UNBOOKED AND ICU SERIES CASE#1

1. UNBOOKED AND ICU SERIESCASE#1 Presented by: HibaAlEnazi Supervised by: Dr.SuzanAlKafy

2. objectives • -case presentation • -chorioamnionitis.definition,incidence ,risk factors ,pathophysiology ,treatment and complications. • -postpartum pulmonary embolism,rate,riskfactors,diagnoses and treatment.

3. 18/12/2012 11:50 a.m. In ER: G3 P2+0 ,unbooked,Saudi lady GA : term c/o labor pain started the day before +vehx of gush of fluid 3 days ago,not sure of color nor the odour. No hx of decrease fm Systemic symtoms :unremarkable. Hx of this pregnancy: totally unbooked Past ob hx: All previous svd >>>uneventful Medical hx: k/c asthma,frank dm not on medication Surgical hx:free

4. On Examination: Vitals in triage: BP 90/68 HR 139 T 38 C O2 % = 100 % RR 24 Pt was distressed in pain,uncooperative. PA: S,C,LL,T FHR 177 b/min PV: 7 cm fully effaced Vx 0 MA Offensive discharge

5. Impression: Active labor+/-chorioamnionitis until proven otherwise. Plan: Transfer pt to L&D unit.

6. 18/12/2012 12:15 p.m. IN L&D: Pt stared ampicillin loading dose 2 g iv then 1 g iv q 6hrs,clindamycin 600 mg q8hrs,gentamicyn 80 mg q8hrs,perfalgan 1g q6hrs. Vitals : BP:111/59 HR: 135 T: 38.6C RR:24 O2 sat= 100% CTG applied: Fhr baseline 180 bpm Minmal variability Variable deceleration No acceleration Ctegory II

7. Senior on call informed Pt observed and he contacted consultant on call and plan for ercs Blood gp O+ hb=8.5 ceasearn section done. Baby girl deleverd at 13:41 w/ apgarscor of 2@1, 6@5 Baby transferred to NICU and intubated. EBL 600 cc.

8. 18/12/2012 6:50 p.m. In Recovery: Pt seen,noSOB,no chest pain Pa: uterus is contracted Soft ,lax Minimal lochia Vitals: BP 138/37 HR 123 T 37.1 RR 20 O2 sat 99% Transfer to PNW

9. 19/12/2012 Day 1 post op In PNW: She was afebrile BP ranged but within normal range HR ranged between 117-137 bpm RR 20 O2 sat 100% Lab results: hb 6.8 Wbc15.11 Platelates: 292 Pt transfused 1 Unit PRBC She was on:ampicillin,clindamycin ,gentamicyn,prophylacticclexan,ISS,ferroussulphate and calcium.

10. Patient was asymptomatic for 24 hrs Active issue: tachycardia

11. In PNW: Pt seen C/O Shortness of breath Chest pain No plapitation No dizziness No cough No hymoptysis on EX: Vitals: HR 114,BP 127/80,T36.8,O2 sat 100%,RR20 Chest is clear No murmers Pa:soft and lax,contracted and tender uterus above the umbilicus No LL edema or tenderness Plan: Spiral ct Cardiac enzyme ECG Medical referral 20/12/2012 Day 2 post op

12. In PNW: Seen by medical: Summary: Anemia with microcytosis Signficantleukocytosi with left shift Fever along w/ tachycardia and tachpnea Normal arterial blood gases Pulmonary angio: Ruled out major pulmonary embolisim but coul not rule out subsegmentalones,bilateral basal atelectic bands seen. Impreassion:chorioamnionitis seems plausable,tachypnea related to atelectasis Plan: Full septic screen Mycobacterium studies Anemia workup Inflammatory markers Echo Dc current antibiotics and start Tazocin Start nebulization sessions. 20/12/2012 Day 2 post op

13. 21/12/2012 Day 3 post op 9:50 a.m. In PNW: Pt seen,still c/o SOB and chest pain Vitals: Bp 143/66,HR 119, RR 51,O2 sat 97 % Pt is unstabal and critical Medical contacted and asked for ICU referral and change heparin to theraputic dose. ICU contacted:orderdCXR,ABG, will send the BiPAP After ICU evaluation ordered to transfer pt to MICU.

14. In ICU: Assessment: Consious,on face mask O2 rate 45,O2 sat99% Hemodynamicallystabel Urine adequte Temp 38, wbc15,81 decreasing on Tazocin Cultures sent On clexan 70 mg subQ BID Lab results: Hb 8 Platelates 364 ESR 123 d dimer2 fibrinogen900 Pt is in distress Plan apply bipap Cbc Chemistry Echo bedside normal Diagnoses: chest infection +/- PE 21/12/2012 Day 3 post op 14:50 p.m.

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

16. 22/12/2012 Day 4 post op 1:36 p.m. In ICU: GCS 15/15 Off inotrps Bp 129/70 On BIPAP 16/7 FIO2 30%,o2 sat 100% Taking orally UOP 200 cc,normal renal function Spiking fever,w/leukocytosis (improving) On tazocin,no +ve cultures Hb 7.6 Normal coagulation Plan: Doppler ll>>> no signs of DVT

17. 23/12/2012 Day 5 post op 11:30 a.m. In ICU: GCS 15/15 Vitals: HR 100 137/101 Rr 26 O2 sat 100% on 2 NC Afebrile Chest is clear CXR showed air bronchogram suggested for consolidation. Histopathology released:third trimester placenta with funisitis and chorioamnionitis Plan: discharge from ICU Con t Abx and trace culutures Cont theraputicclexan and repeat ct chest after 1 week.

18. 25/12/2012 Day 7 post op 4:20 p.m. In PNW: Vitally stabel Uterus well contracted Pv minimal lochia Pt is for discharge Instructed for clexan dose injection regularly Opd in 2 weeks

19. Chorioamnionitis (intra amnoiticinfections)

20. 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 Mycoplasmahominis, found in the lower genital tract of over 70% of women • rarely is hematogeneous spread implicated in chorioamnionitis, as occurs with Listeriamonocytogenes • 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

22. Chorioamnionitis -polymicrobial infection most often due to ascending genital microbes . -over 65% of positive amniotic fluid cultures involve two or more organisms. The genital mycoplasmas, Ureaplasmaurealyticum and Mycoplasmahominis (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 .

24. Selected risk factors and their relative risks for chorioamnionitis,

25. Chorioamnionitis Incidence: -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.

26. Chorioamnionitis Clinical signs and symptoms:

28. Complications of chorioamnionitis

29. Chorioamnionitis

30. 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

31. Chorioamnionitis Antibiotics -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

32. For the mother with chorioamnionitis, serious infectious complications include endometritis, l ocalized pelvic infections requiring drainage, and intra-abdominal infections. Maternal chorioamnionitis or other secondary infectious complications may cause thrombosis of pelvic vessels and the potential for pulmonary emboli. Author Michael P Sherman, MD Professor, Department of Child Health, University of Missouri-Columbia School of Medicine; Director, Fellowship Training Program in Neonatal-Perinatal Medicine, NICU, Columbia Regional Hospital; Professor Emeritus, Department of Pediatrics, University of California, Davis, School of Medicine

33. Postpartum Pulmonary embolism

34. 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 the normal physiologic changes of pregnancy (decreased fibrinolytic activity and effects of estrogen on the coagulation system and vessels) increase the risk of thromboembolism. -Also, cesarean delivery increases the risk of pulmonary embolism 9-fold compared to vaginal delivery.6,7

35. 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

37. Postpartum Pulmonary embolism Diagnoses

38. 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

39. 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.

40. Thank you