MANAGING SEPTIC SHOCK IN A 28-YEAR-OLD POSTPARTUM FEMALE

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Sepsis is the leading cause of death in the intensive care unit (ICU) and a common cause of morbidity and mortality worldwide. Sepsis is also recognized as one of the major factors accounting for admission of pregnant and postpartum patients to the ICU and for maternal death. Postpartum patients with sepsis may appear deceptively well before deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or death. CASE PRESENTATION: In our case report, we present a 28-year-old female who had uncomplicated course of her first pregnancy. Her past medical history includes hypothyroidism. She had no surgical history, and no known allergies. She presented to labor and delivery with early labor at 39 weeks and 1 day. She had premature rupture of membranes, was started with Pitocin and subsequently had a vaginal delivery of a male infant weighing 3460g. Her delivery course was complicated by uterine atony, treated with Methergine and first-degree perineal laceration. Her postpartum course was complicated by persistent tachycardia (ranging from 120s-150s), shortness of breath, and dizziness. Her hemoglobin level dropped from 12 to 9 g/dL requiring two units of packed red blood cells. Her symptoms improved when she was discharged. Two days later, she presented to labor and delivery triage with worsening shortness of breath, orthopnea, right lower quadrant pain and foul smelling lochia. On physical examination, she was alert and oriented but in mild respiratory distress. She had bibasilar rales, fever, tachycardia, tachypnea and anascar.She was admitted to the hospital for severe sepsis with endometritis as a suspected source. Proper fluid resuscitation and broad spectrum antibiotics (Ampicillin, Clindamycin, and Gentamicin) were implemented. Blood and urine cultures were obtained and sent to the lab. Within 48-hrs of admission, she went into septic shock with multi-organ failure requiring intubation, renal replacement therapy, and vasopressors. By day four of her stay MICU, she started to show signs promising recovery and was later transferred to the hospital ward for continue recovery. She was discharged home on day 15 of her second hospitalization. DISCUSSION: Sepsis and septic shock are leading causes of intensive care unit admission as well as maternal and fetal morbidity and mortality.5 Risks factors for endometritis include: older age, untreated vaginal infection, low social economic status, poor hygiene, smoking, internal fetal monitoring, postpartum hemorrhage, chorioamnionitis, retained placental fragments and many others. Endometritis is a clinical diagnosis that is sort in a postpartum woman with fever that is unattributed to other causes. A culture of the endometrium is unlikely to be helpful, as culture results tend to be multi-microbial. CONCLUSIONS: Postpartum patients may appear deceptively well, which may delay their sepsis/septic shock diagnosis Reference #1: Karsnitz DB. Puerperal infections of the genital tract: a clinical review. J Midwifery Womens Health. 2013 Nov-Dec;58(6):632-42 Reference #2: Barton JR, Sibai BM. Severe sepsis and septic shock in pregnancy. Obstet Gynecol. 2012 Sep;120(3): 689-706 Reference #3: Chebbo A, Tan S, Kassis C, et al. Maternal sepsis and septic shock. Crit Care Clin. 2016 Jan; 32(1):119-35 DISCLOSURES: No relevant relationships by Kenneth Iwuji, source=Web Response