In this modern era of antibiotics, knowledge and implementation of good clinical practices for asepsis during pregnancy and labor, we still see a significant number of post abortal or post partum women with major degrees of sepsis.
Sepsis remains a significant corner of the triad of maternal mortality. The tip of the this iceberg hides a large number of women with serious and varying degrees of morbidity caused by such sepsis. Many times after treatment women are left behind with lifelong serious sequalae like secondary infertility, ectopic pregnancies, chronic pelvic pain, subacute or chronic intestinal obstruction and others.
Puerperal or post abortal sepsis usually remains contained within the pelvic cavity. However, when the organism causing the infection is very virulent or the woman is immune compromised or labor has been prolonged, neglected or obstructed or operative interventions have been done then the severity of the sepsis is such that the infection spreads beyond the pelvic cavity involving the general peritoneal cavity leading to peritonitis and all clinical classical signs of peritonitis.
These women on presentation appear sick, have constitutional symptoms, tachycardia, fever, abdominal distension, guarding, tenderness, rebound tenderness, rigidity, foul smelling lochia, uterine tenderness and or sub involution of the uterus. Abdominal distension due to paralytic ileus adds on to the distension caused by collection of the pus or exudate.
Early diagnosis by laboratory investigation and imaging modalities form the cornerstone for further definitive treatment which is essential to reduce morbidity, mortality and sequelae. Complete blood counts, high vaginal swabs for aerobic and anaerobic cultures, ultrasound of the pelvis and abdomen to see the extent, amount, type of collection, state of the uterus and adenxa, remnants of the placenta, products of conception in the endometrial cavity is required
CT scan study with contrast adds to the diagnostic accuracy of ultrasound. A diagnostic tap of the fluid is many times required to identify the causative micro organism. It is essential to differentiate between infection caused by mycobacterium or by other aerobic or anaerobic germs. Tuberculosis needs to be excluded as it flares up in the post abortal or post partum women.
Infections caused by polymicrobial pathogens require broad spectrum antibiotics and myobacteria tuberculosis requires anti tubercular chemotherapy. The chemotherapies are not completely effective in the presence of pus. Drainage of the pus is mandated under cover of effective chemotherapy/ antibiotics. This can be done surgically or by intervention radiology. Surgery allows the drainage of all pus quickly, (though the pus can recollect) so allows the quick action of the appropriate antibiotics. Intraperitoneal drains are usually inserted to ensure continuous drainage and prevent recollection of the fresh exudate. However, in suspected cases of abdominal tuberculosis leaving drains is not advisable as fistulas may form. Placing a pigtail catheter through radiology is a viable alternative in patients who have high surgical morbidity, drainage is slow, catheter can get blocked, may not be able to drain out pus from all areas of the abdomen and reinsertion may be needed. The choice between the two options has to be judiciously selected by the treating doctor. Surgical option is always available if pigtail catheter fails to complete the drainage of the pus.
Every obstetrician must aim to eliminate or drastically reduce the causes responsible for postpartum sepsis. Prompt diagnosis and vigorous treatment can reduce the morbidity and long term sequelae.
I bring the August issue of our journal to our readers and hope that our August readers find the case reports in this issue informative and educative.