PBL 39 Childbed fever by Zayn Zaki

Trigger A

ilyummy00 — 2023-03-15 00:03:04 UTC

Madam Asiah, a 25-year-old primigravida at 38 weeks gestation, was admitted to labour room with leaking of liquor for more than 12 hours. It was associated with regular contraction pain. Her antenatal history was uneventful.
She progressed to active phase of labour. Eight hours later, she had a spontaneous vaginal delivery to a healthy baby boy. She was discharged well on the next day.

B

ilyummy00 — 2023-03-15 00:05:58 UTC

At the end of the first week of puerperium, she developed a high-grade fever with chills and rigors. The lochia was foul-smelling. There were no signs and symptoms to indicate urinary tract infection (UTI) post delivery.

ilyummy00 — 2023-03-15 00:07:15 UTC

On general examination:
Temperature: 38.5° C
Blood pressure: 120/80 mmHg
Pulse rate: 110 beats per minute

Examination of breasts, respiratory system and lower limbs: Normal.
Uterus was tender and fundus was at the level of umbilicus. Episiotomy wound was well-healed.

ilyummy00 — 2023-03-15 00:08:35 UTC

Investigations results:
Total white cell count : 20 x109/L Elevated; predominantly neutrophils (bacterial infection) ,
(80%) Hemoglobin level : 9 g/dl. Low hb - (12-16) - anemic
Blood and Urine C & S : no organism
High Vaginal Swab C&S : Group B beta-haemolytic streptococcus. - fully hemolysed.

Abdominal ultrasound
: empty uterus, no product of conception. check for retain product

Postpartum endometritis, given broad spectrum antibiotic

Primigravida

fatihaainaumaira — 2023-03-15 01:02:35 UTC

Primi - first time
Gravida - number of pregnancy
- what happen to first, 2nd, 3rd trimester (show pic)

Leaking liquor more than 12 hours

fatihaainaumaira — 2023-03-15 01:03:28 UTC

- Leaking amniotic fluid
- Duration (learning issue)
- Risk factor for infection
- E Coli, Gram negative, GBS
- How to differentiate e coli and gbs
- what is leaking liquor, content, duration, risk for pregnancy

38 weeks gestation

fatihaainaumaira — 2023-03-15 01:04:23 UTC

- Not premature (<36weeks)

Regular contraction pain

fatihaainaumaira — 2023-03-15 01:08:52 UTC

- How many hours?
- What happen in phase of labour?
- 1st phase: dilatation of cervix
- 2nd phase: delivery of fetus
- 3rd phase: delivery of placenta

antenatal history was uneventful

fatihaainaumaira — 2023-03-15 01:21:27 UTC

- what condition related to nausea and vomiting?
- morning sickness (hyperemesis gravidarum)
- movement of baby
- how count fetal movement?
- what is common fetal movement? month?
- trauma
- bleeding, risk of miscarriage
- last menstrual period
- any vaginal discharge > certain colour show miscarriage,
- 38 weeks specific condition > ectopic pregnancy, placenta previa

Spontaneous vaginal delivery

fatihaainaumaira — 2023-03-15 01:26:05 UTC

- less risk bcs not c sec
- active phase of labour (put pic)
- not normal example instrumental
- phase and sequence of baby delivery (picture)
- breach delivery > buttock go first

rpraveinesh — 2023-03-15 01:26:10 UTC

healthy baby boy

fatihaainaumaira — 2023-03-15 01:27:58 UTC

- signs of healthy baby
- parameter healthy baby (apgar score
- crying

rpraveinesh — 2023-03-15 01:28:06 UTC

mother discharge

fatihaainaumaira — 2023-03-15 01:34:28 UTC

- is it safe to discharge leaking liquor for more than 12 hours
- is baby safe to be discharged or not?
- if apgar score 7 safe to be discharged according to respiratory stability, control of breathing
- leaking liquor safe or not for baby discharge?
- check any fever symptom of infection
- criteria to safely discharge baby

high grade fever, chills, rigors

fatihaainaumaira — 2023-03-15 01:39:16 UTC

- sign of endometritis and retained products, something left out in uterus, can be placenta

puerperium

fatihaainaumaira — 2023-03-15 01:40:15 UTC

- 6 weeks after delivery
- physiological changes

list of ddx

fatihaainaumaira — 2023-03-15 01:40:45 UTC

- endometritis
- retained product
- UTI (dysuria, increased frequency, unpleasant smell, incomplete bladder emptying, hematuria, suprapubic region tenderness)
- incidence/prevalence UTI in after pregnancy
signs
- abdominal tenderness, guarding, renal punch (pyelonephritis)

pathophysiology of fever

fatihaainaumaira — 2023-03-15 01:42:30 UTC

- when there is infection > inflammation > release of prostaglandin and IL 2 > pyrexia agent > thermoregulatory

pulse rate 110 beats/min

fatihaainaumaira — 2023-03-15 01:49:49 UTC

- tachycardia
- due to infection (compensatory mechanism for increase blood flow to increase immune cell to site of inflammation)
- due to fever

Examination of breast, respiratory system and lower limb

fatihaainaumaira — 2023-03-15 01:52:52 UTC

- any infection, breast enlargement
- respi > sob, pneumonia, urti
- lower limb > lymphadenopathy > infection of pelvic cavity, dvt, vischow's triad

Uterus was tender, fundus at level of umbilicus

fatihaainaumaira — 2023-03-15 01:56:55 UTC

- endometritis, endometriosis >
- palpate at lower abdomen > posterior fornix
- normal at day 1, 2 > at level of umbilicus
- can't palpate at all at 2 weeks
- involution of uterus
- fundus at level of umbilicus? indicate what? pathophysiology

episiotomy

fatihaainaumaira — 2023-03-15 01:58:45 UTC

- one site of infection
- if fever check for the wound
- what is it? how do episiotomy? anatomical structure when do episiotomy?

Investigation

fatihaainaumaira — 2023-03-15 02:06:33 UTC

- wbc - elevated
- predominantly neutrophil - bacterial infection, give broad spectrum antibiotic > management
- low hb - blood loss > physiological changes in puerperium
- blood & urine culture and sensitivity - exclude septicemia
- hvs c&s - gbs is flora in uterus or not? e coli compare
- beta hemolytic - complete hemolysis
- abdominal uterus, no product of conception > rule out retained product

Approach to provisional dx

fatihaainaumaira — 2023-03-15 02:08:44 UTC

1. hx
2. pe
3. investigation

how the approach very important

Learning outcome

fatihaainaumaira — 2023-03-15 02:26:49 UTC

LO1 Discuss the physiological basis of labour to explain the patient’s clinical presentation
- what happen to 1st, 2nd, 3rd trimester (show pic)
- what is leaking liquor, content, duration, risk for pregnancy
- parameter healthy baby (apgar score)
- active phase of labour (put pic)
- phase and sequence of baby delivery (show pic)
- regular contraction of pain (how many hours, what happen in phase of labour)
- antenatal hx (nausea vomitting, fetal movement (common?month? how to count?))
- puerperium physiological changes
- what is episiotomy? how to do? anatomical structure when do episiotomy
- involution of uterus (show pic)

LO2 Interpret and relate the laboratory findings with the patient’s clinical presentation

LO3 Apply the concept of host-pathogen interaction to explain the patient’s clinical presentation
- how to differentiate e coli gbs

LO4 Discuss the psychosocial implications of post-partum infection of this patient to the patient and family
- criteria to safely discharge baby