Presented by:

Hiba AlEnazi

Supervised by:Dr.Suzan AlKafy

UNBOOKED AND ICU SERIES

CASE#1

-case presentation-chorioamnionitis.definition,incidence ,risk

factors ,pathophysiology ,treatment and complications.

-postpartum pulmonary embolism,rate,risk factors,diagnoses and treatment.

objectives

18/12/201211:50 a.m.In ER:

G3 P2+0 ,unbooked,Saudi lady GA : termc/o labor pain started the day before+ve hx of gush of fluid 3 days ago,not sure of color nor the odour.No hx of decrease fmSystemic symtoms :unremarkable.Hx of this pregnancy: totally unbookedPast ob hx:All previous svd >>>uneventfulMedical hx: k/c asthma,frank dm not on medicationSurgical hx:free

On Examination:Vitals in triage:BP 90/68HR 139T 38 CO2 % = 100 %RR 24Pt was distressed in pain,uncooperative.

PA:S,C,LL,TFHR 177 b/min

PV:7 cm fully effacedVx 0MAOffensive discharge

Impression:

Active labor+/-chorioamnionitis until proven otherwise.

Plan: Transfer pt to L&D unit.

18/12/201212:15 p.m.IN L&D:

Pt stared ampicillin loading dose 2 g iv then 1 g iv q 6hrs,clindamycin 600 mg q8hrs,gentamicyn 80 mg q8hrs,perfalgan 1g q6hrs.Vitals :BP:111/59HR: 135T: 38.6CRR:24O2 sat= 100%CTG applied:Fhr baseline 180 bpmMinmal variabilityVariable deceleration No accelerationCtegory II

Senior on call informedPt observed and he contacted consultant on call and plan for er cs

Blood gp O+hb=8.5

ceasearn section done.Baby girl deleverd at 13:41 w/ apgar scor of 2@1, 6@5Baby transferred to NICU and intubated.

EBL 600 cc.

In Recovery:

Pt seen,no SOB,no chest painPa: uterus is contracted Soft ,laxMinimal lochiaVitals:BP 138/37HR 123T 37.1RR 20O2 sat 99%

Transfer to PNW

18/12/20126:50 p.m.

19/12/2012Day 1 post opIn PNW:

She was afebrileBP ranged but within normal rangeHR ranged between 117-137 bpmRR 20O2 sat 100%Lab results:hb 6.8Wbc15.11Platelates: 292

Pt transfused 1 Unit PRBC

She was on:ampicillin,clindamycin ,gentamicyn,prophylactic clexan,ISS,ferrous sulphate and calcium.

Patient was asymptomatic for 24 hrs

Active issue: tachycardia

20/12/2012Day 2 post op

In PNW:Pt seen C/OShortness of breathChest painNo plapitation No dizzinessNo coughNo hymoptysis on EX:Vitals: HR 114,BP 127/80,T36.8,O2 sat 100%,RR20Chest is clearNo murmersPa:soft and lax,contracted and tender uterus above the umbilicusNo LL edema or tendernessPlan:Spiral ctCardiac enzyme ECGMedical referral

20/12/2012Day 2 post op

In PNW:Seen by medical:Summary:Anemia with microcytosisSignficant leukocytosi with left shiftFever along w/ tachycardia and tachpneaNormal arterial blood gases Pulmonary angio:Ruled out major pulmonary embolisim but coul not rule out subsegmental ones,bilateral basal atelectic bands seen.Impreassion:chorioamnionitis seems plausable,tachypnea related to atelectasisPlan:Full septic screenMycobacterium studiesAnemia workupInflammatory markersEchoDc current antibiotics and start TazocinStart nebulization sessions.

21/12/2012Day 3 post op9:50 a.m.

In PNW:Pt seen,still c/o SOB and chest painVitals:Bp 143/66,HR 119, RR 51,O2 sat 97 %Pt is unstabal and critical

Medical contacted and asked for ICU referral and change heparin to theraputic dose.

ICU contacted:orderd CXR,ABG, will send the BiPAP

After ICU evaluation ordered to transfer pt to MICU.

21/12/2012Day 3 post op14:50 p.m.

In ICU:Assessment:Consious,on face mask O2 rate 45,O2 sat99%Hemodynamically stabelUrine adequteTemp 38, wbc15,81 decreasing on TazocinCultures sentOn clexan 70 mg subQ BIDLab results:Hb 8Platelates 364ESR 123 d dimer2 fibrinogen900Pt is in distressPlan apply bipapCbc ChemistryEcho bedside normalDiagnoses: chest infection +/- PE

Mobile CXR:In comparison to a previous radiograph there is anew left lower lobe opacity has developed,consistant with atelectic changes.

22/12/2012Day 4 post op1:36 p.m.

In ICU:

GCS 15/15Off inotrpsBp 129/70On BIPAP 16/7 FIO2 30%,o2 sat 100%Taking orallyUOP 200 cc,normal renal functionSpiking fever,w/leukocytosis (improving)On tazocin,no +ve culturesHb 7.6Normal coagulation Plan:Doppler ll>>> no signs of DVT

23/12/2012Day 5 post op11:30 a.m.

In ICU:GCS 15/15Vitals:HR 100 137/101Rr 26O2 sat 100% on 2 NC AfebrileChest is clearCXR showed air bronchogram suggested for consolidation.Histopathology released:third trimester placenta with funisitis and chorioamnionitis

Plan:discharge from ICUCon t Abx and trace culuturesCont theraputic clexan and repeat ct chest after 1 week.

25/12/2012Day 7 post op4:20 p.m.

In PNW:

Vitally stabelUterus well contractedPv minimal lochiaPt is for dischargeInstructed for clexan dose injection regularlyOpd in 2 weeks

Chorioamnionitis (intra

amnoiticinfections)

Chorioamnionitis

Definition:an acute inflammation of the membranes and chorion of the placenta, typically due to ascending polymicrobial bacterial infection in the setting of membrane rupture.

-can occur with intact membranes, especially common for the very small fastidious genital mycoplasmas such as Ureaplasma species and Mycoplasma hominis, found in the lower genital tract of over 70% of women

-rarely is hematogeneous spread implicated in chorioamnionitis, as occurs with Listeria monocytogenes

-varies according to key diagnostic criteria, which can be clinical (presence of typical clinical findings), microbiologic (culture of microbes from appropriately collected amniotic fluid or chorioamnion) or histopathologic (microscopic evidence of infection or inflammation on examination of the placenta or chorioamnionic specimens

-polymicrobial infection most often due to ascending genital microbes .

-over 65% of positive amniotic fluid cultures involve two or more organisms. The genital mycoplasmas, Ureaplasma urealyticum and Mycoplasma hominis (genital mycoplasmas).

-These provoke a robust inflammatory reaction affecting both maternal and fetal compartments, particularly in preterm gestations .They are commonly isolated from amniotic fluid in the setting of preterm birth or premature membrane rupture with or without clinical chorioamnionitis .

Chorioamnionitis

Risk factor of chorioamnionitis Relative risk Reference(s)

Prolonged membrane rupture (including PPROM)

≥ 12 hours 5.8 13> 18 hours 6.9 15

Prolonged laborSecond stage > 2 hours 3.7 15

Active labor > 12 hours 4.0 14

Multiple digital exams with membrane rupture

≥ 3 exams 2 to 5 13–14

Nulliparity 1.8 14

Group B streptococcus colonization 1.7 to 7.2 14, 16, 19

Bacterial vaginosis 1.7 17

Alcohol and tobacco use 7.9 15

Meconium-stained amniotic fluid 1.4–2.3 7, 14

Internal monitoring 2.0 13

Epidural anesthesia 4.1 15

Selected risk factors and their relative risks for chorioamnionitis,

-1–4% of all births in the US are complicated by chorioamnionitis . –

-Chorioamnionitis (clinical and histologic combined), complicates as many as 40–70% of preterm births with premature membrane rupture or spontaneous labor .

-1–13% of term births .

-Twelve percent of primary cesarean births at term involve clinical chorioamnionitis, with the most common indication for cesarean in these cases being failure to progress usually after membrane rupture.

Incidence:

Chorioamnionitis

Clinical signs and symptoms:

Maternal fever(>/=37.8C)

Fetal tachycardia(>160b

pm)

Uterine tendernessmaternal

tachycardia (>100/min)

purulent or foul amniotic fluid

Chorioamnionitis

Diagnoses of chorioamnionitis

CBCOther blood tests

Amniotic fluid testing

Placental and

umbilical cord patholo

gy

Complications of chorioamnionitis• increased risk for cesarean delivery

• Endomyometritis• wound infection• pelvic abscess• bacteremia • postpartum hemorrhage • PE

maternal

• fetal death• neonatal sepsis • cpfetal

Management

Suppoetive

Antibiotics

Chorioamnionitis

Antibiotics-randomized trials and observational studies demonstrate that immediate intrapartum use of broad-spectrum antibiotics significantly reduces maternal and fetal complications of chorioamnionitis.

-neonatal sepsis is reduced by up to 80%

-optimal antibiotic regimen for treatment of clinical chorioamnionitis has not been well-studied and current recommendations are based largely on clinical consensus

-Intravenous administration of ampicillin every 6 hours and gentamicin every 8–24 hours until delivery is the typical regimen ---cesarean delivery is performed, clindamycin every 8 hours (or metronidazole) is often added for anaerobic coverage

-Optimal treatment should also include administration of a single intravenous additional dose of antibiotics after delivery

Chorioamnionitis

-although genital mycoplasmas are the most commonly isolated organisms associated with chorioamnionitis, the standard antibiotic regimens used for clinical chorioamnionitis do not provide optimal coverage against these organisms

-The standard regimen effectively treats maternal infection (>95% success rate) and reduces neonatal sepsis, and there are currently no published trials suggesting that specific coverage against ureaplasma (with macrolide antibiotics) provides additional benefits

ChorioamnionitisAntibiotics

For the mother with chorioamnionitis, serious infectious complications include endometritis, localized pelvic infections requiring drainage, and intra-abdominal infections. Maternal chorioamnionitis or other secondary infectious complications may cause thrombosis of pelvic vessels and the potential for pulmonary emboli.

AuthorMichael P Sherman, MD Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Director, Fellowship Training Program in Neonatal-Perinatal Medicine, NICU, Columbia Regional Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine

Postpartum Pulmonary embolism

-Pulmonary embolism is the leading cause of maternal death in the UK and Norway . And amongst the leading causes in Australia and the US.

-The rate of venous thromboembolism was 1.72 per 1000 deliveries with 1.1 deaths per 100,000.

-rate of pulmonary embolism following birth is 0.45 per 1000 deliveries and this rate was relatively stable over a 6-year period despite a rise in the Caesarean section rate.

-Pregnancy itself is a risk factor for pulmonary embolism,and increases the incidence by a factor of five because of thenormal physiologic changes of pregnancy (decreasedfibrinolytic activity and effects of estrogen on the coagulation system and vessels) increase the risk of thromboembolism.

-Also, cesarean delivery increases the risk of pulmonaryembolism 9-fold compared to vaginal delivery.6,7

Postpartum Pulmonary embolism

Risk factors:

-38% higher for women ages 35 and older

-64% higher for black women.

-Thrombophilia, lupus, heart disease, sickle cell disease, obesity, fluid and electrolyte imbalance, postpartum infection, and transfusion.

-The risk factor with the highest odds ratio, 51.8 (38.7-69.2) was thrombophilia.

-Maternal transfusion of all types was crudely associated with an increased risk of postpartum pulmonary embolism (RR = 8.90; 95% CI, 5.74, 13.8). For women whose transfusions included fresh frozen plasma, cryoprecipitate, platelets or coagulation factor in addition to packed cells or whole blood, compared with women who did not received any blood transfusion

Postpartum Pulmonary embolism

Pre exisiting Previous VTE

Thrombophilia Heritable:Antithrombin deficiencyProtein C deficiencyProtein S deficiencyFactor V LeidenProthrombin gene G20210 AAcquired (antiphospholipid syndrome)Persistent lupus anticoagulantPersistent moderate/high-titre anticardiolipin antibodies or beta2 glycoprotein 1 antibodies

Medical comorbidities (e.g., heart or lung disease, SLE, cancer, inflammatory conditions (inflammatory bowel disease or inflammatory polyarthropathy), nephrotic syndrome (proteinuria >3 g/day), sickle cell disease, intravenous drug user Age >35 yearsObesity (BMI >30 kg/m2) either prepregnancy or in early pregnancyParity ≥3SmokingGross varicose veins (symptomatic or above knee or with associated phlebitis, oedema/skin changes)Paraplegia

Obstetric Multiple pregnancy, assisted reproductive therapyPre-eclampsiaCaesarean sectionPPH (>1 litre) requiring transfusion

Prolonged labour, mid-cavity rotational operative delivery

New onset/transient Surgical procedure in pregnancy or puerperium (e.g., ERPC, appendicectomy, postpartum sterilisation)

Potentially reversiblea Hyperemesis, dehydrationOvarian hyperstimulation syndromeAdmission or immobility (≥ 3 days' bed rest) (e.g., symphysis pubis dysfunction restricting mobility)Systemic infection (requiring antibiotics or admission to hospital) (e.g., pneumonia, pyelonephritis, postpartum wound infection)Long-distance travel (> 4 hours)

Blood work v/q scan

Pulmonary

angiography

Spiral CT

Diagnoses

Postpartum Pulmonary embolism

Treatment :

Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis, and to discontinue UFH, LMWH, or fondaparinux only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation).[

Women experiencing a thromboembolic event during pregnancy should receive therapeutic treatment with unfractionated heparin or LMWH during pregnancy, with anticoagulation continuing for 4-6 weeks postpartum and for a total of at least 6 months

Postpartum Pulmonary embolism

Chorioamnionitis:-identify signs and symtoms.-start antibiotics immediately.-it is not an indication for ceasearn delivery.-treatment of BV may decease risk .

Pulmonary embolisim:-Pregnancy and postpartum period is a hypercoagulabe state.- identify risk factors to start prophylactic anticoagulant.

Thank you