June 08, 2012

Case report #2
Submitted to Dr Sisay Teklu
Submitted by Samuel Masresha
MDR 6812/02

Department of Obstetrics and Gynecology

TIkur Ambessa Specialized Hospital
Addis Ababa University

Identification:
Name: Lomi Amare Age: 25

Sex: female

Address: Kolfe, kebele 07, Addis Ababa

Occupation: housewife
Christian Orthodox

Marital status: Married

Religion:

Date of admission: 25/09/04

625/3

Ward: C6, Obstetrics & Gynecology

Bed no#

Date of clerking: 28/09/04 E.C

Chief complaint:
Easy fatigability & fever of 7 days duration

HPP:
This is a 25 year old para III mother. She gave birth to her last child 13 days ago.
Her LNMP was 20/12/03 and EDD was 24/09/04. She delivered on 15/09/04 making
the GA of the newborn 38 5/7 weeks by date. The cycle was regular coming every 4
weeks and she has never used contraception.
She knew she was pregnant after she missed two consecutive menses. She then
went to a local health center for ANC during the first trimester. Diagnosis of the
pregnancy was confirmed by urine pregnancy test. General physical examination
and blood test were done. She was screened for RVI, VDRL and HBsAg. She was
given TT vaccination and iron supplement. She tested ve for RVI, VDRL and HBsAg
and she was told everything else was normal and that she should continue her
follow up.
She went to the health center for her second ANC follow up at 28 th week GA. History
was taken, physical examination was done and laboratory tests were ordered. She
was told everything was normal and that she should come after 4 weeks. She was
given iron supplement.
She had her third ANC on 32nd GA. After history was taken, general physical exam
was done and blood and urine sample was taken for analysis, she was told that
everything was normal and that she should come after 5 weeks. She was given the
second TT vaccination.
She went to the health center on 37th week of GA and she was told everything was
normal. She was counseled on how to manage to get to health center if labor
started.

Quickening happened on 15/04/04. Fetal movements were kicking in type. Fetal

kicks had not decreased. She did not have loss of appetite. She used to have 5
meals a day. She had a loaf of wheat wheat bread (100g) with milk (100ml) for
breakfast during most of her mornings. She ate three kurt of Tef Injera (300g)
with Misir(50g) or Shiro(50g) or Yeabesha gomen(50g) or meat(50g) for lunch
and dinner. She usually took two extra meals consisting of a loaf of wheat bread
(100g) or Tef Injera (300g) with Misir(50g). This amounts to an average total of 1764kcal/day. She claims to have gained a total of 10 kg.
There were no significant events during the first, second or third trimesters.
Pushing down pain started at 12:00 PM on 14/09/04. It was progressive, increasing
in intensity and frequency. Membranes ruptured 4 hours later. The fluid was clear,
watery and had no odor. She delivered a female newborn at 6:00 AM on 15/09/04,
unattended at home. She claims the labor progressed too quickly to go to the health
center. It was a spontaneous vaginal delivery with cephalic presentation. The cord
was cut with razor and tied with a string by her neighbor who heard her screams
early in the morning. The placenta was delivered spontaneously 5 minutes after
delivery. She claims there was minimal bleeding and that the baby is currently
healthy.
She presented with easy fatigability & fever of 7 days duration. She was ambulatory
during the second day of delivery date; but starting from third day postpartum, her
weakness forced her to be bedridden. The fever was high grade and persistent. She
had associated palpitations, sweating, vaginal discharge and diarrhea. The
palpitations were on and off type but they showed no predilection towards a specific
time of the day or activity of the mother. The sweating was profuse and happened
continuously throughout day and night. The discharge was yellowish, foul smelling
and amounted to 2 coffee cups per day. There was no associated genital pruritus.
The diarrhea started 5 days ago, lasted for 3 days and has currently subsided. The
frequency was 4/day and the stool was watery, pale, non-blood tinged and there
was no tenesmus. For these complaints, she had gone to a private clinic 4 days ago
where she was assessed as typhoid fever and was treated accordingly with oral
antibiotics. However, she showed no improvement.
There is no history of vaginal bleeding
No history of headache, abnormal body movement, loss of consciousness or vision
disturbance
No history of epigastric or right upper quadrant pain, yellowish discoloration or
bleeding from gums
No history of cough, recent upper respiratory tract infection, chest pain or history of
choking
No history of leg swelling
No history of dysuria, incontinence or frequency
No history of intravenous lines
No history of breast tenderness or lesion on the breast

There is no history of coitus near delivery

No history of contact with a chronic cougher or loss of appetite
She is not from a malarious area and there is no history of recent travel to a
malarious area
No history of any gynecological or surgical operation
No history of DM, hypertension or asthma
Pregnancy was unplanned but wanted and supported. Birth was planned to take
place spontaneously & vaginally at a health center and money for taxi transport and
health expenses was prepared.

Past obstetric history:

Year
1st 1998
EC
n
2
2002
d
EC
r
3
2004
d
EC

GA

Place

route

outcome

wt

39

Home

SVD

Live birth

2.9 kg

Ante/post partum
complication
PROM

38

Health
center
Home

SVD

Live birth

3.3 kg

SVD

Live birth

3.7 kg

Offensive lochia,
fever..

38 5/7

Gynecologic history:
The mother has never used any contraception. She has no history of sexually
transmitted diseases. She is sexually active. She started coitus by the age of 19.
She has coitus at an average of 2x/wk and she is monogamous. She had her last
coitus at 20 weeks of GA. The mother had no abortions. She has no history of
gynecologic operations. She has no history of circumcision.

Menstrual history:
She had menarche at the age of 12. The menses were regular. Duration of flow is 5
days. She uses 1 traditional piece of cloth per day during menses. The flow is dark,
with no clots. She does not experience pain associated with flow of menses.

Past medical history:

She has a history of pneumonia at the age of 12 for which she was treated and
there was no recurrence. She has occasional common cold. She has no history of
medical disorders like DM, or hypertension before the pregnancy. She has had no
previous transfusions. She has not experienced hypersensitivity to drugs. She has
no history of infection with STD during the latest pregnancy.

Family/personal history:
The patient was born and raised in Addis Ababa. She is a single child. She lives with
her husband their newborn and 2 year old child. The children are currently healthy.
Her mother is healthy and lives with the family. The father passed away at the age
of 45 from liver failure. The patient is educated upto the level of 5 th grade. She has
no habit of smoking or illicit drug use. She does not drink alcohol. She is a
housewife supported by her husband with a monthly income of 1000br. Their house
has 4 rooms with a separate kitchen and toilet. They have a clean water supply.
They have one car. There is no family history of hypertension, diabetes mellitus,
tuberculosis, allergies or mental disorders. She did not have twin delivery.

Review of systems:
H.E.E.N.T
Head: no headache, no head injury, no dizziness
Ears: no impaired hearing or discharge, no ringing in the ears
Eyes: no discharge, no redness, no blurred vision
Nose: no discharge, no stuffy nose, no runny nose, no sneezing
Mouth: no dental caries, no bleeding gums, no artificial dentures
Throat: no sore throat, no difficulty in swallowing, no hoarseness of voice
L/G: no mass in the neck, axillae, or groins. There is breast enlargement and
tenderness associated with the pregnancy. No discharge from the nipples. No heat
or cold intolerance
Respiratory: no cough, no expectoration, no chest pain, no wheezing, no cyanosis
Cardiovascular: palpitations, no shortness of breath, PND or orthopnea, no chest
pain, fatigue
Gastrointestinal: one episode of nausea and vomiting, diarrhea, no constipation, no
abdominal pain or heart burn, no change in stool color.
Genitourinary: no frequency, no dysuria, no urgency, no hesitancy, no dribbling, no
reddish discoloration of urine.
Integumentary: no rash, moist skin, no discoloration, no hair changes,
hyperpigmentation on abdomen along the midline from the umbilicus downwards.
Locomotor system: no history of pain, weakness or swelling of the joints,
Central nervous system: no history of numbness, no paralysis, urine incontinence,
seizures or speech defect

Physical examination:
General appearance:
The patient is acutely sick looking. She is sweating profusely. She is supine. She is
lethargic. She is not in cardiorespiratory distress. There is no gross dysmorphic
feature.

Vital signs:
Blood pressure:
110/60 mmHg
Pulse rate: 96/min
right radial artery, full in volume and regular
rhythm
RR:
28 breath/min
tachypnic
Temperature:
38.5c
Weight:
62kg
Height:
176cm

H.E.E.N.T
Head: no scar, no scalp infections, no tenderness, normal hair distribution, clean
Ears: normal contour, normal position, no discharge, no mastoid tenderness
Eyes: pale conjunctivae, non-icteric sclerae, no discharge, no conjunctival
inflammation, no lid lag, no proptosis, no peri-orbital edema, no strabismus,
no nystagmus,
Nose: no discharge, central septum, no visible polyps or deformity
Mouth:
non offensive breath order, wet buccal mucosa, no mucosal ulcers, no
cyanosis, fissures on the lips, no active gum bleeding or ulcers, no dental
carries or fillings, tongue is not fissured or coated,
Throat:
tonsils not enlarged, non-tender

L/G:
2 superficial lymph nodes are palpable over the inguinal areas bilaterally. Each sized
1 cm . They are firm, non-tender and not matted. The breasts are engorged. They
are soft. They are not tender there is no lump. There is no discharge or
inflammation over the nipple. Thyroid is not palpable.

Respiratory system:
Inspection: tachypnic (28/min), no peripheral or central cyanosis or digital
clubbing, chest moves symmetrically with respiration, no gross deformities, no use
of accessory muscles, flaring of ala nasi or grunting
Palpation: central trachea, no chest tenderness, symmetrical expansion,
comparable tactile fremitus

Percussion: resonant over the lung fields, diaphragmatic excursion no done due to
patient condition
Auscultation: bilateral good air entry, vesicular breath sounds heard over the lung
fields, no crepitation, no wheeze, no pleural friction rub

CVS:
Arteries: the pulse is bounding, regular rhythm and full in volume
radial

brachial

carotid

femor
poplite Dorsalis
Post
al
al
pedis
tibial
Right
++
++
+++
+++
+
++
+
Left
++
++
+++
+++
+
++
+
Veins: JVP is 3 cm above sternal angle in 30 inclination. No distended veins
Inspection: mild palmar pallor, no cyanosis, clubbing, Janeway lesion, splinter
hemorrhage or Oslers nodes
Precordium is quiet, no bulge, apical impulse is visible in 5 th left intercostal space, 1
cm lateral to mid-clavicular line
Palpation: PMI is palpable where apical impulse is visible. It is tapping, and localized.
There are no palpable heart sounds
Auscultation: S1 and S2 are well heard. There is a hash mid-systolic murmur at
mitral and tricuspid areas. It is grade III, does not radiate and it is crescendo type.
No pericardial friction rub.

GIS:
Inspection: the abdomen is flat and symmetrical. There is no flank fullness. There is
no localized swelling. There are no distended veins. The abdomen moves upwards
with inspiration and down with expiration. Epigastric pulsations are not visible.
Inguinal, epigastric, umbilical and femoral sites are free of hernia. The umbilicus is
inverted. There is linea nigra and striae gravidarum. No surgical scar.
Palpation: there is no superficial mass. There is tenderness over the suprapubic
area. The uterus is palpable at the symphysis pubis. There is no hepatomegaly, no
splenomegaly. The kidneys are not palpable. No other deep mass.
Percussion: abdomen is tympanic all over, there is no shifting dullness. Total vertical
liver span is 10 cm along the mid-clavicular line.
Auscultation: active bowel sounds of 14/min, no renal arterial bruits.

GUS:
There is no costovertebral angle tenderness.

Pelvic:
Inspection: Sexual maturity rating of 5/5. There is visible vaginal discharge. There
is no visible mass at introitus. There is no swelling over the labia, no ulcer.
Digital vaginal exam: cervix is firm and found at the level of the ischial spine, no
mass over the cervix, there is cervical motion tenderness, no adnexal mass, no
mass bulging from the vaginal mass, no adnexal tenderness, smooth vaginal
mucosa, no blood on examining finger

Integumentary:
Profuse sweating, no rash, striae gravidarum and linea nigra present, mild palmar
pallor, no jaundice, warm skin
normal hair distribution, soft texture and strength
pale nail beds, no inflammation around nails, no clubbing

Musculoskeletal:
No asymmetry of limbs, no gross deformities, no joint swelling, redness or
tenderness. No edema. No limitation in movement.

CNS:
General: lethargic, rates 14/15 on Glasgow scale, conscious, oriented to place,
time & person
Cranial nerves:
CN I
CN II
CN
CN
CN
CN
CN
CN

smells alcohol via each nostril

good visual field and acuity, direct and indirect pupillary
light reflexes are present
III, IV &VI patient looks in all directions with both eyes
symmetrically, no strabismus or nystagmus
V
intact tactile sensation over the face, corneal reflex
present, intact motor part
VII
face is symmetrical at rest and upon voluntary
movements like smiling, nasolabial folds are present
bilaterally
VIII
good hearing on both sides,
IX & X
says ah, no hoarseness of voice
XI
shoulders shrug against resistance, neck turns against

resistance
CN XII

no atrophy of the tongue, tongue is central upon

protrusion
Motor: bilaterally comparable muscle bulk of limbs, no spontaneous or induced
fasciculation,
Muscle power:
RU
RL
LUL
LLL
L
L

POWE
R
superficial reflexes:

5/5

abdominal
plantar
corneal

5/5

5/5

5/5

normal
down going
normal

deep tendon reflex:

Biceps

Rig
ht
2/4

Lef
t
2/4

triceps

2/4

2/4

Brachioradia
lis
patellar

2/4

2/4

2/4

2/4

ankle

2/4

2/4

No clonus on both sides

sensory: pain sensation is intact over all extremeties
Meningeal signs: no nuchal rigidity, absent kernigs and brudzinskys signs.

Summary:
Subjective
Aseptic delivery,
Term, live delivery
fever,
lower abdominal pain
foul smelling vaginal discharge
sweating

generalized body weakness,

Objective
Tachypnea, 28
fever, 38.5
lower abdominal tenderness,
pallor,
mid-systolic murmur
cervical motion tenderness

Differential diagnoses:
Puerperal sepsis 2 to endometritis + anemia
Puerperal sepsis 2 to urinary tract infection + anemia
Pelvic abscess + anemia

Discussion of the differential diagnoses

Puerperal sepsis 2 to endometritis + anemia
Puerperal sepsis or puerperal infection is defined as fever of 38C or greater
recorded in the first 10 days postpartum, excluding the first 24 hours. It is one of
the major causes of pregnancy related maternal mortality, along with hypertension
and postpartum hemorrhage. Puerperal sepsis affects 2-8% of all pregnancies.
Endometritis is the most common cause of puerperal sepsis. The epidemiology of
endometritis varies with the mode of delivery. Vaginal (1-3%,) elective C/S (5-15%),
C/S after prolonged labor with prophylactic antibiotics (15-20%) and C/S after
prolonged labor but without antibiotic prophylaxis (30-35%.) Immediately after
birth, there is a breach in the normal defense of the myometrium, cervical mucus
plug, which predisposes to infection.
The risk factors predisposing to endometritis are: prolonged rupture of membranes,
prolonged labor, low socioeconomic status, breach in aseptic technique, manual
delivery of placenta, iatrogenic (C/S, repeated pelvic exam, operative vaginal
deliveries, catheterization,) anemia, poor nutrition, obesity, chorioamnionitis and
coitus near term.
Etiology of endometritis is polymicrobial. However, the necrotic decidua and lochia
favor the development of anaerobic bacteria. Bacteroides species,
peptostreptococcus, and aerobic streptococci are the common isolates.
The clinical manifestations of endometritis are high fever, lower abdominal pain and
tenderness, foul smelling vaginal discharge leukocytosis. Hypotension, malaise, and
generalized sepsis may be present.
Management is antibiotic therapy that is based on etiology.
Complications of a neglected endometritis may be pelvic abscess formation, septic
pelvic thrombophlebitis or generalized sepsis.
This patient gave birth in aseptic conditions at home. In addition, she has pallor;
which indicates anemia and implicates it as an additional predisposing factor for

endometritis. She presented with fever, which is a hallmark of puerperal sepsis. She
has lower abdominal pain & tenderness and foul smelling vaginal discharge. There
is cervical motion tenderness and the uterus is palpable at the pubis symphysis at
13th day postpartum indicating some degree of sub-involution. Therefore,
endometritis is the most probable diagnosis.
Puerperal sepsis 2 to urinary tract infection
2-4% of women develop urinary tract infections postpartum. UTIs are the second
most common cause of puerperal sepsis. This includes primary involvement of the
bladder and/or urethra. The bladder is normally sterile. Immediately postpartum,
the bladder and lower urinary tract are relatively hypotonic and this leads to
retention of residual urine and reflux, which predisposes to infection.
Risk factors associated with acquiring UTI postpartum are prolonged catheterization,
birth trauma, conduction anesthesia, frequent pelvic examinations, preexisting
chronic UTI, anatomical disorders of urinary tract, instrumental delivery, labor
induction, preeclampsia, prolonged hospital stay and history of UTI during a
previous pregnancy.
Patients with UTI may be febrile but otherwise asymptomatic, but commonly
present with dysuria, frequency and urgency. There might be lower abdominal pain
and hematuria. Pyelonephritis will be accompanied by chills, malaise, nausea and
vomiting with costovertebral angle tenderness.
This patient has fever with lower abdominal pain and tenderness. Since UTI is the
second most common cause of puerperal sepsis, it must be considered. However,
she does not have typical urinary complaints like dysuria, frequency or urgency. She
has no history of UTI during her previous pregnancies. Therefore, this diagnosis is
unlikely.
Pelvic abscess
Less than 1% of patients with puerperal endometritis develop a pelvic abscess.
Abscesses typically are located in the anterior or posterior cul de sac or within the
broad ligament.
The single most important risk factor for developing pelvic abscess during
puerperium is a neglected pelvic infection.
Patients with an abscess complain of persistent fever despite therapy for
endometritis. They usually have malaise, tachycardia, lower abdominal pain and
tenderness, and a palpable pelvic mass anterior, posterior, or lateral to the uterus.
The white blood cell count usually is elevated, and there is a shift toward immature
cell forms. Ultrasound, CT scan, and magnetic resonance imaging (MRI) may be
used to confirm the diagnosis of pelvic abscess.

The usual bacteria isolated from abscess cavities are coliforms and anaerobic gramnegative bacilli, particularly Bacteroides and Prevotella species.
Patients with a pelvic abscess require surgical intervention to drain the purulent
collection. When the abscess is in the posterior cul de sac, colpotomy drainage may
be possible. Open laparotomy is indicated when access is limited or the abscess is
extensive.
This diagnosis must be considered in this patient as she has failed to seek medical
attention after an unsafe delivery and only came 7 days after her symptoms
started. She has fever, lower abdominal pain and tenderness. However, the absence
of a palpable pelvic mass anywhere near the uterus goes against diagnosis.

Investigations
CBC with differential

to check for leukocytosis

to quantify anemia
lochia culture
choice

to confirm infection
for management

to identify etiology

for antibiotic

(sample preferably collected with gloved culture device to avoid

contamination)
urinalysis

to check for pyuria, bacteruria, microhematuria

to R/O UTI

pelvic ultrasound
abscess

to check for any hidden mass (abscess)

to R/O pelvic