Presented by:
Hiba AlEnazi
Supervised by:
Dr.Suzan AlKafy
 -case presentation
 -chorioamnionitis.definition,incidence ,risk factors
,pathophysiology ,treatment and complications.
 -postpartum pulmonary embolism,rate,risk
factors,diagnoses and treatment.
In ER:
G3 P2+0 ,unbooked,Saudi lady
GA : term
c/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 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
18/12/2012
11:50 a.m.
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
Impression:
Active labor+/-chorioamnionitis until
proven otherwise.
Plan:
Transfer pt to L&D unit.
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
18/12/2012
12:15 p.m.
Senior on call informed
Pt 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@5
Baby transferred to NICU and intubated.
EBL 600 cc.
18/12/2012
6:50 p.m.
In Recovery:
Pt seen,no SOB,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
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,prophylactic clexan,ISS,ferrous
sulphate and calcium.
19/12/2012
Day 1 post op
Patient was asymptomatic for 24 hrs
Active issue: tachycardia
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
In PNW:
20/12/2012
Day 2 post op
Seen by medical:
Summary:
Anemia with microcytosis
Signficant leukocytosi 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
subsegmental ones,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.
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:orderd CXR,ABG, will
send the BiPAP
After ICU evaluation ordered to
transfer pt to MICU.
21/12/2012
Day 3 post op
9:50 a.m.
In ICU:
Assessment:
Consious,on face mask O2 rate 45,O2
sat99%
Hemodynamically stabel
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.
Mobile CXR:
In comparison to a previous radiograph there is anew left
lower lobe opacity has developed,consistant with atelectic
changes.
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
22/12/2012
Day 4 post op
1:36 p.m.
In ICU:
23/12/2012
Day 5 post op
11:30 a.m.
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 theraputic clexan and repeat ct chest after 1 week.
In PNW:
Vitally stabel
Uterus well contracted
Pv minimal lochia
Pt is for discharge
Instructed for clexan dose injection regularly
Opd in 2 weeks
25/12/2012
Day 7 post op
4:20 p.m.
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
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, 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 .
Selected risk factors and their relative risks for chorioamnionitis,
Risk factor of chorioamnionitis
Relative risk
Reference(s)
≥ 12 hours
> 18 hours
5.8
6.9
13
15
Prolonged labor
Second stage > 2 hours
3.7
15
Active labor > 12 hours
4.0
14
≥ 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
Prolonged membrane rupture (including PPROM)
Multiple digital exams with membrane rupture
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.
Chorioamnionitis
Clinical signs and symptoms:
Maternal
fever(>/=37.8C)
Fetal
tachycardia(>160bpm)
Uterine tenderness
maternal tachycardia
(>100/min)
purulent or foul
amniotic fluid
Diagnoses of chorioamnionitis
CBC
Other
blood
tests
Placental
Amniotic
and
umbilical
fluid
cord
testing
pathology
Complications of chorioamnionitis
maternal
fetal
• increased risk for cesarean
delivery
• Endomyometritis
• wound infection
• pelvic abscess
• bacteremia
• postpartum hemorrhage
• PE
• fetal death
• neonatal sepsis
• cp
Chorioamnionitis
Management
Antibiotics
Suppoetive
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
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
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
Postpartum Pulmonary embolism
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 6year 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
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
Pre exisiting
Previous VTE
Thrombophilia Heritable:
Antithrombin deficiency
Protein C deficiency
Protein S deficiency
Factor V Leiden
Prothrombin gene G20210 A
Acquired (antiphospholipid syndrome)
Persistent lupus anticoagulant
Persistent moderate/high-titre anticardiolipin antibodies or beta2 glycoprotein 1
antibodies
Obstetric
New onset/transient
Potentially reversiblea
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 years
Obesity (BMI >30 kg/m2) either prepregnancy or in early pregnancy
Parity ≥3
Smoking
Gross varicose veins (symptomatic or above knee or with associated phlebitis,
oedema/skin changes)
Paraplegia
Multiple pregnancy, assisted reproductive therapy
Pre-eclampsia
Caesarean section
Prolonged labour, mid-cavity rotational
PPH (>1 litre) requiring transfusion
operative delivery
Surgical procedure in pregnancy or puerperium (e.g., ERPC, appendicectomy,
postpartum sterilisation)
Hyperemesis, dehydration
Ovarian hyperstimulation syndrome
Admission 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)
Postpartum Pulmonary embolism
Diagnoses
Blood work
v/q scan
Pulmonary
angiography
Spiral CT
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
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