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The Case..
Maria is a 21 year old primigravida at term, who presents at the labour ward in the morning with prelabour rupture of membranes (PROM) On examination she appears well nourished, without evident anaemia BP 110/60mmHg, Pulse 84bpm, Temperature (axillary) 36.5C On abdominal palpation she has a gravid, non-tender uterus, SF height of 37cm The foetus has a cephalic presentation with 1/5 palpable over the symphysis pubis The foetal heart rate is 144 bpm. The woman has no contractions
No, however a sterile speculum examination may be useful to confirm PROM and take a swab if there is doubt regarding ruptured membranes Cord prolapse is not likely as the head is engaged (cephalic 1/5 palpable) and FH rate normal Digital vaginal examination should be avoided to minimise risk of introducing ascending infection
How should this woman be further managed? Mobilise, regular assessment of fetal movements/foetal heart rate/maternal temperature If Preterm Prelabour Rupture of Membranes (PPROM) give antibiotics (ampicillin IV 2 gr. stat then 1 gr each 6 hours) Induction of labour after 18 24 hours.
Other than body temperature, what other tests could be used to monitor for the first signs of ascending genital tract infection?
Maria establishes regular contractions after 4 hours of observation On vaginal examination the cervix is 4cm dilated and fully effaced
After a further 4 hours of unremarkable labouring VE shows her cervix to be 5-6cm dilated
The labour is augmented with oxytocin. After a further 5 hours she gives birth to a daughter by vacuum extraction due to maternal exhaustion and persistent OP position
The delivery is complicated by an atonic uterine bleed with an estimated loss of 800mls
The bleeding is eventually controlled by ergometrine IM and cytotec tablets administered rectally Mother and child are transferred to the postnatal area a short time later in a stable condition
PROM
Ventouse extraction Episiotomy PPH/Anaemia
On day 2 postpartum, Maria complains of headache, nausea and generalised abdominal discomfort. What examinations would you perform? BP 110/50mmHg, Pulse 110bpm, Temp 38.2C
What information relating to this patients antenatal care may be of relevance in this initial evaluation?
Maria is managed with Fanzidar, 3 tabs STAT with malaria as a working diagnosis. A blood smear is sent. She is kept on the post-natal ward for further examination.
Anaemia Jaundice
Splenomegaly
As soon as patient can take orally infusion is replaced by tablets (same dose and intervals)
Treatment length: 7 days. Monitor vital signs, blood sugar, urine output and consciousness level
On day 3 the patients condition is worsening. She is weak, she has no appetite, her abdominal pain is worsening which she now relates to her lower abdomen. She has no urinary symptoms but has passed some loose motions On examination, BP 90/50mmHg, Pulse 120bpm, Temp 39.2C. The patient seems restless with an increased respiratory rate. The chest is clear on auscultation There is slight abdominal distention along with rebound tenderness in the lower abdomen
Septic shock
The diagnosis of septic shock is based on clinical signs relating to disturbed physiology: BP Pulse Resp. rate Temp or Glasgow coma scale Oliguria
Ideally cultures and malaria-slide should be obtained prior to the commencement of treatment
Consider
DEXAMETAZONE 4 mg/kg IV/6 hrs Move patient to an area where repeated assessment can be performed (ideally ITU) and catheterise bladder to accurately measure diuresis
Malaria
Meningitis
Suspect
retained products of pregnancy; perform evacuation under antibiotic coverage. still no improvement after 24 hours? laparotomy for wound revision, maybe hysterectomy.
If
Perform
Prevention? Hygiene Prevent anaemia Safe obstetric and surgical techniques AVOID CESAREAN SECTIONS AT STILBIRTHS IF POSSIBLE
Any Questions?