OBSTETRIC COMPLICATIONS AS A CAUSE OF MULTIPLE ORGAN FAILURE
Vesna Elvedji- Gašparović1, I. Kuvačić1, V. Gašparović2, M. Kopjar3
1 University Department of Gynecology and Obstetrics, School of Medicine, Zagreb,
Croatia
2 Institute of Emergency and Intensive Care Medicine, University Department of
Medicine, University Hospital Center, Zagreb, Croatia
3 Department of Gynecology and Obstetrics, Zabok General Hospital, Zabok
SUMMARY
Obstetric complications include an array of events, from pathologic states during
gestation, complications during delivery through various puerperal disorders. These
events may entail functional deterioration in a number of organs. as in puerperium, the
metabolic- immune and defense capacities have not yet reached full equilibrium, an
irregular course of lying- in should be expected. The syndrome of multiple organ failure
in puerperal sepsis is the most severe complication during the puerperium, involving
almost all organ systems. During a 5- year period, at the University Hospital for
Gynecology and Obstetrics in Zagreb, Croatia, hospitalization was prolonged or
rehospitalization required in 44 puerperas, whereas five patients were transfered or
admitted to the Institute of Emergency and Intensive Care Medicine for multiple organ
failure after retained abortion and delivery. Three patients from the latter group died
from general failure of all organs and organ systems. Multiple organ failure is a very
serious prognostic factor predicting unfavorable outcome in spite of young age of the
patients. Timely diagnosis of the endometritis and treatment of infection might have a
beneficial effect on the prevention of the clinical syndrome of multiple organ failure.
INTRODUCTION
Puerperal endometritis is the most common form of puerperal infection, with puerperal
sepsis as the most severe complication. The prognosis of puerperal sepsis, especially
when accompanied by formation of microabscesses ( septic endometritis) , is still very
poor, frequently requiring surgical removal of the focus ofinfection to save the woman's
life.
Clinical syndrome of multiple organ failure in the puerperium is perhaps the most
severe sequel of puerperal sepsis. The aim of this study was to assess the incidence of
multiple organ failure in patients hospitalized for puerperal sepsis. Patients hospitalized
at the University Department for Gynecology and Obstetrics, and at the Institute of
Emergency and Intensive Care Medicine , Department of Medicine , Zagreb University
Hospital, were followed up during a 5- year period.
PATIENTS AND METHODS
During the period from January 1, 1990 till December 31, 1994, 44 patients were
rehospitalized at the University Department for Gynecology and Obstetrics, and
another five patients at the Department of Emergency and Intensive Care Medicine,
Department of Medicine , University Hospital Center, for high postpartal febrility. The
available data werw retrogradely analyzed. High febrility was defined as body
temperature elevation to 38,5 C. Urine culture was obtained in all patients, whereas
peritoneal swab was taken from a patient with perforating appendicitis. Blood culture
data were available for six patients, and werw positive in three of them. The data
showed that cervical swab was obtained from 11 patients, with four positive findings.
Data where obtained from admission registry at the two departments, and from medical
records ( history, microbiological findings, pathohistologic findings ).
RESULTS
Histories of the patients with admission diagnosis of puerperal febrility and those
showing signs of failure of one or more organ systems on admission were considered.
In six patients only, hospitalization was prolonged after delivery for febrility during
their stay in the hospital, whereas 38 puerperas werw first discharged and then
rehospitalized for the development of febrility as a complication. Thirteen patients
werw admitted with the diagnosis of febrility, urinary infection was verified in four and
endometritis in 19 patients, in two and one of them as a consequence of spontaneous
and artificial abortion, respectively. Clinical picture of mastitis was present in four
patients. Diffuse peritonitis due to perforating appendicitis developed in one puerpera,
whereas two puerperas had postpartal psychosis. In one puerpera , cardiac
decompensation developed due to aorticomitral defect ( Department for Gynecology
and Obstetrics). Five patients with syndrome of multiple organ failure in puerperium
were hospitalized at the Institute of Emergency and Intensive Care Medicine. In the
series of patients hospitalized at the Department for Gynecology and Obstetrics, there
werw four patients who had undergone cesarean section and two with vacuum
extraction. Premature amniotic fluid escape was recorded in four, protracted labor in
four , and early amniocentesis in one patient. Exploration of the endometrium was
carried out in five patients. In three patients, blood culture positive for Klebsiella
pneumoniae , Escherichia colli and proteus mirabillis was found in one each. In four
positive cervical swabs, Proteus mirabillis, Enterococcus, Lactobacillus spp. and
Escherichia colli werw isolated in one each.
Five patients admitted to the Institute of Emergency and Intensive Care Medicine
showed signs of respiratory and renal insufficiency, CNS disorder and coagulation
disorder. Three patients were admitted in puerperium, and two after evacuation of
retained abortion. Criteria for the diagnosis of acute renal failure included two- fold
kreatinine value, which was found in all the puerperas admitted. respiratory
insufficiency was defined as pO2 < 6 kP and pCO2 > 6kP. Artificial ventilation was
required in all patients hospitalized at the Institute of Emergency and Intensive care
medicine. CNS insufficiency ranged from mild consciousness disturbances in two
patients ( sopor and somnolence ) through deep coma in three patients. Signs of
disseminated intravascular coagulopathy were presented in all of the five patients.
Subarachnoidal , intracranial hemorrhage developed in one patient.
In three of five puerperas admitted, lethal outcome in the picture of electromechanical
dissociation of myocardium, toxic myocarditis, with respiratory insufficiency in spite of
artificial ventilation, coagulation collapse and deep consciousness disorder, i.e. coma ,
followed. The mean age in these patients was 25 years. Two patients had previously
undergone cesarean section, one patient had had retained abortion, and one incomplete
abortion. In one of two survivors from this group, Sheehan' s syndrome developed. In
both survivors, complete recovery from the multiple organ failure was subsequently
recorded.
DISCUSSION
Obstetric complications including array of pathologic processes that may occur in
women during the periods of gestation , delivery and puerperium. Each of these periods
has some specific features and pathology. Results of our study pointed to the utmost
importance of timely recognition of the pathologic process and proper choice of
treatment, in order to prevent the development of complications affecting many organ
systems. Such extensive changes are not favorable for the puerpera' s body as a whole ,
especially during the first 14 days , Immune metabolic and defence capacities have not
yet reached full equilibrium, therefore an irregular course of lying- in should also be
considered.
In this period , the endometrium with micro- organisms, which may give rise to the
spread of infection through open blood vessels and lymph pathways all over the body.
This necessitates proper knowledge about the complication that may be expected in the
puerperium, to be able to detect them on time and introduce proper therapy, thus
preventing further propagation of the inflammatory process to the fallopian tube,
surrounding tissues and the entire body.Our results showed that febrility in puerperium
may originate from various sources, e.g. from some local reason ( endometrium, urinary
tract, respiratory tract, visceral organ perforation) or consequentially to a systemic event
( sepsis). The latter may be associated with development of multiple organ failure. It
should be emphasized that the picture of sepsis does not develop consequentially to
puerperal complications exclusively, but also in case of retained or incomplete abortion.
As described above, practically all body systems are then involved. Not infrequently, a
coagulation disorder is the initial factor for failure of other organ systems. In the
completely developed clinical picture , respiratory insufficiency is observed, usually
requiring artificial ventilation, then renal failure requiring hemodialysis, CNS disorder
with various degrees of consciousness disturbance , and coagulation disorder. In this
study, renal failure as a rule was a sequel of pregnancy pathology and postpartal
complications, as previously reported. Multiple organ failure is a very serious
prognostic factor which may lead to an unfavorable outcome , in spite of the young,
reproductive age of the patients.
The results obtained indicated that clinicians should pay attention to close follow- up of
the puerperium in particular, to avoid possible septic complications which, related to
multiple organ failure may lead to lethal outcome in young women and mothers. The
prognosis of puerperal sepsis is still poor, quite frequently necessitating the focus of
infection to be surgically removed to save the woman's life.
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