A 30 year old woman, para 1 living 1, presented with high fever, vaginal discharge of pus, and abdominal distension for 10 days. She had undergone a lower segment cesarean section in a private hospital 10 days ago, for breech presentation and pregnancy induced hypertension.. She started getting fever from the third postoperative day. She was found to have a positive Widal test and was treated with ceftriaxone. She was sent to us on the 10th postoperative day. On examination, her general condition was poor. Her temperature was 300 C, pulse rate 86/min, respiratory rate 22/min, blood pressure 140/90 mm Hg. Respiratory system showed decreased air entry in the lung bases, accompanied by crepitations in that area. The abdomen was distended, tense, and tender. Peristaltic sounds were normal. The uterus was of 18 weeks' size. The cervix was open and purulent discharge was found to be draining from it. Her hemoglobin was 9.2 g/dl, white cell count 18000/cmm, polymorphs 73%, lymphocytes 16%, platelets 1.8 lakh/cmm, blood urea nitrogen 7 mg/dl, serum creatinine 0.8 mg/dl, fasting plasma sugar 96 mg/dl, serum bilirubin 0.8 mg/dl, SGOT 16 mIU/ml, SGPT 12 mIU/ml, PT-INR 1.19. Abdominopelvic ultrasonography showed the uterus of 16x8x6 cm, and a large collection fluid with internal echoes measuring 22x13x8 cm of above the uterus. A computed tomography of the abdomen and pelvis showed that there was a 23x7.7x21 cm collection of fluid above and in front of the uterus extraperitoneally, deep to the rectus sheath, spread in front of the anterior parietal peritoneum. It was communicating with the collection of fluid in the uterine cavity through a rent in the uterine scar.
A diagnosis of puerperal sepsis after cesarean section, with formation of a large collection of pus in the uterovesical space and the space between the posterior ectus sheat and the anterior parietal peritoneum was made. The collection was drained by insertion of a tube under ultrasonographic control. 1800 ml of pus was drained. She was administered piperacillin-tazobactum, metronidazole and amikacin parenterally. Her blood culture showed no growth of any bacteria. The pus removed through the tube grew E. coli which was sensitive to piperacillin-tazobactum. The The tube continued to drain purulent fluid measuring 200 ml, 150 ml, 110 ml, 70 ml, 50 ml and 20 ml over successive days, while the vaginal discharge of pus ceased. She became afebrile 7 days after the initial drainage. The tube was drained on 12th postoperative day, after it had stopped draining over 48 hours. Abdominopelvic USG done after two days showed no collection of any fluid in the abdominal wall or pelvis. She made an uneventful recovery. She was advised to avoid another pregnancy and counseled to use effective contraception like combination contraceptive pills or condoms.
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