Author Information
Shah S*, Pardeshi S**, Warke H***, Mayadeo N****.
(* Second year resident, ** Assistant Professor, *** Associate Professor, **** Professor. Department of Obstetrics and Gynecology, Seth GS Medical College & KEM hospital, Mumbai, India.)
Abstract
Puerperal sepsis is one of the major cause of maternal mortality among the developing countries as well as worldwide. In modern obstetrics with increasing number of hospital deliveries, deliveries by trained personnel, introduction of aseptic measures and availability of higher antibiotics the incidence of maternal mortality due to puerperal sepsis has greatly reduced. Here we are presenting a rare case of puerperal sepsis following a failed attempt of manual removal of placenta which then warranted an obstetric hysterectomy.
Introduction
Puerperal sepsis is defined as infection of the genital tract that occurs during the time period between the onset of labor or rupture of membranes, and the 42nd postpartum day with any of the following two criteria:
a. Fever (temperature greater than 38.0o C or 100.4o C).
b. Pelvic pain
c. Abnormal vaginal discharge
d. Sub involution of the uterus (< 2 cm per day during the first 8 days).
Usually symptoms are seen after 24 hours and up to 10 days. Most common infection is that of the uterus and its surrounding areas, hence it is also known as postpartum metritis.
Puerperal sepsis if diagnosed at the right time is treatable. Major complications can be prevented, but when it goes unrecognized for a long period of time, it may lead to maternal mortality and those salvaged are left with irreversible morbidity.[1]
Case Report
A 22 year old primipara was referred to our tertiary care center in view of puerperal sepsis. She gave history of delivery of a dead fetus at home 19 days ago, following which she had excessive vaginal bleeding and was taken to a private hospital in an unconscious state. Manual removal of the placenta for retained placenta was done there under general anesthesia. She was discharged on day 5. She developed fever of 1030 C on day 14 of manual removal of placenta and went to another private hospital from where she was referred to our hospital in view of retained placenta with puerperal sepsis. On examination she was conscious and oriented in time, place and person but pallor was present. She was febrile. Her temperature was 38 degree C, pulse rate was 110/ min and blood pressure was 110/70 mm of Hg. On abdominal examination uterus was 14-16 weeks in size, deviated to the right side and there was tenderness in bilateral iliac fossae. On speculum examination there was copious amount of purulent foul smelling discharge extruding through the cervix. On vaginal examination uterine size was 14-16 weeks, it was deviated to the right side, and with significant fullness in the pouch of Douglas. Her hemoglobin was 7 gm%, total leukocyte count was 29,400/cmm for which broad spectrum antibiotics were started and she was transfused with one unit of packed cells. DIC profile was within normal limits. Tests for malarial parasites, leptospirosis and dengue NSV1 antigen were negative. Ultrasound of the pelvis showed a bulky uterus with a hypoechoeic lesion within the uterus of size of 7 x 5 x 3 cm suggestive of retained placenta. There was no evidence of adherent placenta. A 9 x 8 x 6 cm sized hypoechoeic lesion with septae was seen in the pouch of Douglas having volume of 216 cc. Magnetic resonance imaging was suggestive of a retained placenta within the fundus in a puerperal uterus with a large recto-uterine pouch collection measuring approximately 4 x 6.7 x 9 cm. The collection appeared to be traversing superiorly till L 5 vertebra. Another collection of size 1.7 x 3.7 x 3.5 cm along the right posterosuperior aspect of the uterine fundus was noted. Decision to perform an exploratory laparotomy was taken with consent for obstetric hysterectomy if required. Intraoperatively frank pus of about 300 ml was found in the peritoneal cavity. Parietal peritoneum was adherent to the bowel. Uterus was about 14-16 weeks size with a rent in the right cornual region measuring about 2 x 2 cm in size. It had necrosed edges. Bilateral ovaries were normal and covered with a thick layer of pus. Decision to perform obstetric hysterectomy was taken in view of the ragged perforation in the cornual region that was friable and suturing would have been difficult. Following obstetric hysterectomy a peritoneal drain was inserted in the peritoneal cavity.
Figure 1. Pus in the peritoneal cavity
Figure 2. Uterus with pus flakes and necrotic edge of the rent in its wall.
After surgery the cut section of the uterus showed retained placental tissue, with uterine perforation in right superior quadrant near the cornual region. It had a necrotic and friable edge.
Figure 3. Uterine rent in right cornual region.
Figure 4. Retained placental tissue in the uterine cavity
She was started on parenteral broad spectrum antibiotics- meropenem, metronidazole and gentamycin after surgery. Culture sensitivity report of the drained pus was awaited. Peritoneal drain drained pus for 4-5 days. Culture sensitivity report showed methicillin resistant staphylococcus aureus (MRSA) sensitive to linezolid for which oral linezolid was given in therapeutic doses for a period of 14 days. On postoperative day 5 wound check was done which showed minimal serous discharge and peritoneal drain was removed. Wound swab was sent for culture sensitivity, which did not grow any organisms on culture. Suture removal was done on day 19 of obstetric hysterectomy. Postoperative course was uneventful and she was discharged on day 20.
Discussion
Maternal sepsis (10.7%) is the third leading cause of maternal mortality after hemorrhage (27.1%) and hypertension (14%) as per statistical analysis by WHO in 2015.[2]
The most important associated risk factor for uterine infection is the route of delivery. A study conducted showed that most incidents of sepsis resulted following home vaginal deliveries.[3] Most common factor associated with puerperal sepsis is anemia.[1,4,5] Other predisposing factors are home delivery, unhygienic means of delivery, retained products of conception, septic abortion, repeated vaginal examinations and prolonged rupture of membranes. Puerperal sepsis most commonly includes uterine infections such as endometritis, endomyometritis and endoparametritis.
A high index of suspicion for uterine perforation should be present whenever any patient who has undergone any intrauterine procedure, presents with symptoms of vascular or visceral injury 2-3 weeks following surgery.[6] Women with delayed diagnosis of uterine perforation may typically present with signs and symptoms of associated complication such as sepsis and anemia. The cause of complications should be further evaluated so as to confirm suspected uterine perforation. Though uterine perforation cannot be confirmed or excluded with any imaging studies, febrile anemic patients presenting with pelvic mass or tenderness in the pelvic region should have an ultrasound done as it is the test of choice for evaluation.[6]
Management strategy includes blood & blood product transfusion, antibiotic therapy, intravenous fluids & surgery wherever indicated. Uterus should be inspected for any perforation if abdominal exploration is performed. In absence of any visible defect previous uterine perforation cannot be excluded, since small defects might close spontaneously. Uterine perforation may weaken the uterine wall and raises concerns for an increased risk of uterine rupture during a subsequent pregnancy.[7-9] Group B streptococcus, E. coli and staphylococcus aureus especially MRSA are the most common causative agents of postoperative infections and puerperal sepsis.[1, 4] Importance of timely surgery and obstetric hysterectomy if indicated along with broad spectrum antibiotics is most effective in reducing maternal morbidity and preventing maternal mortality.[10]
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Shah S, Pardeshi S, Warke HS, Mayadeo NM. Obstetric Hysterectomy: A Life Saving Measure For Puerperal Sepsis. JPGO 2016. Volume 3 No. 11. Available from: http://www.jpgo.org/2016/11/obstetric-hysterectomy-life-saving.html