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.