DICPUERPERRAL SEPSIS

Puerperal sepsis

• Bacterial infection of genital tract after delivery.

• Organism :polymicrobial

• Mode of infection:Exogenous: external sourcesEndogenous: organism already present in genital tract-anaerobic

streptococci.Autogenous: from septic focus in the patient

Puerperal sepsis

• Predisposing factorsGeneral causes: anaemia, diabetes

Local causes: ROM, laceration, retained placenta

• Site of infection:Primary: laceration, placental bed, retained tissueSecondary: tubes, ovaries, peritonium, parametrium, pelvic veins

pathology

• Localized= putrid endometritis= mild formInfection is limited to the superficial layer of endometrium

• Spreading=septic endometritis= severe form

The endometrium is the commonest site of puerperal sepsis

Clinical picture• Infected tears: local pain , mild fever, dysuria

• Endometritis: fever in the 3rd day, lower abdominal pain , tender uterus, offensive excessive lochia

• Septicaemia: 3rd or 4th day, high temp, pulse rapid, lochi is scanty and not offensive

• Salpingooophoritis:

• Parametritis: 2nd week

• Peritonitis

• Pelvic thrombophlebitis: 2nd week, mild fever,

Investigation

• CBC+ Diff WCC

• Blood culture

• MSU , culture sensitivity

• Cervicovaginal swab

• Ultrasound

• ? X ray chest, widal test, blood film for malaria

ttt

• Prophylactic:During pregnancy: ttt anaemia

During labour: aseptic condition, VE <, antibiotic if SROM > 18H, complete delivery of placenta,

Puerperium:avoid hospital acquired infection,

ttt

• General measures

• Antibiotic

• Drainage : fowler, semisitting,

• Heparin for pelvic vein thrombosis

DIC

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

Causes of DIC

• Abruptio placenta 60-70%• Missed miscarriage• IUFD• Sepsis• AF embolism• Severe preeclampsia and eclampsia• Massive bleeding• Massive blood transfusion• Incompatable blood transfusion• Acute fatty liver of pregnancy

Diagnosis of DIC• Bleeding per nose , haematuria

• Bleeding from puncture sites

• PPH

• Clot observation test= Weiner test =bed sit test

Failure of any clots in 5ml tube blood within 10 minutes indicate fibrinogen ?100mg%

If a clot forms the tube incubated at 37c . If clot dissolves after 30 minutes it means excessive fibrinolytic activity

Diagnosis of DIC• Low fibrinogen

• FDP > 40 micrograms/ml

• Platelet < 100,000/cumm

• Prothrombin time is increased ( N 10-15 second)

• Thrombin time is increased ( N 25-35 second)

• PTT is increased ( N 25-35 Second)

• Antithrombin 111 deficiency

• D-Dimers is increased > 0-5 microgram/ml is abnormal

Treatment of DIC• Treat the cause: infection-antibiotic

• Fresh blood

• Fresh FP

• Cryoprecipitate

• Give platelet if Platelets <50,000

• Antithrombin 111 adminstration

• Heparin to increase fibrinogen

Treatment of DIC

Remember• Dextran more than one liter may cause DIC

• Dextran interferes with cross matching

• One unit platelets raises the platelet count by 10,000/mm3

• Each unit cryoprecipitate raise the fibrinogen level by 10mg/dl

• One liter of FFP Supplies 3 gm fibrinogen and all clotting factors