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Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 77-85 Continuing Surgical Education Rural Surgeons and Obstetrical Emergencies S.K. Basu A-258, Shivalik, Malaviyanagar, New Delhi-110 017 Paper received: July 2002 Code Number: is03016 Abstract Rural surgeons are often called upon to manage a range of emergency obstetric problems despite their limitations in technological, nursing and consultant resources. One ASI survey revealed that 80% of rural surgeons manage obstetric emergencies. The purpose of this article is to help such a rural surgeon gather enough knowledge about this subject so that he is able to decide if he can manage the patient himself and if not, how to prepare her for a safe transport to the next centre. Obstetrical problems happen without or with very little warning and are often life-threatening emergencies. They may not be fit for transfer to distant centres. They need immediate emergency care. Such conditions include bleeding, eclampsia, obstructed labour, ruptured uterus, septic abortion and puerperal sepsis. All these conditions are important causes of maternal death. Proper management will reduce the maternal mortality in rural areas. Key words: Bleeding in Pregnancy, Abortion, Ectopic Pregnancy, Obstructed Labour, Puerperal Sepsis, Ruptured Uterus, Septic Abortion. INTRODUCTION When a rural surgeon is alone in his area, he has to face the management of all emergencies including the obstetric ones. The term Emergency Obstetrical Care (EmOC) was coined by the 'safe motherhood division' of WHO. These emergencies include bleeding, eclampsia, obstructed labour, ruptured uterus, septic abortion, and puerperal sepsis. These are also important causes of maternal mortality. If the rural surgeon is properly informed about how to manage these conditions, it will certainly improve the health care of rural ladies. Some salient aspects of these conditions are highlighted in the following pages. BLEEDING IN PREGNANCY Vaginal bleeding during pregnancy, other than slight bleeding that can occur with
the onset of labour, is abnormal. Mothers often Following are the causes of bleeding in early pregnancy 1. Abortion: 2. Ectopic pregnancy 1. Abortion Abortion is defined as a loss of pregnancy before 20 weeks of gestation. Threatened abortion: This represents the commonest type of abortion seen in an emergency set-up. Patients present in early pregnancy with vaginal bleeding. Clinical examination reveals closed cervical os without any protrusion of products of conception. Essentially, everything is normal on clinical examination, except for the presence of vaginal bleeding. Pregnancies that are destined to end in miscarriage are more likely to have associated uterine cramps and pain. There is no medical treatment that can prevent loss of pregnancy in most of the threatened abortions. Though not substantiated by scientific data, recommendations include avoidance of strenuous activity and sexual intercourse until the bleeding has stopped. Inevitable Abortion: An abortion is considered inevitable when the cervix has dilated, the amniotic membrane has ruptured or the bleeding is severe and potentially life threatening. The patient will have additional symptom of severe colicky lower abdominal pain. These pregnancies do not continue and termination is generally advised. Incomplete Abortion: Once products of conception have been expelled or can be seen protruding through the cervical os, the pregnancy is obviously lost. Immediate termination is recommended. Termination: This is usually done with suction evacuation and curettage to remove the remaining foetal and placental tissue. Suction curettage is preferable to sharp curettage, since the latter can result in more blood loss and possible uterine damage. Overzealous curettage must be avoided especially with a sharp curette; it can result in the development of Asherman's syndrome. Generally, miscarriages that occur between 6 and 14 weeks of gestation are considered incomplete and routine curettage is recommended. Complication of suction evacuation and curettage are uterine perforation, haemorrhage, sepsis and cervical tear. Rh sensitisation can occur after both induced and spontaneous abortions. All un-sensitised Rh-negative women should receive D immunoglobulin following abortion, unless the father of the baby is known to be Rh negative. For pregnancies of less than 12 weeks of gestation, a dose of 50 ug is sufficient. Abortions occurring after 12 weeks should receive the standard 300-ug doses. Missed Abortion: The diagnosis of missed abortion is made when a pregnancy is considered to be nonviable by ultrasonography. In the pre-ultrasound era the lack of diagnosis of missed abortion frequently resulted in retention of a dead foetus for several weeks. This is not an emergency situation. However, it is important to remember that disseminated intravascular coagulation can develop on account of a dead foetus. This usually occurs after 3 to 4 weeks of foetal death. Rural surgeons who intend to manage such cases should do blood clotting studies before taking up the case. The requirement of laboratory tests for any kind of abortion should be determined by the clinical presentation of a particular case. Laboratory evaluation may not be necessary in the emergency departments for patients in whom ectopic pregnancy is not suspected and who have only spotting or light vaginal bleeding. Those with more bleeding should have a complete blood count. Women who are haemodynamically unstable or who have profuse bleeding sufficient to require immediate hospital admission or suction curettage may need packed red blood cells. Rh blood type should be obtained. Unless indicated by clinical presentation, additional laboratory tests are generally unnecessary and only serve to increase the cost of medical care. Septic Abortion: Any of the abortions mentioned above, associated with the evidence of infection of the product of conception or uterus is labelled as septic abortion. Septic or infected abortion is one of the commonly treated conditions in rural areas. Usually they stem from induced abortion, illegally performed with non-sterile instruments by unskilled abortion providers. Patient may present with history of amenorrhoea followed by vaginal bleeding with foul vaginal discharge, lower abdominal pain and fever, often with chills. In severe cases patient may present with signs of septic shock, oliguria, and a tender rigid lower abdomen consistent with generalised peritonitis. To label a case as a septic abortion the clinical criteria, namely (1) temperature >100.40 F (38o centigrade), (2) foul smelling vaginal or cervical discharge, (3) extra uterine spread of infection are usually considered. Fortunately, in the majority of cases infection is localised in the uterus. However, it may spread to the surrounding pelvic structures and finally may cause generalised peritonitis. The infection is mostly polymicrobial in origin. Whenever possible, routine Hb% estimation, TLC, DLC, urine analysis, endocervical and vaginal swab culture is useful for management. Very rarely blood culture is needed. Management Antibiotics: Since the condition is of polymicrobial origin, initial antibiotic selection must include broad-spectrum drugs, which cover both aerobic and anaerobic Gram-positive and Gram-negative organisms. Initial antibiotic therapy should be parenteral and intensive. High doses should be continued till the woman's clinical response improves. Mild cases can be treated with Ampicillin/ Amoxycillin or simple first generation Cephalosporins. Patients with parametritis or peritonitis should be treated aggressively with aminoglycosides, third generation cephalosporins and metronidazole, all parenteraly. I. V.fluids: Monitoring fluid balance is essential to prevent circulatory shock and renal failure, one of the most serious complications of a septic abortion. When monitoring of CVP is not possible, several clinical signs, namely jugular vein distension, rales at the base of the lung, urine output and specific gravity of urine can indicate a woman's state of hydration. Surgery is the third major element of treatment for septic abortion. Early uterine evacuation is favoured. Delaying curettage increases the likelihood of septic shock and bleeding. Septic shock of untreated septic abortion is one of the gravest complications in obstetrics. It is characterised by reduced blood circulation, inadequate tissue perfusion resulting in deficient oxygen supply to cells and metabolic acidosis. Aggressive treatment is required as soon as shock is diagnosed. The objectives of this treatment are to control infection and to restore patient's blood circulation. Both medical and surgical techniques are used. The major elements in medical management are antibiotics, appropriate fluid therapy and use of steroids and vasoactive drugs. Steroids are most useful when used in pharmacological doses early in shock. The second major focus of treatment is surgical and that is to remove the source of infection, the infected contents of the uterus. Prognosis in septic shock, as in septic abortion in general, is improved if the uterus is evacuated as soon as possible. If curettage and early antibiotic treatment do not improve the patient's condition, hysterectomy is recommended. Other indications for hysterectomy are a perforated uterus, pelvic or myometrial abscess and presence of detergents and caustic materials in the uterus. Intrauterine clostridial infections always require removal of uterus. 2. Ectopic Pregnancy The classic triad of amenorrhoea, pain and vaginal bleeding should raise the suspicion of an ectopic pregnancy. The character of the pain is often non-specific. It may be diffused, unilateral, bilateral or even contralateral to the side involved. Rupture of the tube may result in a sudden onset of sharp shooting pain. Surprisingly, in some cases, the pain decreases when a rupture flattens tubal distension. Tubal rupture is often accompanied by significant haemoperitoneum. Shoulder pain is possible due to irritation by blood of diaphragmatic surfaces. It is not unusual for a patient initially to deny having missed any periods. On careful review, the most recent period may be described as lighter and abnormally timed, perhaps representing pathological bleeding from decidual sloughs. Heavy bleeding or bleeding with clots is distinctly atypical and is more characteristic of imminent or incomplete abortion of an intrauterine pregnancy. Pelvic examination reveals an adnexal mass in 50% of the cases. The uterus is usually normal or slightly enlarged and is often noted to be soft, secondary to the effects of placental hormones. Ectopic pregnancy can mimic a number of other gynaecological and non-gynaecological disorders. Since most of these disorders are not immediately life threatening, it is important that the surgeon excludes ectopic pregnancy when considering differential diagnosis in a woman of reproductive age with abdominal pain or abnormal bleeding. A high index of suspicion for ectopic pregnancy must be maintained to avoid catastrophic oversights. Initial evaluation should include a directed gynaecological history, a physical evaluation that includes a vaginal and bi-manual pelvic examination and sensitive and rapid urine pregnancy tests. Ultrasonography is diagnostic of ectopic pregnancy only if a gestation sac can be identified and localised outside the uterus. Identification of the characteristic adnexal mass, an echogenic adnexal ring or gestation sac, with live foetal pole and yolk sac form confirmatory evidences. During the ultrasonographic evaluation, the cul-de-sac of Douglas and abdominal cavity should be evaluated. Although the presence of free blood in the cul-de-sac suggests ectopic pregnancy, it may also be encountered in women with a ruptured corpus luteum, injury to other viscera or even in a normal menstrual period. Culdocentesis, which can be performed readily in the emergency department, may expedite the evaluation of women suspected of having a ruptured ectopic pregnancy when sophisticated modalities such as vaginal probe, ultrasound or sensitive hCG test are not available. Culdocentesis entails puncturing the cul-de-sac of Douglas with a needle and aspirating its contents. The results may be positive when the aspirate is 'non-clotting' blood; negative when it is fluid or blood-tinged fluid and non-diagnostic when there is no fluid or only clotting blood. If the patient is non-hypotensive, it may be useful to have her walk, stand, or sit to facilitate pooling of peritoneal fluid in the cul-de- sac before the test. As technology has evolved, the painful and invasive procedure of culdocentesis has become less relevant in diagnosing ectopic pregnancy. Where the facilities are available, an intra-vaginal sonography supported by urine hCG study clinch the diagnosis of ectopic pregnancy. In an emergency set-up, when a patient of suspected ectopic pregnancy is brought in a state of shock and hypovolaemia and one intends to do a rapid urine pregnancy test, urine sample should be collected, if necessary by catheterisation of bladder, before starting any IV fluid for resuscitation. Otherwise, hCG level in urine, which is already low in ectopic pregnancy, may get further diluted and show a false negative result. Management A patient of ectopic pregnancy may present with minimal symptoms of irreversible shock leading to death. The patient should have fluid replacement followed by appropriate blood component therapy, if indicated. Although haemodynamic stability is desirable before subjecting a patient to surgical anaesthesia, often a quick surgical intervention may be required to achieve stability by control of active haemorrhage. Rupture of ectopic gestation results in tubal damage. Laparotomy followed by partial salapingectomy (removal of ruptured part of the tube with gestational sac) is the rule. However if the patient is stable and ultrasonography suggests an intact tube or pregnancy sac, there are different therapeutic options for management, particularly for those desiring future fertility. In such cases the lady must be directed to a gynaecologist adept at reconstructive conservative management of the tube. If the abdomen contains a large volume of liquid blood, it can be used for Auto transfusion. 3. Bleeding after 20 weeks of pregnancy Following are the causes of bleeding after 20 weeks of pregnancy
Of these, alarming situations of bleeding are common in pre-term labour, Abruptio placenta or placenta previa, all of which require immediate hospitalisation. They are managed as follows: A. Stabilise the Patient: Patients with significant blood loss will have evidence of hypovolaemia. They may require fluid or blood replacement. B. Assess Foetal well-being: Since pregnancy beyond 24 to 25 weeks of gestation is often viable, monitoring of foetal heart rate and uterine activity is necessary to determine whether immediate delivery is needed. If the patient's condition is stable and there is an abnormal foetal heart rate pattern, the patient may be transferred to a hospital with advanced obstetric services. C. Rule out placenta previa: Placenta previa can be ruled out easily if ultrasonography is available. Digital examination in a patient with placenta previa can cause life-threatening haemorrhage and subsequent foetal loss. If ultrasound is not available, gentle speculum examination can be performed to determine cervical dilation to rule out advanced labour. However, speculum examination cannot exclude placenta previa. D Rule out labour: Once placenta previa is excluded, digital examination can be performed to determine cervical dilation and effacement. A patient in labour should be assisted for delivery. However, if the facilities for delivery are lacking, the patient may be transferred to a suitable obstetrical unit as soon as the patient is haemodynamically stable. This is only possible if the patient is not in advanced labour and if delivery is not anticipated before transfer is complete. Laboratory Tests Patient in labour with minimal bleeding and stable vital signs does not require laboratory evaluation in the emergency department. Patients in acute distress with vaginal bleeding, severe pain, or clinical evidence of hypovolaemia require hospital admission and immediate management as necessary. Laboratory tests should be ordered on an emergency basis and should include a CBC, grouping and cross-matching of two or more units of blood, and clotting studies (platelet count, fibrinogen, PT, PTT). For patients who are not in acute distress, initial evaluation with ultrasonography is most helpful. After obtaining the ultrasonography results, more appropriate laboratory tests can be ordered. Patient with ultrasonographic diagnosis of placenta previa and vaginal bleeding requires hospital admission. Placenta previa is not associated with disseminated intravascular coagulation (DIC), unless this results from excessive blood loss. Therefore blood-clotting studies are not necessary for these patients. If placenta previa and labour are excluded, Abruptio placenta should be suspected unless another cause is obvious. When Abruptio placenta is suspected, appropriate laboratory studies include a CBC, platelet count, fibrinogen, PT, PTT, serum BUN and creatinine, blood grouping and matching for four or more units of blood. If possible, immediate consultation with an obstetric service is indicated. 4. Postpartum haemorrhage (PPH) PPH is a major contributor to maternal mortality and constitutes approximately 4% of deliveries. It is the third major cause of maternal mortality. Uterine atony, retained placenta, and laceration during birth are the major causes of PPH. The effect of PPH depends to a considerable degree upon the non-pregnant blood volume, the magnitude of pregnancy-induced hypervolemia and the degree of anaemia at the time of delivery. In an emergency setting, the diagnosis of PPH is not difficult. However, one has to differentiate the cause. If the uterus is firm and well contracted, the most likely cause of haemorrhage is laceration. Bright red blood, trickling from the vagina also indicates laceration. Management Bleeding after delivery of placenta If the feel of the uterus is not firm and the fundus height is increasing in size, it suggests intrauterine accumulation of blood. Immediate IV ergometrine 0.2 mg has to be given. Massage the uterus briskly till it becomes hard. Start an IV line with a wide bore cannula and collect blood sample for grouping, cross- matching and the coagulation status; add oxytocin (10-20 units) into the IV drip bottle. Higher doses may be used depending upon the need. Catheterise the urinary bladder till empty. If the patient is in a state of shock, treat the shock first with resuscitative measures like blood volume replacement, O2 inhalation etc. Examine the placenta at the earliest opportunity to be sure that it is complete and there is no evidence to suggest that part of it is left inside uterine cavity. If either a cotyledon or a lobe is missing, exploration of the uterine cavity is needed. If bleeding continues even after the uterus hardens up, laceration of the lower genital tract may be suspected. In such cases the cervix and vagina should be examined by means of Sim's speculum and with the help of three pairs of sponge forceps to hold the cervical lip. Any episiotomy wound, if present and vulva, particularly near clitoris, must be examined properly to exclude tear. Any active bleeding should be properly controlled with suturing if necessary. In case the bleeding continues even without any evidence of cervical and vaginal tear or without any clotting defect, it may be due to minor inversion of uterus. If oxytocin and ergometrine are unable to harden the uterus for a long period, the possibility of uterine rupture has to be kept in mind. In such cases the uterus should be thoroughly explored. Bleeding before delivery of placenta The first thing to do is to massage the fundus of uterus vigorously till it hardens. IV or IM ergometrine has to be injected, depending upon the rapidity of blood loss. Look for signs of placental separation. If it has not separated and the patient continues to bleed, try to remove the placenta by controlled cord traction (Brandt-Andrew's technique). If it comes out successfully, give a second dose of ergometrine to reinforce contraction. Massage the uterus for some time to maintain the state of contraction. In case the attempt fails, the placenta does not come out and the patient continues to bleed, it may be necessary to give a further dose of ergometrine, while anaesthesia is being initiated. An IV line with 5% dextrose and 10-20 units of oxytocin drip has to be stared. If the patient is in shock, resuscitate her with proper IV infusion, blood, and oxygen. Empty the urinary bladder by catheterisation. Manually remove the placenta once the systolic blood pressures exceeds100 mm of Hg. It is difficult to remove the placenta when there is morbid adhesion. It may be impossible to remove it without leaving shreds of tissue behind. In these circumstances whatever best can be done, should be done. Sometimes, even after the successful removal of placenta, the uterus remains atonic and haemorrhage continues unabated. Usually IV ergometrine and oxytocin drip restores uterine tone. However, one may have to resort to bimannual compression of the uterus to get the uterus well contracted. OBSTRUCTED LABOUR Obstructed labour is often the result of neglected obstetrical care and poor transport facilities. The common causes of obstructed labour are 1. cephalopelvic disproportion, 2. malpresentation, 3. foetal abnormalities like hydrocephalus, 4. foetal ascitis and rarely due to 5. cicatrized cervix following cervical operation. In the presence of an obstruction, powerful uterine contractions ultimately result in foetal distress. When the labour gets arrested, the presenting part is jammed resulting in a large caput. The foetus by that time usually dies. The lower uterine segment is stretched not only longitudinally but also circumferentially, forming 'Bandl's ring' (pathological retraction ring) visible externally, demarcating the contracted retracted upper segment and the markedly thinned out lower segment that accommodates most of the foetus. This creates a state of impending rupture. Prolonged interval after the rupture of membranes and repeated pelvic examination by an untrained birth attendant lead to intra partum sepsis. Pressure of the presenting part on the urinary bladder may predispose it to vesico-vaginal fistula. The patient, often short statured, primi, gives history of being in labour for several hours after rupture of membrane. She is dehydrated, exhausted, with a slight rise of temperature and pulse. Foetal heart rate may be absent or irregular. Bandl's ring, as mentioned before, may be visible. Vaginal examination shows oedematous vulva, dry, hot, bruised vagina, fully dilated cervix and a large caput over the presenting part which is jammed into the pelvis. Following are the management guidelines:
RUPTURE UTERUS Rupture of gravid uterus is an obstetrical emergency, which threatens the
life of both mother and foetus. In the past, the commonest cause of the spontaneous
rupture of the uterus was obstructed labour.
Improved obstetrical care has brought down the
incidence of such rupture in recent times. With
the upsurge of LSCS, the rupture of previous scar of uterus has become one of the
predominant causes in recent times. Causes of rupture
due to obstetrical manipulation are also
decreasing due to a decrease in the practice of
difficult breech extraction, forceps delivery and
internal version. Although there is a definite but
limited The clinical picture is of generalised shock: rapid pulse, fall of blood pressure and pallor. There is a tender abdomen with an abnormal uterine contour, foetal parts are often felt superficially and foetal heart sounds are absent. Vaginal examination often shows evidence of obstructed labour with a large caput over the presenting part associated with vaginal bleeding. In the lower segment scar rupture, there may be supra pubic tenderness and fullness. Once the diagnosis is made, the treatment is immediate laparotomy. Intravenous infusion of dextrose saline is started and compatible blood is requisitioned. After foetus, placenta and blood clots are removed, the uterine rent is inspected. The options are either a)-repair of rent with or without tubal ligation or b)-hysterectomy. If the edges of the tear are clean cut with minimal infection, repair of the rent is a better option, as it is a shorter and quicker procedure. It increases the chances of survival for these patients in shock. A subtotal hysterectomy is a quicker procedure than total hysterectomy and is indicated in lateral tears, with gross infection and in multiparas with irregular and friable margins of the rent. If a vesical tear is seen, it has to be closed in layers. Rupture often extends to involve both the cervix and the vaginal vault as well, an accident, which not only increases the bleeding but also often makes any conservative surgical procedure impractical. Wound sepsis is the commonest complication. If the rupture is due to obstructed labour, patient may develop VVF. After surgery, careful postoperative supervision is needed to combat shock and sepsis or peritonitis. To minimise the chances of VVF, the bladder has to be drained in all cases of rupture and in those where vesical repair was performed. ECLAMPSIA Eclampsia is the development of convulsions, coma, or both in a pregnant woman with hypertension aggravated by pregnancy called pre-eclampsia. Other causes of seizures like epilepsy, arterial and venous thrombosis, poisoning etc. may be excluded with a detailed clinical history and presence of 1)-high blood pressure, 2)-proteinurea and 3-) oedema, which are diagnostic of eclampsia. Eclampsia can be ante-partum, intra-partum, or postpartum; approximately 50% of cases occur ante-partum. Management The immediate care during a convulsion is to ensure a patent airway. Once this has been established, adequate oxygenation must be maintained. MgSO4 is given to control the convulsions according to following protocol. As soon as possible a venous access is secured. A 4- to 5-g loading dose of MgSO4 is given over 15 to 20 minutes. If the woman convulses after the loading dose, another 2-g bolus may be given intravenously in 3 to 5 minutes. Alternatively, along with the I.V., a loading dose of 5g of MgSO4 can be given into each buttock deep intra-muscularly. This can be followed by further 5g i.m. every 4hours, provided the respiratory rate is above 16/min, urine output>25ml/h, and knee jerks are present. Prevent maternal injury during the convulsion. Maintain adequate oxygenation. Once the convulsions have stopped and the woman has begun spontaneous respiration, oxygenation status is monitored. If spontaneous respiration is not present, ventilatory support will be required. Minimise the risk of aspiration. Position the woman to let oral contents flow out. Suction equipment in working order should be readily available. Also, if supplemental oxygen is being administered by a facemask, remember that vomiting under the mask and aspiration is possible. A chest radiograph may help to rule out aspiration. Rapid assessments of uterine activity, cervical status, and foetal status are done. During the convulsion, membranes may rupture and the cervix may dilate because the uterus becomes hypercontractile and hypertonic. If birth is not imminent the timing and route of delivery (induction of labour versus caesarean delivery) depend on maternal and foetal status. If the foetus is premature for independent neonatal existence, transfer the lady to a tertiary care centre where pregnancy can be continued under strict supervision. Side effects of magnesium sulphate are dose dependent and include flushing, nausea, vomiting, headache, lower maternal temperature, blurred vision, respiratory depression, and cardiac arrest. Nursing responsibilities are
To keep calcium gluconate (antidote for magnesium toxicity) at the bedside and To discontinue MgSO4 and notify if signs of toxicity develop (loss of knee-jerk reflexes, respiratory depression, oliguria, respiratory arrest, cardiac arrest) or if the woman complains of shortness of breath or chest pain. If signs of magnesium toxicity occur, give 1 g of calcium gluconate (10 ml of a 10% solution), as a slow intravenous bolus. Antihypertensive Therapy Drugs to control significant hypertension include a variety of agents like Hydralazine hydrochloride, Labetelol, Nifedipine, Methyldopa etc. There are several general precautions to be considered. When blood pressure is about or greater than 160 mmHg systolic or 110 mmHg diastolic, therapy is initiated to prevent maternal cerebral vascular accidents. Effects of the agent may depend on intravascular volume status and hypovolaemia, secondary to increased capillary permeability and haemoconcentration. These may need correction before the initiation of therapy. Diastolic blood pressure should be maintained between 90 to 100 mmHg to sustain uteroplacental perfusion. Postpartum Management After birth, most women will stabilise within 48 hours. However, because of the risk of eclampsia during the first 24 to 48 hours, careful monitoring of vital signs, level of consciousness, and deep tendon reflexes and laboratory assessments need to be continued. Additional assessments focus on identifying the postpartum haemorrhage, disseminated intra-vascular coagulopathy, pulmonary oedema, HELLP syndrome (haemolysis, abnormal liver function test and thrombocytopaenia), increased intra-cranial pressure and intra-cranial haemorrhage. PUERPERAL SEPSIS Puerperal sepsis is the infection of the genital tract up to 42 days after delivery. It is an important cause of maternal mortality and morbidity. In India it tops the list of causes of maternal death, followed by haemorrhage and toxaemia. The patient usually presents with high fever and chills, tachycardia, subinvolution of uterus, lower abdominal pain, sometimes with rigid abdomen, profuse and foul smelling lochial discharge. The infection is of polymicrobial origin with a mixture of both aerobic and anaerobic organisms. The increasing incidence of caesarean section has increased the incidence of puerperal sepsis by causing puerperal endometritis, anaerobic pathogens playing an important role. However in rural areas, prolonged labour, premature rupture of membranes, repeated internal examination, quite often by an untrained birth attendant, unsterile material and unhygienic surroundings (of the delivery room) contribute to the cause of puerperal sepsis. The use of antibiotics has revolutionised the outcome of this condition. As the disease is of polymicrobial aetiology, 'multiple agent therapy' is the rational choice to cover gram-negative, gram- positive and anaerobic organisms. However, there is no consensus as to the most effective antibiotic therapy for puerperal sepsis. Newer broad-spectrum semisynthetic penicillin as well as cephalosporins or penicillin plus aminoglycoside are found to be sufficient for patients developing endometritis after vaginal delivery. Patients developing endometritis after caesarian section need good anaerobic coverage. Gentamicin along with clindamycin and metronidazole are good options. Pelvic vein thrombophlebitis is one of the serious sequelae of puerperal sepsis. Enigmatic fever associated with it does not respond even after a suitable dose of antibiotic. However it responds to heparin therapy. Sometimes patients may report appearing seriously ill with high fever and chills, unilateral abdominal pain, marked tenderness and muscle guard and a mass. This is usually due to acute thrombosis of the ovarian veins and is termed as the ovarian vein syndrome. Unless the condition is kept in mind as one of serious (unilateral or bilateral) sequelae of puerperal sepsis, there is a possibility of missing the diagnosis. For a precise diagnosis, a CT or a MRI has been found to be of great value. Treatment of choice is heparin and antibiotics. CONCLUSION Maternal mortality continues to be a major challenge to obstetricians of the developing world. The causes and strategies to prevent it do not differ much in urban and rural areas. However, conditions in rural areas make the situation difficult. The above-mentioned conditions are the formidable risks that many women may face in their reproductive years. Rural surgeons with their dedication, will power and sustained efforts, can help these women enjoy a safer motherhood. Copyright 2003 - Indian Journal of Surgery. Also available online at http://www.indianjsurg.com |
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