satisfactory condition patient can be sent home with continuation of antibiotics if course (7-10 days) has not completed Decision of discharge from hospitalshould be according to patient’s wishes and clinical circumstances. On discharge from hospital she is advised to complete oral antibiotics course . She is advised to seek medical help if develops any symptom or fever again. She should be advised about taking medication timely, having plenty fluids, healthy and nutritious diet and avoid immobility, continue breast feeding and saline perineal baths (if needed) and return for follow up. She should be given appropriate advice for contraception.
		Posted by drvimaladkm@yah K. Sat Jan 16, 2010 02:16 pm
Tachycardia, hypotension, fever suggests serious condition of septic shock for which patient has to be admitted immediately. Airway ,breathing & circulation is taken care with IV fluids and oxygen if needed. Detailed delivery history regarding any delay in the different stages of delivery, premature rupture of membranes & duration (specially due to beta hemolytic streptococci & Bacterial vaginosis with frothy discharge in late pregnancy) any surgical cut given or any perineal injury, details of placental delivery regarding any retained bits of tissue, any postpartum haemorrhage ,if present indicates the possibility of puerperal sepsis. Current history of fever with chills and rigors, fowl smelling lochia, lower abdominal pain with or without distension suggests puerperal sepsis. Swelling & pain in the breasts with difficulty in feeding suggests mastitis. Backache, pain & burning urination with chills & rigors suggests urinary tract infection(pyelonephritis).Leg pain with swelling suggests deep vein thrombosis. Previous history of preexisting Diabetes mellitus and Anaemia or Immuno deficiency conditions predispose for sepsis. Clinically systemic examination should rule out serious respiratory (crepitetions, diminished breath sounds) or cardiac problems. Breasts examination to be done for any engorgement or abscess. Abdominal palpation for subinvoluted uterus,or other organomegaly like Liver or Spleen or distention of abdomen is noted along with bowel sounds.(in generalized peritonitis). High & low vaginal Swabs done for culture prior to local examination. Local examination of perineum may show infected, oedematous, tender, gaping episiotomy or perineal lacerations.Internal examination may show cervical or fornicial tenderness with or without abnormal lochia. Localised temperature,swelling,erythema of a leg indicates deep vein thrombosis. Initial investigations are: Blood sample for FBC,including differential count, C-reactive protein, urea , Electrolytes, Renal & Liver function tests for renal or hepatic involvement. Blood culture , Urine culture, vaginal, urethral and wound swabs are done for culture & sensitivity of polymicrobial organisms including aerobic anaerobic & bacteroids organisms. Coagulation screen in cases of coagulation failure with severe sepsis. Ultrasonography for any retained placental tissues or, any pelvic fluid or pus collection. Abdominal x-ray in suspected cases of paralytic ileus or intestinal obstruction. Following resuscitation & investigations IV broad spectrum antibiotics (3rd or 4th generation of cephalosporin 12th hourly) with antibacteroids(Metronidazole 8th hourly) and aminoglycoside like Gentamycin(8th hourly) is given to cover all types of organisms. Fluid management is essential with intake & output measurements in severe sepsis with peritonitis. Blood & blood products transfusion may be required in cases of secondary Postpartum haemorrhage, coagulation failure or severe anaemia. Thromboprophylaxis with Low molecular weight heparin may be required. Daily dressing of the perineal wound may be required with clean wash & antiseptic (betadine) cream. Involving obstetrical consultant, surgical management may have to be done with laparotomy & drainage in generalized peritonitis. Evacuation of retained placental tissues may be required in cases of retained placental tissues. Monitoring of the patient is done regarding her general condition including pulse, blood pressure, temperature & respiratory rate. involution of uterus and change in lochial discharge. Abdominal girth measurement to be noted in cases of peritonitis. Multi organ failure can occur in severe sepsis involving renal,hepatic,cardiac, encephalopathy and coagulopathy. In such conditions physician, hematologist have to be involved for further management. VDKM
		Posted by SRABANI M. Sat Jan 16, 2010 03:39 pm
SM a. Puerperial sepsis is a common occurrence , with incidence of 5%.Initial assessment of this lady will comprise of taking history ( including medical & obstetrical history), general examination, local examination to identify the cause of sepsis & also quickly checking her record of any significant event , particularly antenatal, intrapartum or immediate postpartum period.Puerperial sepsis with signs of septic shock warrant admission of the lady in HDU with involvement of consultant anaesthetist, consultant obstetrician & consultant Microbiologist. Airway, breathing ,circulation should be checked along with recording of GCS & close monitoring of pulse, temperature,BP , intake output chart should be done.Clinical assessment should be done to find out the etiology of sepsis .In benign fever there may not be any other clinical finding except raised temperature & it usually subsides in 24hrs without any specific treatment.Chest should be examined to excude signs of infection & evidence of consolidation at lung bases.Abdomen should be examined including suprapubic tenderness .She may complain of loin to groin pain, dysuria, frequency etc & UTI is suspected in this situation, occur in 2-4 % cases.Any wound infection around perineum should be examined as this may cause sepsis & it is the second most cause of puerperial pyrexia.There may be erythema, discharge from wound or abscess around perineal wound.If there is fever, rigor, abdominal tenderness and offensive vaginal discharge , endometritis may be suspected.Uterus may be palpable & tender.Breasts should be examined to exclude mastitis / breast engorgement.Examination may reveal enlarged, erythematous breasts with tenderness.Also any doubt about PE should be excluded by further investigation b. Invesigations for this lady should be started with baseline investigation like FBC which may show leucocytosis, CRP may be raised but nonspecific, blood culture may be helpful.Sputum can be send in suspected chest infection like TB, & also chest Xray may be helpful.Urine dipstick & MSU for culture & sensitivity may be helpful for suspected UTI.Wound swabs from suspected wound infection are needed.In suspected VTE/DVT, Doppler scan of leg vessels may be helpful.Venogram of leg or ECG may be done in suspected VTE. In suspected PE V/Q scan will be helpful.Swabs from vagina & endocevix should be sent to exclude endometritis which occur in 1.6% of cases.USS may be helpful to localise any abscess. c. Management of this lady should be initiated in HDU/CCU with involvement of consultant obstetrician, consultant anaesthetist & consultant microbiologist as septic shock is a life thretening condition. She should have supportive therapy including proper hydration, antipyretic & close monitoring with inotropic support if needed. Specific management will depend on the origin of sepsis.Benign fever causes 3% of postpartum pyrexia & usually resolve within 24 hr without any specific treatment. The most common cause of pyrexia is UTI ( 2-4%) & broad spectrum antibiotic like cefuroxime ( I/V) should be started after urine dipstick & MSU for culture & sensitivity has been sent. Antibiotic may need to be altered after urine result is back.For suspected wound infection, antibiotic should be started after taking swabs (prior to the results are available) & after discussing with microbiologist or according to local guideline.Antibiotic may needs to be altered later depending on the swab result.If there is any abscess , it needs to be incised & drained ,if conservative management fails.In suspected endometritis , antibiotic should be started as per local guideline ( like Augmentine ) & may need alteration when swab results are back.In breast engorgement /mastitis, antibiotics, antiinflamatory analgesics should be given.Breast abscess may need incision & drainage.In suspected chest infection, antibiotic (amoxicilin) , supportive therapy with O2 and physiotherapy may be required.In suspected PE, V/Q scan shold be done to exclude this cause & treatment shold be started with anticoagulant , if diagnosis confirm VTE. The lady will be informed about long term consequences of her condition including subfertility in case of endometritis.she should be discharged with appropriate advice of contraception and also regarding her future pregnancy.
		Posted by Ulduz A. Sat Jan 16, 2010 08:29 pm
a) The clinical scenario is suggestive of septic shock.Sepsis is a significant cause of maternal mortality and clinical investigations and management should be taken concurrently. If patient needs resuscitation maintaining adequate Airway,Breathing and Circulation. Proper history should be taken when patient is stable or from the accompaning person and patient notes reviewed to find the cause of sepsis.History of prolonged rupture of membranes,positive GBS can give clue about chorioamnionitis .Flu,cough,chest infection may give rise to pneumonia.History of breast feeding inquired rule out breast abssess.Notes reviewed to find out if patient had episiotomy and condition of episiotomy asked to rule out wound infection.History of prolonged labour is significant.History of urinary symptoms,loin pain, postpartum catheterisation asked for to rule out UTI and pyelonephritis.History of offensive discharge asked to rule out postpartum endometritis. Examination includes auscultation of chest to rule out pulmonary causes.breasts checked to rule out engorgement,masses,enlarged lymph nodes,local enduration. Abdominal examination done to check uterine involution. Tenderness of renal angle and suprapubic tenderness can point out renal causes. Episiotomy checked, if present to rule out wound infection and breakdown. Bimanual examination done to check uterine size and adnexia. Speculum exam allows to check vaginal discharge and condition of the lochia and to take swabs. b)While resuscitating iv access bloods should be obtained for FBC,coagulation screen,U&E\'s,LFT\'s,CRP,group and save or x-match if appropriate.Blood cultures should be taken before antibiotic therapy started.Urine cultures obtained and vaginal swabs,wound swabs sent if appropriate.Antibiotic treatment should not be delayed while waiting for pending results. c)As mentioned before resuscitation if needed.Patient airway checked,adequate breathing ensured and supplemental O2 started.Fluid resuscitation with colloids and crystalloids started. Ideally,patient should be managed in ICU. Multidisciplinary team-senior obstetrician,anesthethst and microbiologist should be involved from the beginning of the management. Source of infection should be attempted to determine. After iv access obtained and bloods sent iv antibiotics should be started without delay due to high mortality of the condition.IV broad spectrum antibiotics started according to the unit policy. Advice should be obtained from senior microbiologist in order to get the better results.Treatment should be reviewed after results of the cultures are back. Invasive monitoring of vital signs,BP,RR and temperature,SO2,Urine output and arterial blood gases required. Any detoriration should be taken very seriously and seniors should be informed immediately.
		Posted by Ulduz A. Sat Jan 16, 2010 08:30 pm
a) The clinical scenario is suggestive of septic shock.Sepsis is a significant cause of maternal mortality and clinical investigations and management should be taken concurrently. If patient needs resuscitation maintaining adequate Airway,Breathing and Circulation. Proper history should be taken when patient is stable or from the accompaning person and patient notes reviewed to find the cause of sepsis.History of prolonged rupture of membranes,positive GBS can give clue about chorioamnionitis .Flu,cough,chest infection may give rise to pneumonia.History of breast feeding inquired rule out breast abssess.Notes reviewed to find out if patient had episiotomy and condition of episiotomy asked to rule out wound infection.History of prolonged labour is significant.History of urinary symptoms,loin pain, postpartum catheterisation asked for to rule out UTI and pyelonephritis.History of offensive discharge asked to rule out postpartum endometritis. Examination includes auscultation of chest to rule out pulmonary causes.breasts checked to rule out engorgement,masses,enlarged lymph nodes,local enduration. Abdominal examination done to check uterine involution. Tenderness of renal angle and suprapubic tenderness can point out renal causes. Episiotomy checked, if present to rule out wound infection and breakdown. Bimanual examination done to check uterine size and adnexia. Speculum exam allows to check vaginal discharge and condition of the lochia and to take swabs. b)While resuscitating iv access bloods should be obtained for FBC,coagulation screen,U&E\'s,LFT\'s,CRP,group and save or x-match if appropriate.Blood cultures should be taken before antibiotic therapy started.Urine cultures obtained and vaginal swabs,wound swabs sent if appropriate.Antibiotic treatment should not be delayed while waiting for pending results. c)As mentioned before resuscitation if needed.Patient airway checked,adequate breathing ensured and supplemental O2 started.Fluid resuscitation with colloids and crystalloids started. Ideally,patient should be managed in ICU. Multidisciplinary team-senior obstetrician,anesthethst and microbiologist should be involved from the beginning of the management. Source of infection should be attempted to determine. After iv access obtained and bloods sent iv antibiotics should be started without delay due to high mortality of the condition.IV broad spectrum antibiotics started according to the unit policy. Advice should be obtained from senior microbiologist in order to get the better results.Treatment should be reviewed after results of the cultures are back. Invasive monitoring of vital signs,BP,RR and temperature,SO2,Urine output and arterial blood gases required. Any detoriration should be taken very seriously and seniors should be informed immediately.
		Posted by Shamita S. Sat Jan 16, 2010 09:54 pm
Ans This patient is in sepsis and a rapid asesssment of her to .be done looking for her hydration staus ,the respiratory rate ,to auculate tthe chest to assess if she is maintining adequate ventilation .abdominal exmination to look for tenderness ,to rule out any pelvic collection , a per speculum examination to look for any abnormal discharge ,.a bimanual examination to assesss size of uterus status of involution and any pelvic collection .at the same time history of symptoms of causitive organ to be assessed like symptoms of cough ,breathing difficulty ,urinary symptoms like painful micturation ,.haematuria ,pain in the lower abdomen and foul smelling discharge p/v would suggest genital tract infection.history of diarhoea and vomiting to assess sepsis and gut irritation,or gastroenteritis Investigations would inclde FBC to look for leucocytosis and toxic granules as wbc count may be raised due to pregnancy also.blood sugar to be seen blood for urea creat to be seen to asses renal fuction ,serum electrolytes to be checked also .blood to be sent for aerobic and anaerobic culture .vaginal swab to be taken for culture sensetivity to look for genital tract infections urine cuture to be done if urinary nitries positives to lok for causative organism,an ultrasound of the lower abdomen to lok for any retained products or pelvic collectiona chest x ray for effusion r atelectasis Infection may be rapid and overwhelmning and death unavoidable so early intervention is required to prevent irreversible damage ,hence she needs to be admitted in a consultant led unit ,start i.v fluids and oxygen therapy to be started,intravenous broad spectrum antibiotics to be started immediately on strong clinical suspision of sepsis even if diahroea could sugest gastroenteritis as a possible diagnosis,advise from a microbiologist should be sought early to ensure appropriate antibiotic therapy . Subesequent monitoring to assessment of improvement or detoriration would be by recording temperature ,blood pressure pulse and respiratory rate as instable temperature, increase in hypotension ,tachypnoea or altered mental status would indicate patient progresssing to early septic shock ,oxygen saturation to be monitored to assess pt is not going to respiratory failure urinary output to be recorded as oliguria could be presenting as late septic shock .blood to be repeated for FBC to check if total count is reducing ,blood to be cecked for clotting profile as patient can develop DIC, blood for sugar to look for hypoglycaemia .as it can be present aif patient going in shock.once the patient stabilises attempts for treating cause of sepsis to be undertaken .
		Posted by Bgk H. Sat Jan 16, 2010 11:46 pm
:-) A. This patient is likely in puerperal sepsis. She need prompt assessment and timely treatment to prevent maternal mortality and morbidity. Source of infection need to be identified and treated accordingly. History of altered consciousness, headache, and neurological deficit may suggest central nervous system involvement such as meningitis. History of respiratory symptoms, recent contact with pneumonia and abnormal lung findings may suggest respiratory infection. History of difficult delivery, manual removal of placenta and perineal repair associated with abdominal pain, abnormal and foul smelly lochia may suggest genital and uterine infection such as endometritis, infected wound or retain product of conception. Breast examination should be done as mastitis may be the source of infection. History of shortness of breath, calves pain and tenderness may suggest pulmonary embolism. B.I will perform full blood count to look for any evidence of leucocytosis that may present on septic patient. Her haemoglobin level should be checked as anaemic patient may prone to sepsis and will delay recovery. Her urea and electrolytes level should be reviewed as it is common to be deranged and need to be corrected. I will take her coagulation profile as there is frequent finding of disseminated intravascular coagulopathy in septic patient. I will send her blood, urine and vaginal swab for culture and sensitivity to identify any growth and appropriate antibiotics requirement. I will do chest xray to look for any evidence of lung infection and perform abdominal pelvic ultrasound to rule out any retain product of conception. C.She should be treated as an inpatient and monitored in intensive care unit for close monitoring. Multidisciplinary approach needed involving anaesthetist, infective disease team, and haematologist. She should be under single consultant led management and one to one nursing care. Strict input and output need to be charted and fluid balance should be maintained. Temperature charting, vital signs monitoring need to be recorded. The treatment is lead by the source of infection. I will start her on hydration to prevent circulatory failure however may need central line monitoring to prevent fluid overload. I will commence broad spectrum antibiotics while awaiting culture and sensitivity. Blood product should be given accordingly if patient anaemic or in DIC. If there is presence of retain product of conception, evacuation should be arrange after 24 hours coverage of antibiotics provided patient is stable. Pain relief if needed should be given carefully as there may worsened the patient condition and mislead the clinical assessment. Repeated blood count should be done frequently to look at the response of the treatment and to decide further management. If she is not in DIC she should be started on thromboprophylaxis to prevent development of deep vein thrombosis and its sequel as patient may have intravascular volume depletion. Ted stocking should be given and physiotherapy of the lower limb should be given. Breast feeding is not contraindicated; her partner should be informed regarding her progress.
		Posted by F N. Sun Jan 17, 2010 01:45 am
A healthy 30 year old woman is referred to the maternity assessment unit 4 days after spontaneous vaginal delivery because she is feeling generally unwell. Her pulse is 120 / minute, BP = 90/50 mmHg and her temperature is 39 C. (a) Discuss your initial clinical assessment [5 marks]. (b) Discuss the investigations that you will perform [3 marks]. (c) Justify your initial treatment and subsequent monitoring [12 marks]. History of risk factors for postnatal sepsis like prolong rupture of membranes,retained products of conceptions and mannual removal of placenta should be noted.History of cough,cold,urinary symptoms,abdominal pain,vaginal bleeding,foul smelling vaginal discharge, pain and swelling in the breast should be obtained as it will help to diagnose the source of infection. As an assessment for an acutely ill patient,the Airway, breathing ,circulation and concious status of the woman should be checked.Chest should be auscultated for signs of infections.Tender uterus on palpation may be suggestive of retained products.Breasts should be examined for signs of mastitis.Loin tenderness and suprapubic tenderness may be suggestive of UTI or pyelonephritis.Speculam and vaginal examination should be done if there is history of abnormal discharge and retained products.Lower limbs should be examined for signs of DVT. b:The history and examination will guide the investigations required.Full blood count and clotting is requested to check for inflammatory markers,Hgb and platelets.CRP is raised in sepsis.Urea and electrolytes and liver functions should be requested.Blood cultures and urine cultures should be requested to determine the focus of infection. Arterial blood gases and lactate levels can be done tolook foe metabolic acidosis. Vaginal swabs should be taken if there is evidence of pelvic infection.Pelvic ultrasound is done to exclude retained products.Ultrasound of kidneys can be requested if there is suspiscion of pylonephritis.V/Q scan,CTPA can be requested to exclude venous thrmboembolisim. c:Intravenous fluids and broad spectrum intravenous antibiotics preferably in consultation with the micobiologist should be commenced as soon as possible.Multidisciplinary approach involving consultant obstetrician,microbiologist, intensive care team and medical team should be initiated as early as possible to ensure best outcome for the patient. This lady should be admitted to ITU for invasive monitering.Arterial line should be inserted for continous BP monitering and Central venous line for monitering CVP to guide fluid replacement.She should be cathterized to moniter urine output.LMWH should be given if there is suspicision of PE.Surgical evucuation of uterus should be arranged for retained products.It should be done by an experienced operater idealy under I/V antibiotic cover. Daily bloods for full blood count,urea,electrolytes,liver funtion tests and CRP should be done to moniter the patient well being and response to treatment.Antbiotics can be changed according to the results of cultues.Hourly urine output should be recorded.TEDs and prophylactic LMWH should be statred if there is no containdication.
		Posted by Seham S. Sun Jan 17, 2010 02:35 am
SS (a)This is a case of a puerperal pyrexia which may have many underlying causes.Detailed history about onset of symptoms,when discharged from hospital after delivery.History of last delivery and if she had prolonged labour,prolonged rupture of membrane.Iwill ask her about urinery symptoms like dysuria, frequency and lower abdominal pain.Iwill ask her if she have cough or difficulty in breathing for respiratory infection.I will ask her if she is breast feeding or not,and if she have breast pain or nipple crackes which make breast feeding is difficult and lead to breast engogment.Iwould ask her about lochia and if she noticed change in coulor,amount or odour.Pain in lower limb oedema of one limb in relation to the other.Examination include BMI for obesity which lead to increase incidence of thombo-embolic problems.examination of breast for engorgment,swelling ,redness ,abnormal discharge and nipple fissures.Abdominal examination for uterin size, tenderness,loin pain. Speculum examination for coulor of lochia,odour and if there is missed towel.Inspection of episiotomy for healing signs or infection.lower limb examination for similarity and redness or calf tenderness.chest auscultation for breathing sounds or crepitations. (b) Investigation include FBC for leucocytosis and anaemia. CRP for follow up and to detect response to treatment. urin analysis for nitrites,leucocytes,pus cells.sample is better taken by catheter to avoid cotamination with vaginal biood and discharge.Blood should be taken for culture and sensitivity to detect septicaemia.High vaginal swab during speculum examination and uterin swab for culture and sensitivity to detect endometrites.swab from abnormal breast discharge should also be taken. chest x-ray for chest complain and doppler u/s for lower limb signs of DVT. (c) pateint should be admitted for more evaluation and proper monitoring of her condition.I.V fluid for good hydration should be started.Broad spectrum antibiotic as cephalosporins should also be started till results of culture and sensitivity be ready then change to appropriate one .Antipyretic as paracetamol can be given to decrease temperature and give analgesia if she has pain. temp.,pulse and BP should be measured frequently to assess response to treatment. pulse oxymetry for O2 saturation and O2 mask is given incase of decreased saturation. I f patient condition improved and results of investigations show urinery tract, respiratory tract infection or mastitis or even endometrites treatment after giving appropriat antibiotic and anti pyretic is what is needed ,pateint can be discharged and she can continue treatment at home with appointment after one or two weeks for follow up.Breast abscess should be evacuated under general anaesthesia by surgery team with appropriate antibiotic and analgesic.If pateint has +ve doppler study so,heparin should be started immediatly till objective tests for diagnosis of pulmonery embolism can be done.On the other hand, if pateint in spite of initial managment done is deteriorating , septic shock should be suspected especialy if blood culture is +ve and there is persistant hypotention . senior help should be seeked from senior obestetrician,anaesthetist and pateint better to be transfered to high dependency unit for strict monitoring as CVP and more investigation as coagulation profile,kidney function,liver function to be done. corticosteroids could be started and combination antibiotics can be given. septic shock carry high mortality rate and should be diagnosed early and treated promptly .
		Posted by Im F. Sun Jan 17, 2010 03:33 am
Take a short history if patients condition permits other wise read her antenatal records to check for risk factors for sepsis as premature rupture of membrane ,diabetes ,instrumental delivery .Monitor B.P pulse and pulse oximetry and check BMI .inquire about pain redness off breast, pain in abdomen, fowl smelling lochia ,urinary frequency ,dysuria.swelling and pain of leg. Examination breast redness tenderness.Chest auscultation for rhonchi and cardiac murmurs. Abdomen for tenderness and gaurding,size of uterus and palpable for the bladder Perineal examination wound infection ,heamatoma and wound breakdown. Per speculum for foreign body such as gauze piece and lochia amount colour and smell.lower limbs for varicose veins calf tenderness redness.Per anal examination to look for infected hemorrhoids. Inform senior obstetrician and anesthetist. send all relavent investigations. B FBC for raised wbc count suggesting infection,platelet count to check for platelet consumption in case patient is in DIVC coagulation profile.blood culture and sensitivity.Swab from perineal wound and endocervical swab .urinary analysis for nitrites and wbc and glucose.chest x ray to rule out lung infection.breast pus swab for culture and sensivity.doppler scan of both lower limbs for deep venous thrombosis.scan abdomen to look for mass and retained products. C Tepid sponging and paracetamol to control temperature .iv fluids to restore hydration. Broad spectrum iv antibiotics to combat infection. oxygen to reduce hypoxia to tissue. monitor B.P pulse and temperature Breast abscess needs incision and drainage to help reduce inflammation and promote healing. Analgesic to reduce the pain. Endometeritis may be associated with postpatum heamohhage which may require blood transfusion and clotting factor if cogulopathy is developing. if persistant uncontrollable bleeding hysterectomy may be required .If retained products are diagnosed need to do evacuation after antibiotics are started to reduce spread of infection. Urinary tract infection require adequate hydration to maintain urinary out put and antibiotics ..Thromboprophylaxis with low molecular weight heparin as postpartum infection is a risk factor for venous thrombosis.perineal wound heamatoma need to be evacuted and if wound is infected and pus discharging than it requires draining.
		Posted by ASB -. Sun Jan 17, 2010 04:41 am
ASB (a)The most likely diagnosis is septic shock . assessment of conscious state as well as assessment and maintenance of airway , breathing and circulation should be performed first .symptoms suggestive of the aetiology should be obtained like cough, haemptysis for respiratory tract infection ; dysuria frequency for urinary tract infection ; breast pain ,redness or swelling for breast problems ; leg pain , swelling for possible thrombophelibits; abdominal pain and foul vaginal discharge for genital tract infection. history of the last delivery and review of delivery notes may suggest genital tract infection if instrumentation of uterus was performed for removal of remenant of product of conception examination should include measurment of vital signs . breast examination for swelling or tenderness. throat and chest exaination for signs of infection . lower limb examination for swelling ,reddness and tenderness. abdominal examination for uterine tenderness and size . vaginal examination may detect infected episiotomy or perineal tear or foul vaginal discharge. (b)measurment of oxygen saturation .FBC may show leucocytosis suggestive of infection or thorombocytopenia .liver function and renal function should be assessed . Mid stream urine for microscopy and culture and sensitivity.blood sample for culture . swabs from infected episiotomy or perineal tear should be obtained . If clinically indicated , throat swabs and sputum culture should be obtained . (c) managment should be in high dependency unit . insertion of 2 large bore iv canulae , urinary catheter , elevation of patient legs and avoidance of coldness are first general measures . iv hydration with 3 litres of iv fluids per 24 hours to increase intravascular volume . O2 inhalation to improve tissue hypoxia and consequently improve the suspected lactic acidosis. use of vasoactive substance like dopamine to improve tissue perfusion . Broad spectrum antibiotic should be started according to unit protocol and could be changed when culture results are available . Regular monitoring of vital signs and fluid input output should be performed
		Posted by Sarika N. Sun Jan 17, 2010 11:21 am
S/N This is a case of septic shock which carries a high risk of maternal mortality and morbidity. Initially patient will need careful assessment regarding her Airway , breathing and circulation as well as level of consciousness . History about her labour including intrapartum pyrexia especially if she had prolonged rupture of membranes and history of any additional manover during labour as manual removal of the placenta ,suturing of perineal tear or episiotomy. History of offensive lochia and perineal pains. Urinary symptoms ; dysuria,frequency of micturtion ,breast symptoms ;pain reddness nipple discharge and if she starts breastfeeding or not. Lower limbs symptoms as leg pain ,swelling to rule out DVT.any symptoms of chest infection like Cough, expectoration ,pain and dyspnoea. Her examination will include urine dipstick for leucocytes count ,blood cells ,Nitrites, abdominal examination to rule out uterine subinvolution and tenderness or any other tenderness or abdominal swelling. Chest examination for any crepitations , diminished air entry and respiratory rate. Breast examination for tenderness, swelling, fluctuation. speculum examination and high vaginal swab as well as vaginal examination if infected haematoma or episiotomy is suspected. B) Initial investigations will include FBC for leucocytosis ,platlet count to rule out DIC especially in cases of septic shock. Urea and electrolytes, LFT . clotting screening ,CRP althought it not conclusive as it could be elevated normally post natal. Blood culture before starting any antibiotics . urine mid stream culture as well as culture from abnormal nipple discharge, sputum if any .Other investigations could include USS if retained products is suspected , chest X-ray if any suggestive chest symptoms and Doppler US leg when DVT is suspected. C) This patient is best to be managed in HDU for close monitoring and advice will be taken from MDT team include Consultant obstetricians, intensive therapist , microbiologist. IV broad spectrum antibiotics will be started which should be against aerobic and anaerobic microorganisms until blood culture results obtained .and should continue 24 hours after subsiding of temperature when oral antibiotics will take over. Fluid management is very crucial as cases of septic shock could end by renal cortical necrosis.So strict fluid input and urine output volumes will be recorded via Foley’s catheter and central line is advisable when she developed oliguria to avoid pulmonary oedema. Pyrexia will be controlled by paracetamol either IV or rectally until subsides, her risk of DVT will be assessed and TEDs are applied until advice obtained from haematologist regarding prophylactic LMWH based on her coagulation study. Once result of all investigations are available treatment plan will be decided accordingly Additional investigation will be needed if Temperature did not subside, looking for any other source of infection and advice can be obtained from other specialty as well as advice with Microbiologist will be helpful. Oral antibiotics will be commenced once temperature controlled and her temperature will be monitored, advice regarding her baby feeding from paediatrician during her admission is helpful, then monitoring her FBC, U&E Renal function test and her coagulation profile is important. Until they return back to normal otherwise any residual problem will be managed. Follow up appointment will be booked before discharge to discuss all the investigation results and for any residual complaint as well as contraceptive advice.
		Posted by Lilantha W. Sun Jan 17, 2010 12:23 pm
(a) I would take a history and review of case notes to identify risk factors for puerperal sepsis of this patient. Antepartum risk factors such as prolonged pre labour rupture of membranes (PROM), group B streptococcal colonisation, urinary tract infection or high BMI; intrapartum risk factors such as prolonged labour, multiple vaginal examinations, urethral catheterisation or chorioamnionitis; post partum risk factors such as PPH causing anaemia, retained placenta or concerns about placental completeness, perineal tear/episiotomy with subsequent suturing may be found. History of breast feeding problems, breast engorgement, pain and redness may indicate mastitis or breast abscess. History of urinary frequency, dysuria, suprapubic pain and loin pain would suggest urinary tract infection (UTI). Unilateral leg pain, swelling, warmth, around a vein would suggest venous thrombophlebitis. History of productive cough with shortness of breath suggests pneumonia. Apart from pyrexia (>38C), tachycardia (90bpm) and hypotension (SBP<90) other signs of septic shock will be looked for: tachypnoea (>20 breaths/min), hypoxia (oxygen saturation <95% on air), oliguria (<1/2ml/h/kg body wight), anuria (not passing any urine for 12h) cold, clammy peripheries with capillary refill (>2s) and dry mucous membranes may be found. Examination of breast should aim to recognise breast engorgement, focal redness, warmth, and tenderness suggesting either mastitis or breast abscess. Cracked nipples may be the underlying cause. Abdominal examination may reveal palpable, enlarged, tender uterus suggesting endometritis or retained products. Suprapubic tenderness and loin tenderness may coexist with a UTI. Inspection of the perineum would reveal signs of perineal injury or infection or haematoma. Speculum examination would reveal offensive, profuse, bloodstained vaginal discharge in endometritis. Vaginal wall is inspected to look for signs of para-vaginal haematoma. Bimanual examination may reveal very tender uterus and tenderness on cervical movement. Adenexial masses are looked for. Chest is auscutlated to look for coarse crackles and dull percussion note in effusions which are features of pneumonia. (b) I would take blood for culture into paired blood culture bottles to identify the organism causing septicaemia. Drug sensitivity can also be revealed. Venous blood will be urgently sent for FBC (Hb, Platelet count ), U&E (fluid resuscitation), LFT, CRP (inflammation), lactate (metabolic acidosis). PT, APTT, fibrinogen & D-dimer are important to recognise disseminated intravascular coagulation (DIC) which is a serious complication of sepsis. A group and save is done as a blood transfusion is likely. Arterial blood gas is checked to look for metabolic acidosis. Urinalysis is checked. If positive, urgent microscopy will be requested and MSU is sent for culture as UTI is a very common cause. Wound swabs for perineum, a low vaginal and high vaginal swabs are taken as recognising the causative organism may only be possible in this way urgent gram staining can also be useful change the treatment soon. Depending on the clinical diagnosis, pelvic ultrasound scan is necessary to rule out retained products of conception. Similarly, compression duplex ultrasound of leg veins to rule out DVT, a chest X ray to rule out pneumonia can be required. Ultrasound of the breast may be necessary if I&D is planned for potential breast abscess. (c) Two 16G cannule are inserted. Fluid resuscitation with 2L of normal saline is done promptly to initiate the treatment for septic shock aiming to increase the systolic BP and urine output >1mL/h/kg body weight. Inadequate tissue perfusion can cause coma and death as a consequence of shock. Appropriate end organ perfusion is reflected on a good urine output. A packed cell transfusion and FFP+ cryoprecipitate may be followed, if anaemic or DIC. Indwelling catheter is inserted and urine output is measured hourly. 10L of oxygen is given via face mask with a reservoir. Continuous ambulatory monitoring of pulse, BP, pulseoxymetry, is done and be recorded in a MEOWS chart to recognise any acute deterioration of the condition. Broad spectrum intravenous antibiotics is started promptly according to the local guidelines as gram negatives (gentamycin), grm positives (Third generation cephalosporin like ceftrioxone) and anaerobes (metronidazole) must have to be covered. Vancomycin is added, if MRSA or staphylococcus sepsis suspected to avoid serious sepsis. Appropriate thromboprophylaxis is given as the risk of venous thromboembolism is very high in this case. A full length TED stockings for legs and rehydration are essential. Requirement of LMWH is considered after reviewing risk of DIC with blood results to prevent iatrogenic haemorrhage. Antipyretics such as paracetamol 1g qid and ibuprofen 400mg tid is given. NSIDS eg. diclofenac 50mg tid is also prescribed as inflammation can be severe. Dihydrocodeine or morphine may be required for pain. Patient and the family is explained of what has happened and appropriate reassurance given. Treatment for underlying cause is carried out next eg. incision & drainage of breast abscess, ERPC or perineal wound re-suturing. The patient should be admitted to a HDU or ITU which can provide better critical care for a patient in septic shock which is associated with good prognosis. Continuous monitoring of acid base balance is needed particularly if metabolic acidosis was encountered. An arterial line or a CVP line may be required for this purpose as well as good fluid balance. Continuous monitoring of oxygen saturations, pulse rate, capnography is done. BP is checked every 30 min. Urine output is checked hourly. Arterial blood gas may be required every 1-2 hour until the acidaemia settles. U&E, LFT may be deranged and repeated 6 hourly in first 24 h along with FBC, PT ratio, APTT ratio and fibrinogen. CRP and D-dimer is done daily basis. Blood cultures are repeated with spikes of temperature , if pyrexia persists and she is unwell. Lochia is checked 4 times a day. MRSA screening may be performed. Patient is kept nil-orally for about 24h or sooner if she settles earlier. Daily physiotherapy is needed.
		Posted by Bee N. Sun Jan 17, 2010 04:47 pm
(Bee) A healthy 30 year old woman is referred to the maternity assessment unit 4 days after spontaneous vaginal delivery because she is feeling generally unwell. Her pulse is 120 / minute, BP = 90/50 mmHg and her temperature is 39 C. (a) Discuss your initial clinical assessment [5 marks]. (b) Discuss the investigations that you will perform [3 marks]. (c) Justify your initial treatment and subsequent monitoring [12 marks]. A)I will commence a continuous blood pressure , pulse and oxygen saturation monitoring and then perform an electrocardiogram to ensure patient is in sinus rythm.I will commence oxygen by face mask if needed. I will insert 2 wide bore cannula for fluid resustitation and start .I will inform the on call aneasthetist . This patient is in a shock state and so history will be brief so transfer to high depency unit can be done. I will ask about heavy vaginal bleeding which may indicate endometritis. I will ask about breast feeding and breast tenderness which may indicate breast infection. I will ask for a history of dysuria and frequency for urinary tract infection. I will ask for a history of cough and chest pain for chest infection and history of headache and photophobia to rule out intracranial infections. I will then conduct examination with more attention to likely organ affected as indicated in her history. This may include the CNS, breast, chest and abdomen. I will perform a speculum examination to take a high vginal swab for culture. B) The Investigations I will perform will mostly be directed by the likely cause of shock. However they may include Urine for urinalysis and then culture and sensitivity, I will take blood for full blood count, liver function test, electrolyte and urea and c reactive protein to check for infection. I will also perform blood cultures to find evidence of septiceamia. I will then arrange a pelvis ultra sound scan to rule out retained products. C)I will tranfer this patient to high dependency unit where continuous monitoring of vital signs can be done. I will commence on IV fluids with colloids. I will catheterise her and check for input output of fluid. I will then commence antibiotics to cover anearobes as well as gram positive and negative bacteria with a cephalosporine and metronidazole. I will commence on a regular anti pyretic such as paracetamol 1g 4- 6 hourly.Blood investigations such as full blood count, liver function test, electrolyte and urea and c reactive protein will be repeated at least daily. I discuss care of her new born as breast feeding is encouraged when patient feels well enough to do so. Further imaging such as CT scan will be warranted if source of infection is not apparent. I will evaluate for thromboprophylaxis using low molecular weight heparin as this patient is still at pueperium and is having an on going infection.
		Posted by shmaila S. Sun Jan 17, 2010 10:58 pm
DR.SAS A)The most likely diagnosis is Puerperal sepsis,and she is in septic shock.Her airway and breathing should be assesed and high flow oxygen should be administered.Her circuation should be evaluated and I/V access should be maintained.BP,Pulse,respiratory rate,SPO2 should be monitered continously by oximeter and automated moniters.Temperature shoul be checked every 15min.History of burning or increased frequency of urine suggestive of urinary tract infection should be taken.Lower abdominal pain,fowl smelling vaginal discharge and any swelling or pain at the site of perineal repair should be enquired about as endometritis and wound infection are common causes of puerperal sepsis.She should be asked about any pain or swelling in the breasts,as breast engorgement,abcess or mastitis can also cause sepsis.History of swelling,pain or redness in the lower limbs suggestive of DVT should be taken.Symptoms of distant infection,like cough with sputum,diarrhoea and colicky abdominal pain should be asked to look for any respiratory or GIT cause.General examination showing warm and well perfused peripheries with bounding,rapid pulse is suggestive of septic shock.Chest should be examined for rhonchi or crepitation suggestive of respiratory infection.Breasts shold be examined for engorgement,tenderness or abcess.Abdomen should be examined for uterine tenderness as it is a sign of endometritis.Pelvic examination to look for fowl smelling vaginal discharge.abcess,haematoma and wound infection should be done. b)Blood should be taken for FBC,ESR,CRP,Urea and electrolytes,LFT to locate source of infection and monitoring.ABG should be done to detect acidosis and hypoxia.Urine dipstick for proteins,nitrates and blood should be done for UTI.MSU should be sent for culture and sensitivity.Wound and vaginal swab,sputum sample and blood culture should be sent to look for source of infection.Pelvic ultrasound is done for retained products,abcess,haematoma and septic pelvic thrombophlebits. c) The aim of treatment is to treat the underlying infection,provide supportive therapy and to prevevnt the complications including pulmonary edema,DIC,ARDS renal failure and thromboembolism.Fluid balance should be corrected by administration of crystalloids or colloids by I/V infusion, to correct hypovolaemia and dehydration.High flow oxygen should be administered.Multidisciplinary team including obstetrician,anaesthetist,haematologist and physician should be involved in her care.ABG\'S should be done 4-6hourly as lungs are frequently involved and any acidosis or hypoxia can be diagnosed.In severe cases respiratory support with mechanical ventilation may be required.Transfer to ITU should be considerd for subsequent monitoring and should be nursed in isolation if infection with B-haemolytic GAS is suspected. .Bladder should be catheterised for fluid monitoring ,urine output should be maintained at >30ml/hr.Invasive monitoring with arterial or central venous line may be required for strict fluid balance to prevent fluid overload.If the response to circulatory support is not satisfactory then inotropic agents(dobutamine/dobutrex) should be given.FBC,Coagulation profile shoul be done 4-6 hourly as there is a risk of thrombocytopenia,coagulation derrangements and DIC.FFP,platelet concentrates and cryoprecipitates should be given in DIC in consultation with haematologist.Urea,electrolytes and creatinine should be monitered as there is risk of renal failure.Haemodialysis should be resorted to sooner.LFT should be done regularly to look for hepatorenal failure.Broad spectrum antibiotics(like cefuroxime) including metronidazole and gentamicin should be administerd and continued.CRP should be done twice weekly to see for the resolution of infection.Corticosteroids could be administered although its value has not been established.
		Posted by nida H. Mon Jan 18, 2010 04:19 am
A)This patient is in septic shock. It should be dealt with expeditiously,as it may rapidly progress to multiorgan failure with a high maternal mortality. Initial assessment would be to check her Airway, Breathing and Circulation. I will secure airway, ensure that she is spontaneously breathing, give facial oxygen by mask and maintain circulation by starting intravenous fluids. Senior obstetrician should be informed. History is taken to identify the focus of infection. Lower abdominal pain,excessive or foul smelling lochia ,vomiting or diarrhoea would point to pelvic infection. Her delivery notes should be reviewed to see if she had GBS bacteriuria,prolonged rupture of membranes, prolonged labor, instrumental delivery or manual removal of placenta.All these are risk factors for pelvic infection. Fever with chills and rigors,dysuria would suggest urinary tract infection.Cough-productive,with chest pain may indicate pulmonary infection. General examination-I whould include her level of consciousness and pallor for anemia,as anemic women are more prone for puerperal sepsis. Vital signs-Pulse,temperature,blood pressure and respiratory rate and are noted.oxygen saturation is checked. Chest examined for bilateral air entry.Abdominal examination for any localised tenderness,loin tenderness,uterine size and tenderness.Uterus may be subinvoluted and tender in pelvic infections,loin tenderness may be found in pyelonephritis.Pelvic examination-I will look for presense of vulval hematoma,perineal wound if infected,amount and odor of lochia,cervical os ,if open or any retained products of conception.Bimanual examination for adnexal masses B)Investigatins would include FBC,for Hb , leucocytosis.CRP is done,that is useful indicator of infection.Urea electrolytes done to see electrolyte imbalances that is common with sepsis.LFTs and coagulation profile done ,coagulopathy may be indicative of DIC. Urine forMSU.Swabs are taken from throat,perineal wound, vagina and cervix.blood and urine cultures are sent.Chest xray is done to look for lung pathology .USS pelvic for any retained products of conception. C)Patient should be admitted preferably in HDU and should be under multidisciplinary care by obstetrician,microbiologist and intensivist.Hydration is maintained by giving I.V fluids ,crystalloids or colloids may be given.Further treatment may be medical or surgical. Intravenous antibiotics are started without waiting for microbiology results.High dose broad spectrum antibiotics such as cefuroxime and metronidazole to cover anaerobes may be life saving.Serum levels of antibiotics should be checked to ensure they are within therapeutic range,while following the microbiology results.If the fever does not subside in 24-48hrs or the patients condition is deteriorating,anti biotics should be changed and gentamicin or alternative antibiotics added,guided by the expert advice of consultant microbiologist.She should be closely monitored with pulse,BP,Temp,and respiratory rate and SO2,every 15-30 mins.Hourly input-output chart maintained.If hypotension persists even after one hour,inotropes may be needed.Blood results should be followed and if coagulopathy is detected it should be promptly corrected by blood or blood products. Surgical treatment may be required if there are retained products of conception,hematoma or pelvic abcess.
		Posted by Green K. Mon Jan 18, 2010 07:20 am
a) History of increasing vaginal bleeding and foul smelling discharge to suggest endometritis. History of pain at the perineum or episiotomy site to suggest wound breakdown. History of pain at the loins with preceding history of urinary tract infection to suggest pyelonephritis. History of pain at the breasts with feeling of engorgement to suggest mastitis. History of pain at the lower limbs with unequal swelling to suggest presence of deep vein thrombosis and venous thromboembolism. History of respiratory symptoms such as cough and productive sputum to suggest pneumonia. History of haemoptysis and frothy sputum to suggest pulmonary embolism. History regarding immediate post partum events such as retained placenta requiring manual removal or presence of delayed 3rd stage to suggest possibility of retained product of conception. Examination of oral mucosa to assess hydration status as she is tachycardic and hypotensive. Pulse Oximetry to assess her oxygen saturation. Respiratory rate will be recorded. Lungs osculated to detect crepitations to suggest pneumonia. Breast examination to assess for engorgement and tenderness. Abdominal assessment to assess uterine size, tenderness and abdominal mass. Tenderness at the renal angle to suggest pyelonephritis. Perineal inspection to assess episiotomy or tear site if any to look for areas of wound breakdown. Speculum examination to view any haematoma at the vaginal wall as well as to obtain high vaginal swabs for culture. Lower limbs examined to look for unilateral swelling or tenderness to suggest deep vein thrombosis (DVT). b) Urine will be tested with dipstick to test for presence of leucocytes and blood. This would point to possibility of urosepsis if present. Ketones in the urine will help determine the hydration status of the patient. Urine will be sent for culture and sensitivity. Full blood count to look for presence of leucocytosis to suggest infection. Hemoglobin level will suggest if any bleeding if present is excessive as well as to determine if blood transfusion is necessary. C-reactive protein to confirm presence of ongoing sepsis or inflammation as well as to be used as a marker to assess disease progression. Blood will be sent for culture and sensitivity. Blood urea, electrolytes and liver profile will be done as a baseline. Arterial blood gasses done to determine oxygen saturation. High vaginal swabs will be sent for culture and sensitivity. Chest X- Ray will be done if presence of respiratory symptoms or features of pulmonary embolism. Ultrasound Doppler to assess presence of DVT if suggestive features are present. Ultrasound abdomen to detect obvious presence of retained tissue. c) Patient will require admission to stabilize her as well as to determine the source of sepsis. Patient will be informed regarding plan of management and investigations needed. She will be cannulated and hydrated with cystalloids. Her blood pressure, pulse rate and temperature will be monitored half hourly initially. Urine input - output charting will be done hourly initially. She should be managed by a multidisciplinary team with the involvement of consultant obstetrician, anesthetist, microbiologist and midwives. She would be started with broad spectrum intravenous antibiotics pending the result of the blood, urine and swab test. If her status deteriorates then management in a high dependency unit would be appropriate with central venous cannulation and intravenous inotropes to maintain blood pressure , hydration and urine output. If breathing is labored or refractory respiratory acidosis is present, she may required intubation and ventilation. Appropiate antibiotics or changes in antibiotics will be guided by the result of culture and sensitivity tests and needs to be discussed with the microbiologist. She would be given thromboembolic deterrent stockings to wear and prophylactic low molecular weight heparin given as she would be admitted for a few days at least. Subsequent monitoring will depend on the patient\'s clinical status. Her blood pressure, pulse rate,respiratory rate and temperature will be monitored half hourly initially gradually extended to 4- 6 hourly if stable. Her urine input and output charting will be done half hourly initially then gradually extended to 4-6 hourly if stable. She will require serial full blood count and C-Reactive protein to assess disease progession. Serial creatinine, urea and electrolytes to enable correction of any electrolyte imbalance. Serial liver function test and PT/APTT if liver function deranged. Patient\'s general condition will be assess at least twice daily and more frequently if in high dependency unit. Any feature of deterioration wlll require a reassessment and a continuous multidisciplinary input.
		Posted by sutha C. Mon Jan 18, 2010 02:17 pm
SC a) The most likely diagnosis is septic shock. I’d ask the regarding her antenatal care, if she had prelabour rupture of membranes as it is a risk for chorioamnionitis. Her delivery notes will be reviewed, looking if she had prolonged labour, was her placenta complete or did she have retained membranes or did she require manual removal of her placenta for retained products of conception and if she had a episiotomy performed. Her post partum notes are also reviewed, looking to see if she had post partum urinary retention or deep vein thrombosis after the delivery. I’d like to ask her if she has any symptomps of cough which may indicate possibility of pneumonia. History of difficulty in voiding and dysuria while at home with loin pain may indicate pyelonephritis. Foul smelling lochia is also enquired into with associated abdominal pain as it may indicate endometritis. Enquiry is made if she is breast feeding and if she has breast engorgement or even tenderness in one breast which may indicate breast abscess. Examination would be auscultation of her lungs for crepetation which may indicate pneumonia, breast examination looking for abscess which may be the source of infection. Abdominal palpation checking for any tenderness in the suprapubic area or the loin may indicate urinary infection. The uterus is checked making sure it is contracted. A speculum examination is also done, looking at the colour of the lochia and the episiotomy if it was performed. Examination of the lower limb looking for any swelling and tenderness. A chest x ray and ultrasound of the uterus is done looking at the endometrial thickness and the adnexa for any evidence of an ovarian cyst that might have undergone torsion. b) Investigation done would be blood investigation like full blood counts, urea and electrolyte , liver function test and a coagulation profile as septicaemia has a multiorgan involvement. Blood is also sent for culture and sensitivity testing. High vaginal swab and if indicative a throat swab is also sent. Urine for microscopy and culture and sensitivity is also sent looking out for any evidence of urinary tract infection. c) Initial treatment is aimed at stabilizing the patient and starting empirical treatment until further investigations results are available. She would be placed in a propped up position and oxygen given via a face mask at 5l/min. 2 large bore 16G branula is placed and fluid resuscitation is started at the same time. Initially 1L of Hartmans is given over 2 hours in the hope of bringing up her blood pressure. Subsequently fluids are given at 80ml/hr. At the same time her urine output is monitored as we would not want to overload her’ Hourly input and output monitoring is performed. If monitoring is difficult , a central venous pressure monitoring may be required to facilitate the fluid resuscitation. She would be monitored in a high dependency unit where there is 1 to 1 care and her vitals will be monitored every 15 minutes until it is stable and there after it can be monitored every 4 hourly. Broad spectrum antibiotics are also started , intraveneous cefuroxime 1.5 gm immediately followed by 750mg three times a day and intraveneous metronidazole 500mg three times a day. Subsequent management will depend on the investigation findings. If the cultures come back positive for an organism, the antibiotics will be changed accordingly. She will require intraveneous antibiotics until she is afebrile and it will be changed to oral antibiotics subsequently which she has to complete a total of 14 days. If there is evidence of retained products of conception, evacuation is performed after 24 hours of antibiotics. If her episiotomy wound is unhealthy the wound is cleaned for a few days with seitz bath. Once the wound is clean, then resuturing can be done. If she has a breast abscess, incision and drainage is performed and she is advised to continue feeding the baby with the opposite breast and to express and discard the milk form the affected breast. Her general practitioner will be informed regarding the admission to hospital and she is advised to visit him once she is discharged from the hospital.
		Posted by fluffy F. Mon Jan 18, 2010 06:32 pm
From Fluffy A) History regarding place of delivery , as hospital delivery, has better aseptic measures than home deliveries with birth attendant. Any problems during the delivery, post partum haemorhage, retained placenta , did she require any blood transfusions , which will indicated some problems during delivery , higher risk of infection and endometritis.History breast engorgement and sore nipples , which can cause fever due to mastitis.History of fowl smelling lochia with abdominal pain suggestive of endometritis. History of pain at perineum and fowl smeling discharge at episiotomy suggests infected episiotomy wound .History of dysuria , incomplete voiding and frequency suggest urinary tract infection. Examination - general appearance , toxic looking , hypotensive and tachycardic suggestive of septic shock.Examine breast for engorgemement or any signs of abscess . lungs , crepitations and reduced air entry at bases suggestive of pneumonia. Cardiovascular system , on auscultation ,any murmur heard with fever suggestive of infective endocartis.Per abdomen , tender lower abdomen , uterus subinvoluted , suggestive of endometritis . Examine the perineum , episiotomy wound if clean or infected , per speculum examination for lochia , if fowl smelling suggests endometritis. Examine her lower limbs for swelling , redness and tenderness suggestive of deep vein thrombosis. B) A Full blood count , to look for leucocyotosis and the differential count , suggestive of bacterial or viral infection. Blood culture and sensitivity , urine culture sensitivity sent to look for any evidence of infection. A high and low vaginal swab to examine for evidence of endometritis . If on examination suggestive of lung infection , a chext xray must be done .Ultrasound abdomen and pelvis. For the uterus size , a large uterus with thickened endometrium , suggestive of endometritis. C) Admit the patient . Monitor her blood pressure and pulse closely. As she is tachycardic with fever , need to commence on intravenous broad spectrum antibiotics such as cefuroxime and metronidazole . Start intravenous drip and adequate hydration of 80-100 ml/hour of crystalloids, to avoid dehydration. Oral or suppository paracetamol every 4-6 houly to reduce the fever. If her condition deteriorates , she will require ionotropes and intensive care management . she will need close input output monitoring and a central venous pressure will be ideal.She should be referred to the physician , anaesthetists for multi disciplinary care management . Once the blood , urine cultures are available , she should be given the appropriate antibiotic according to the sensitivity.
		Posted by Dr Dyslexia V. Mon Jan 18, 2010 11:34 pm
X a) Patient is in puerperal sepsis and we need to rule out all the infective causes pertaining to it, such as urinary tract infection (UTI), genital tract infection, puerperal mastitis, and other non specific infections. A quick look into her delivery notes and pertaining history is important. History of UTI include dysuria, frequency, loin pain or frothy urine taken. Endometritis or vaginal tract infection could be suggested by foul smelling lochia, history of chorioamnitis or PPROM. Or any extensive perineal tear or manual removal of placenta. History of breast pain, painful breast feeding or pustular or bloody milky discharge from nipple could suggest breast infection. History suggesting respiratory infection such as cough, sputum, throat pain taken. Calf pain or leg swelling history should also be taken to rule out deep vein thrombosis. Examination should include level of consciousness, vital signs noted is important. A quick examination of her throat to suggest upper respiratory tract infection, lung auscaltation for crapitation or rhonchi suggesting infection, breast examination for breast tenderness, mass or engorgement done. Abdominal examination for uterine involution, tenderness should also be done. A pelvic examination to look for foul smelling lochia, integrity of perineal repair or tear, and foreign body done. b) I will do a full blood count to look for evidence of infection such as leukocytosis in bacterial and also assessing her hemoglobin status as well. Septic work up include urine culture, high vaginal swabs, blood culture for aerobe and anerobe microorganism. CRP levels taken to suggest sepsis. Arterial blood gas taken to assess metabolic acidosis in overt sepsis. Ultrasound examination is of value to assess uterine cavity for retain product of conceptus or any other mass in the abdomen i.e. broad ligament hematoma. c) My initial treatment include to assess airway breathing and circulation and establishing it. Transfer to ITU will be adviced and starting her on imperical antibiotics which infection suggest. Usually a third generation cephalosporin and subsequently changed according to sensitivity of organism. Her vital signs and input and output chart is important in monitoring her general well being while looking for evidence of SIRS. This management should be a multi disciplinary approach including obstetrician, physician, and anesthetist. Regular full blood count, renal profile to look for evidence of renal compromise and CRP to monitor the sepsis should be done. Occasionally procedures such as evacuation of retained product of conceptus or incision and drainage of pus will be required to overcome infection. Clinical response could be monitored in terms of decrease of fever, and full blood count response. Other treatment should include DVT prophylaxis. Explanation to spouse and family members and patients is important to alleviate anxiety. Breast feeding could be encouraged if there is any contraindication.
		Posted by Preethi A. Tue Jan 19, 2010 02:52 am
postpartum pyrexia is associated with serious morbidity and mortality most commonly it is pregnancy related espescially with history of ruptured membranes in labour and if associated with feeling unwell with lower abdominal pain,foul smelling lochia with clinically subinvoluted uterus and tender to palpate other possible source is breast if associted with history of pyrexia with redness, tenderness, localized mass or cracked nipples. wound infection is possble cause if episiotomy or perineal trauma repair or cesearean section wound is associated with signs and symptoms of infection symptoms of dysuria, lion pain and pyrexia might sugesst urinary tract infection history to exclude other causes pain in the upper abdomen, chest heart leg should be further investigated. Baseline full blood count, clootting screen, hepatic and renal funtion to done as sepsis can be associated with multi organ failure High vaginal swab,blood cultures and urine microscopy to identity the possile organism and give appropriate antibiotics ultrasound abdomen and pelvis to assess uterine size and involution and presence of any retained produts of conception additional investigation include hepatitis HIV, tuberculosis,CXR,ECG doppler of leg and pelvic veins. CT scan to look for abdominal and renal abscess immediate admission for intravenous hydration, if patient looks unwell ,shocked , tacchycardic, hypotensive and breathless senior help should be taken and admitted to critical care. observation like temp pulse respiratoryrate, oxygen saturationsand strict input out put charts to be maintained IV antibiotics braod spectrum like co-amoxiclav or cefuroxime and metronidazole should be commenced even before microbiology reorts are available as sepsis in postpartum can very rapid and fulminating course. If there is no response with the antibiotics in 24-48 hours microbiologist should be contacted for antibiotic to be changed or gentamicin to be added consultant obstetrician shold be meade aware of patients admission multidisciplinary management by involving aneasthetics, radiologist, heamatologist and surgeons depending patients requirment the need for high dependency bed should be anticipated and necessaary arrangments made available
		Posted by SUNDAY A. Tue Jan 19, 2010 10:08 am
SOS answers. a) My initial clinical assessment would be to stabilise the patient by ensuring she is comfortable and lying in a supine position with airway patent. I would give low flow oxygen by face mask and secure an intravenous access. Thereafter, i would ask about the onset of the pyrexia, medication used and effect, loss of appetite, and any significant intrapartum events such as use of epidural analgesia or intrapartum haemorrhage, problem with delivery of placenta (complete or otherwise).History of vaginal bleeding, passage of clots, feeling of weakness, tiredness and dizziness should be ascertained. History of vomiting, chest pain or shortness of breath, calf or leg pain and swelling should be excluded. Bowel and Urinary symptoms should also be ascertained. A general examination to check for pallor, cold and clammy extremities and regular observation should be done including oxygen saturation, BP, temperature, respiratory rate. I would check for any abnormal breath sounds and murmurs. The size of the uterus should be noted on abdominal examination. A pelvic examination should be done to exclude any infected perineal tear, offensive and heavy lochia and tenderness on bimanual pelvic examination. b) The investigation would include baseline blood test such as FBC, U/Es, LFT, CRP, clotting profile and Group and save and blood cultures. Electrocardiogram ( ECG) should be requested in view of the tachycardia and Arterial blood gases can be requested if oxygen saturation on air is below 95%. A pelvic scan can be requested if there is suspicion of retained products or endometritis. Urine culture and High vaginal swab should also be requested. c) The patient would require close monitoring on the delivery suite HDU with monitoring of fluid input and output charting with ½ hourly observation including oxygen saturation. Broad spectrum IV antibiotics should be stated as per unit protocol. Regular antipyretic such as paracetamol can be given intravenously. Simple measures such as tepid sponging, use of fan or cold compress can help reduce the pyrexia. If there is any evidence of retained pieces of placenta or membranes this should be removed with suction evacuation in the theatre with senior obstetrician supervision as very high risk of uterine perforation. Antibiotics should be given for 24 hours before surgical intervention. Infected perineal tear should be managed conservatively with antibiotics. If patient is anaemic with Hb of less than 8g/dl , consideration should be given for blood transfusion after discussion with the patient the benefits and risk. Regular observation ( 2- 4hourly )of BP, respiratory rate, Temperature, oxygen saturation would be required. Results of HVS, blood cultures should be chased as antibiotics regimen may need to be changed as per the sensitivity pattern. Urine output should monitored initially every hour and should be more than 30mls/hour. All routine bloods can be rechecked every 24 hours and management focussed on any abnormality. Patient’s general wellbeing including control of pyrexia, good urine output, improving blood profile, and ability to mobilise would suggest improvement of clinical condition while oliguria, worsened blood profile, persistent pyrexia, unresponsive patient would indicate a clinical deterioration.
		Posted by tahira jabeen J. Tue Jan 19, 2010 11:35 pm
this patiet is having post partum sepsis.I will take detailed history related to her current symptoms associated with fever like dysuria ,loin pain..pt will be asked about abdomial pain ,foul smelly vaginal discharge.any breast pai n or swelling,pain at episiotomy site.her case notes will be revised to see if she had prolonged rupture of membranes,Group B sterp.+ve in HVS,.if she had manual removal of placenta.I will examie the patient ,see her general condition,dehydration,oxygen saturation,abdominal palpation to see if costovertebral tendernesssuggesting UTI,teder u terus,i will examine her breast for any swelling or discharge,will examie her episiotomy site if wound infection.will do vaginal examination to see lochea,amount,if foul smelly discharge can be due to edometritis. b) i will do full blood count to see hemoglobin,leucocytosis for assessment of pallor and severity of infection.i will do midstream uri analysis,high vaginal swab culture& sensitivity ,blood culture, wound swab for culture & sesitivity if any signs of infection.pelvic uss will be done to see if any signs of edometritis or abcess. C) management will depend upon the origin of pyrexia but as patient vital signs are showing picture of seticemia patient will be admitted in critical care unit& will be managed by multidiciplinary approach involving consultant obstetrician,microbiologist,infection control team. her intravenous access will be taken and started crstylloids ,antipyretics will be give although it will not change the course of disease but will make patient. comfortable,.Patient will be started on broad spectrum antibiotics till culture results are available. if patient in septicemic shock may need inotropic.If cofirmed endometritis management will be optimal if antibiotics cover Bacteroids fragalis and pencillin resistant aaerobs.when uncomplicated endometritis oral therapy following intravenous therapy is unnecessary. if abscess at wound site or breast abscess surgical drainage with antibiotics .
		Posted by Jan I. Tue Jan 19, 2010 11:57 pm
JAN A) This patient has presented with features suggestive of septic shock. Initial assessment would be aimed at locating a likely focus of infection. I would review her casenotes for details of perineal trauma sustained during delivery and whether the placenta was thought to be complete. I would check for any significant past medical history including raised body mass index, asthma, diabetes or thromboembolism as these would modify clinical suspicion of some diagnoses. General clinical assessment including respiratory rate, pulse oximetry and capillary refill should be performed as may indicate the severity of the condition and dictate the urgency of treatment. I would take a history from the patient. A history of worsening abdominal pain, offensive lochia or increasing bleeding associated with a tender uterus and cervical excitation would be compatible with endometritis. A history of productive cough with sputum and/or chest pain with added sounds on chest auscultation would be compatible with respiratory tract infection. A history of urinary frequency, dysuria and increasing loin pain associated with renal angle tenderness and suprapubic tenderness would suggest an ascending urinary tract infection (UTI). A history of focal breast pain with bleeding/discharge from the nipple associated with a focally tender, red breast would suggest mastitis or a breast abscess. A history of a hot, red painful calf or sudden onset pleuritic chest pain would suggest a deep vein thrombosis (DVT) or pulmonary embolus (PE) respectively. A history of worsening perineal pain & discharge associated with a wound breakdown would suggest perineal wound infection. Although rare in an obstetric population in any patient presenting with tachycardia & hypotension acute coronary events should be considered. One would also consider incidental surgical causes including appendicitis, pancreatitis and cholecystitis depending on abdominal findings. B) I would do blood tests. These would include a full blood count looking for a leucocytosis and a serum C-reactive protein assay which if raised would be compatible with infection. Liver function tests & amylase may be useful if cholecystitis or pancreatitis are suspected. Clotting assays, renal and liver function tests should be taken as severe abnormalities in these may indicate multi-organ failure or coagulopathy associated with severe sepsis. I would take blood for culture to isolate any bacteraemic organisms. I would take a urine specimen for dipstick looking for blood, protein, white cells and, most specifically, nitrites that would indicate a UTI. A sample would also be sent for microscopy & culture. Further investigations would be guided by clinical findings. I would take vaginal swabs for culture if endometritis or perineal infection were suspected. I would take sputum samples for culture if present. I would arrange a chest x-ray to look for radiological evidence of a pneumonia if clinically suspected. I would arrange lower limb venous doppler studies (or contrast venography) to look for a DVT if clinically suspected. I would arrange a ventilation-perfusion scan (or CT pulmonary angiography) to investigate PE if suspected. A breast ultrasound scan may help to confirm a breast abcess. An abdominal/pelvic ultrasound scan may demonstrate a pelvic collection, pyosalpinges or retained placental tissue compatible with ascending genital tract infection. C) Initial treatment would start with basic resuscitation including facial oxygen and intravenous fluid support. A central venous pressure line may be warranted for monitoring in the case of cardiovascular instability in an ITU setting. If appropriate low molecular weight heparin should be considered as a septic postnatal patient represents a high risk for subsequent thromboembolic events. TED stockings should be worn by the patient. Specific treatment would be guided by clinical assessment and results of investigations. If endometritis were suspected then intravenous antibiotics should be started to treat the infection. This would include a broad spectrum agent (cephalosporin) and metronidazole for anaerobic cover. Antibiotic choice may be modified based on the sensitivity of causative bacteria if isolated on culture. Microbiological advice may be warranted. If pelvic collections were found then consideration should be given to laparotomy and drainage thereof to remove a persistent focus of infection that may be resistant to medical management only. If retained placental tissue was suspected then evacuation of the utrine cavity should be undrtaken being mindful of the increased risk of perforation and subsequent visceral injury. Antibiotic treatment would also be started for a local perineal infection. Wound refashioning may be necessary later to restore functional anatomy. If a UTI or pyelonephritis were suspected then intravenous antibiotics should be started which should cover gram negative organisms as these are the most commonly the cause. If a mastitis is likely then antibiotics should be started. This is usually flucloxacillin with anaerobic cover. Surgical drainage of an abscess, if present, is usually necessary. Appropriate intravenous antibiotic therapy should be commenced if a respiratory tract infection were suspected. Medical review and chest physiotherapy should be arranged. If a DVT or PE is confirmed then full anticoagulation with heparin should be started immediately while the patient is started on warfarin for long term anticoagulation. Subsequent monitoring would be dictated by clinical condition. If the patient was cardiovasculary unstable, had multi-organ involvement or coagulopathy then ITU level support would be needed for intensive monitoring and correction of metabolic and haematological problems as well as treatment of primary pathology/infection. This would include monitoring of central venous pressure with a CVP line and arterial line blood pressure & oxygen monitoring. A urinary catheter would be passed to allow regular urine output measurement as a reflection of renal function and volume status. In less severe cases monitoring should include frequent and regular pulse, blood pressure, temperature and pulse oximetry to confirm initial response to treatment. The frequency of these observations can be reduced once clinical improvement is established.
		Posted by G. K. Wed Jan 20, 2010 12:55 am
GSK A) Initial assesement includes checking of the patint\'s orientation in time , place and person by a mini mental state examination. If she\'s coherent, she should be asked about any associated symptoms of chest pain and cough with productive sputum, which could point towards pneumonia as a cause of her condition.She should be asked about painful breasts and any associated redness.Questions should be asked about lochia, whether heavy or foul smelling since it could point towards endometritis. Also inquiry should be made regrding any urinary symptoms such as dysuria, loin pain or frequency of voiding to rule out pyelonephritis.If the patient is unable to answer,her attendent\'s help, if present could be sought. Examination should include chest examination to look for signs of pneumonia e.g coarse crackles on auscultation, bronchial breathing, reduced breath sounds. Percussion should be done to look for areas of dullness depicting pleural effusion or fibrosis. Breast should be examined for any inflammmation, abscess formation. abdomen should be palpated for fundal height/ tenederness since a subinvoluted and tender uterus could point towards endometritis. Finally her perineum should be checked for any signs of infection or haematoma. Her notes should be reviewed to see if the placental delivery was complete or if the membranes were ragged.Whether a manual removal was needed. B) Investigations will include full blood count to check for platelet count and leukocytosis . Coagulation screen to make sure that DIC is not superimposing. CRP to monitor the inflammatory response. Bseline renal function and liver function tests should be done. Blood cultures should be taken to ascertain the pathogen responsibleso as to tailor the antibiotic therapy accordingly. Chest xray should be done to rule out a respiratoy cause. Ultrasound of pelvis to rule out retained products of conception. C) Initial management will include asseseement of airway breathing and circulation. IV access should be obtained and IV fluids suchas crytalloids should be comenced to avoid dehydration. Broad spectrum IV antibiotics should be commenced. Oxygen by mask gi should be given.Her care should be in intensive care setting with a multidsciplinary approach including obstetrician, physician, haematologist,intensivists, microbiologist and ITU nurses.The patient should have a CVP line inserted to monitor fluid input. She should be catheterised to maintain strict fluid balance.TED stockings and LMWH should be commenced to avoid thromboembolism. Treatment should be according to the cause. If pneumonia is the cause, then appropriate antibiotics should be prescribed after dicussion with the microbiologist. Similarly pyelonephritis should be treated withIV anibiotics.Antibiotics can be reviewed after blood culture results are available.If pelvic ultrasound shows retained products , then an evacuation of retained products should be performed after atleast 12 hours of IV antibiotics. Pelvic abscess or prineal haematoma present should be drained. After treatmen tand recovery a full debriefing should be done and any questions answered.
		Posted by R S. Wed Jan 20, 2010 06:53 am
R S a. Careful history is taken to reach the underlying cause, so we enquire about causes of infection like prolong rupture of membrane before delivery, prolong labor or retained placenta with manual removal. We try to explore other symptoms like vaginal bleeding which usually accompanied retained pieces of placenta or endometritis. Presence of offensive vaginal discharge is a hint of pelvic sepsis. We try to ask about other causes of fever like presence of cough, sputum or breast pain which reflect mastalgia. Painful swollen leg is a clue of DVT which can cause fever also. General examination is done to assess consciousness, presence of jaundice or dehydration. Presence of cold extremities can raise the possibility of septicemia. The abdomen is examined to find out whether it’s soft or tense, also to detect uterine level and whether its contracted or lax, we also look for presence of mass as intra-abdominal hematoma can cause fever and sepsis. Pelvic examination is done to detect perineal hematoma, also to detect nature of vaginal discharge. b. Full blood count including WBC count and differentiation is obtained to detect infection, also C-reactive protein. Blood group and saving is done as she may need blood transfusion later on. MSU for culture and sensitivity to detect urinary tract infection. Blood culture is also obtained. Abdominal US is done to ensure that uterine cavity is empty, it can also detect pelvic collection and hematoma. High vaginal swab should also considered. Chest X-Ray is done if there are chest symptoms. Renal function test and liver function test are done to exclude end organ dysfunction. c. The patient has puerperal sepsis. Intravenous access is obtained and iv fluid is started, preferably crystalloid solution. Broad spectrum is give paranteraly like third generation cephalosporin (ceftriaxone). Metronidazol vials should also be considered to eradicate anaerobic infection. The antibiotic can be modified according to result of blood culture. Antipyretic is given like paracetamol with encouragement of cold sponging. Foleys catheter is inserted to monitor urine output. Further treatment will be directed by history, examination and investigations result. A chart is started to monitor the patient including her general condition, her vital signs, fluid input, urine out put and medication received. The patient is put on pulse oximeter to measure oxygen saturation. Multidisplinary team is involved in her management including physician and microbiologist. Adequate information is given to the patient and to her family. Clear documentation is of paramount. Monitoring is done by re-assessment of her general condition and response to initial management. WBC, CRP, Blood urea, serum creatinine and liver function test are repeated twice weekly. The patient is followed up closely to detect development of new signs and symptoms like petichea which occur in streptococcal septicemia. If US examination reveals any abnormality, they will be managed accordingly. Intra-abdominal hematoma can be managed conservatively with triple antibiotics and blood transfusion. US monitoring will be needed once weekly to detect reduction in size of heamatoma.
		Posted by Sahithi T. Fri Jan 22, 2010 01:18 am
ST (a))- I will take history of her presenting complaints when and how these symptoms started. I will ask more about delivery and whether she had any perineal repair done. I will check her oxygen saturation and respiratory rate. I will examine her breasts for any tenderness, any cracks surrounding nipples and area of localised redness and pain. I will examine her chest to rule out any respiratory infection. I will palpate abdomen for any area of tenderness guarding and rigidity. Pelvic tenderness suggests pelvic infection. I check for uterine height and note of involution of uterus. Sub-involution points towards uterine infection. Suprapubic tenderness points towards urinary tract infection. I will then proceed for speculum and vaginal examination. Foul smelling lochia is a sign of endometritis. Tenderness in fornices and tender cervical movements are seen in pelvic infection. I will check both legs for any swelling and tenderness in calf muscles to rule out deep vein thrombosis. (b))- I will send her blood sample for checking full blood count, c-reactive protein, and electrolytes. I check her blood for urea and creatinine. This will give me severity of infection and status of her renal functions. I will check liver function tests and coagulation profile. I will send blood culture to know the organism causing sepsis and its sensitivity to antibiotics. I will send high vaginal cervical swabs and mid steam urine for microbiological culture and sensitivity. I will do chest x ray and pelvic scan to search for infective focus. The scan may show any retain bits of placenta if present in uterus. Along with this periodic check on arterial blood gases, full blood count, CRP, coagulation profile and renal functions are necessary to know her wellbeing. (c))- I will admit her in high dependency unit and put her on HDU chart of monitoring as this is a case of purperial sepsis and woman can suffer with septic shock. I will put central and arterial line. This will help to check for any volume overload, check for blood pressure and frequent checks for blood gases. I will involve anaesthetic, physician and microbiologist in her care. There inputs will help to optimise her treatment. I will start her on intravenous fluid, and intravenous broad spectrum antibiotics. I will catheterise her. Cephalosprins or Co-amoxiclav (1.2 grams 8 hourly) along with metronidazole (500 mg 8 hourly) should be started before culture reports are available. Gentamycin 1.5 mg/kg 8 hourly can be added after checking renal functions. Paracetomol is used to control pyrexia. Depending on her saturations nasal oxygen can be started. I will start her on thrombo- prophylaxis (Claxane 1mg/kg/day SC). I will arrange all her investigations listed above. I will ask neonatologist to review her baby to check for any signs of sepsis in baby. After initial stabilisation of general condition of this woman, I will search for focus of infection and treat accordingly. I will monitor her pulse, blood pressure and temperature according to HDU protocol. Her fluid intake and output should be monitored. Her full blood count, CRP, coagulation profile, urea, creatinine and electrolyte levels should be checked twice daily. There is risk of coagulopathy with sepsis. There is increased risk of renal failure, metabolic acidosis and multi organ failure in septicaemia. These investigations and monitoring will help to diagnose these complications earlier. If any evidence of retained placental bits in uterus, evacuation after systemic antibiotics should be considered earliest. If any significant pelvic collection or abscess noted, laparoscopic or open drainage of it should be done. Specific antibiotic treatment should be started after culture reports are available and with liaising with microbiologist.
		Posted by AFSHEEN M. Mon Feb 8, 2010 12:46 am
A healthy 30 year old woman is referred to the maternity assessment unit 4 days after spontaneous vaginal delivery because she is feeling generally unwell. Her pulse is 120 / minute, BP = 90/50 mmHg and her temperature is 39 C. (a) Discuss your initial clinical assessment [5 marks]. (b) Discuss the investigations that you will perform [3 marks]. (c) Justify your initial treatment and subsequent monitoring [12 marks]. a) I will aske her about history of lower abdominal pain,offensive vaginal discharge or heavy bleeding wiyh clots.I will also ask about history of urinary frequency,urgency or dysuria or diarrhea and vomitting.I will enquire about cough,chest tightness,shortness of breath or breast swelling or pain ,if breastfeeding.I will also ask about history of oliguria. On examination,I will recheck her pulse,BP,temperature,alongwith respiratory rate and oxygen saturation.I will examine her skin and peripheries for mottling or cold and clammy.I will examine abdomen for tenderness,and uterine size and contraction.Speculum examination may reveal offensive vaginal discharge,os may be open with some visible retained products.I will assess uterine size,tenderness and adnexal fullness on Bimanual examination.I will also examine her legs, chest and breasts. b)I will perform FBC, U&Es,LFTs,CRP/ESR and coagulation sceen as baseline.WCC and CRP/ESR will help to monitor response to treatment,as inflammatory markers.I will peform a urinalysis fo ketones,leucocytes and nitrites and send for midstream specimen of urine for microscopy and culture and sensitivity if uine dip positive.I will perform high vaginal swab to detect vaginal infections such as bacterial vaginosis and take blood cultures for sensitivity. I will peform a chest X ray,as guided by history and pelvic USS if suspicion of retained products of conception. c)I will admit her,insert 2 wide bore cannulae and monitor observations every 15 minutes till stable.I will start her on IV fluids and broad spectrum antibiotics,such as cefuroxime nad metronidazole,in conjucttion with consultant micribiologist, after obtaining blood cultures.I will give her antipyretics and anlagesia.I will insert a foley\'s catheter and commence a fluid balance chart with hourly input and output measurement.The next step is to identify the focus of infection.If there is suspected UTI or chest infection, I will continue with IV antibiotics for at least 24 hours after symptomatic relief, in conjuction with microbiologist alongwith supportive treatment such as IV fluids and anlgesia.If mastitis is suspected,I will advise her about breast support and encourage breast dainage with a beast pump.If a besat bacess, it will need drainage after appropriate antibiotic cover.However, if os is open , themost likely diagnosis is retained products of conception. I will, therefore ,organise evacuation of retained products, under general anesthesia,after approximately 24 hous of IV antibiotic cover.I will inform her about increased risk of uterine perforation and possible blood transfusion and will arrange 2 units of cross match blood before operation.Procedure should be performed by a senior anesthetist and consultant gynaecologist.i will give her syntocinon 5IU and possibly infusion afterwards and send products fo histology.I will monitor her onbservations half hourly till stable.Before discharge,I will explain findings to her,review all the investigations and advise about contraception.