Differential diagnosis, investigations and treatment
In the first day, the vital signs after admission was BP:95/60, PR=92,
RR=19 and T=36.5°. The clinical examination showed the abdomen is soft
and without guarding. Lungs were normal and vesicular. She has not
uterine tenderness and in uterine examination by speculum, the cervix
was closed. The fetus FHR was 135. Therefore, after clinical
examinations Ampicillin (AMP, 2gr; QID-IV, no discharge), Azithromycin
(Cap, gr P.O, Stat), Betamethasone (AMP,12mg I.M Stat), Magnesium
sulfate (2 gr, Stat for 12 hrs.) and NST +Toco (daily) was prescribed
for patient.
During the fetal ultrasound on the first day of hospitalization a
cephalic embryo, amniotic fluid= 132, and a posterior placenta was
observed in uterine. The fetus weight was 1690 and was in
90th percentile of growth curve. The conducted
biophysical was 10/10.
During the second and third days, the vital symptoms were stable and no
fever was detected. In the second day after admission, in trans-vaginal
sonography showed the length of the cervix was 23 mm and the cervix
path was open and qualified. In third day, due to FHR drop, fetal
heart failure and umbilical cord prolapse, the patient underwent
emergency cesarean section (CS). During CS, first the Pfannestiel
incision conducted on abdomen and horizontal incision in lower segment
of uterine applied. But due to back down transverse of fetus, the
incision changed to T incision to achieve the fetus. The CS outcome was
a fetus with PH=7.26, PCO2=50.1, PO2=15, HCO2=22.5, BE-CCF= -4.8,
BE-B=-5.2, weight 1700gr and Apgar is first and 5 minutes was 7 and 9,
respectively. Due to high risk of mother following cesarean, Ampicillin
(2gr, QID), Gentamicin (80gr, TDS) and Clindamycin (900, TDS) prescribed
for 48 hrs.
The first day after CS, the patient’s general condition was good. The
bandage site was dry and vaginal bleeding was normal and the uterus is
contracted. Nevertheless, she has not defecation. On the second day
after the CS, the patients had defecation, but at 11 pm, her fever was
37.9 and she had tachycardia. On the third day after the CS, due to high
fever, PCR Covid 19 and without contrast CT from abdominal/pelvic was
requested. Moreover, Apotel (Amp), Enoxaparin (Amp, 400mg BD), Pentazole
(Tab, 20mg BD) is ordered.
In forth day after CS, infectious disease specialist replaced Vancomycin
(AMP, 4.5 gr, QID) and Tasosin (AMP, 1 gr, BD) with Ampicillin (2gr,
QID), Gentamicin (80gr, TDS) and Clindamycin (900, TDS). In addition,
blood culture showed the proteinuria and PCR Covid-19 test were negative
and the CXR did not show lung perfusion involvement. In forth day after
CS, Doppler sonography did not show evidence of deep vein
thrombosis (DVT) and pelvic artery thrombosis. Moreover, low fluid and
hematoma in the uterus and evidence in favor of a subcutaneous lesion
collection in 20 × 22 × 48 diameters was seen. The vital sign was
BP:116/81, PR:130, RR:21, and T=39.3°. Moreover, CRP was higher 1200 and
leukocytosis (WBS=12500) and neutrophil was 80%. Five days after CS,
based on the medical commission, the patient was transferred to the
operating room and subcutaneous lesion collection was evacuated with
laparotomy. Uterine fascial dehiscence was not seen and a little post
operation inflammation was seen at the site of CS. The culture of lesion
collection showed positive E-Coli and therefore, Tasocin was hold
but vancomycin, Meropenem (1gr, IV, TDS), Pantazol (Amp, 40mg) and
Enoxaparin (40ml Daily) were prescribed.
After operation at fifth day and 10th days after CS
all things was normal. On the 11th day after CS, a purulent discharge
was observed during the washing of the wound and due to a 37.9 degrees’
fever, the infection probability at the operation site or an abscess was
raised. Therefore, a biopsy was then taken from the wound tissue for
culture and Wright and Coombs 2ME test was requested. The patient, went
to the operating room again due to high fever and for debridement of
dehiscence. She underwent NPO in last night and transferred to the
operating room by diagnosing infection of CS wall without purulent
discharge. Laparotomy was performed and during laparotomy the dehiscence
were released and then she was transferred to the ICU.
During washing and debridement in the operating room, we noticed fascia
dehiscence, in which the fascia opened and we entered the abdominal
cavity, and uterine dehiscence was completely seen in the T-incision.
Debridement and repair of the uterus were performed and the uterus was
preserved. Therefore, fascia and infection debrided and fascia was
repaired, then drain was implanted and cutaneous and subcutaneous of
skin maintained open. Then, two units of pack cells, 2 units of FFP and
Apotel (Amp) and continuing vancomycin and Meropenem (1gr, IV, TDS) is
prescribed.