CASE 81: PAIN AND FEVER IN PREGNANCY
History
A woman aged 26 years is referred by her general practitioner. She is 36 weeks’ gestation in
her fourth pregnancy, having had one miscarriage and two term vaginal deliveries.
In this pregnancy she has been seen twice in the day assessment unit, the first time at 31
weeks for an episode of vaginal bleeding for which no cause was attributed. The second time
was at 35 weeks after she awoke with damp bed sheets. No liquor had been detected on speculum examination at the time and she was discharged. For the last 2 days she has been feeling
generally unwell with a fever, decreased appetite and a headache as well as abdominal discomfort. She reports the baby moving less than normal for the last few days, with approximately 8–10 movements per day.
She has not noticed any vaginal bleeding but her discharge has been more than normal and
there is an offensive odour to it.
Examination
Her temperature is 37.8°C, blood pressure 106/68 mmHg and heart rate 109/min. On abdominal palpation symphysiofundal height is 34 cm and the fetus is cephalic with 3/5 palpable.
There is generalized uterine tenderness and irritability. On speculum examination the cervix
is closed and a green/grey discharge is seen within the vagina.
INVESTIGATIONS
Normal range for
pregnancy
Haemoglobin 10.9 g/dL 11–14 g/dL
Mean cell volume 80 fL 74.4–95.6 fL
White cell count 17.3×109/L 6–16×109/L
Platelets 327×109/L 150–400×109/L
C-reactive protein 68 mg/L <5 mg/L
The cardiotocograph (CTG) is shown in Fig. 81.1.
HR
60
80
100
120
140
160
200
HR
60
80
100
120
140
160
200
UA
25
75
100
04:50 05:00
180
UA
25
50
75
100
UA
25
50
75
100
180
50
Figure 81.1 Cardiotocograph.100 Cases in Obstetrics and Gynaecology
228
Questions
• What is the diagnosis?
• How should this woman be managed?Case 81: Pain and fever in pregnancy
229
ANSWER 81
The diagnosis is of chorioamnionitis secondary to prolonged preterm rupture of membranes.
Although spontaneous rupture of membranes was not confirmed at the previous attendance
at 35 weeks, it seems probable that in fact this did occur at that time. Ascending organisms
have thus colonized the uterus and resulted in infection. The result is a maternal systemic
reaction causing her symptoms and signs: tachycardia, tenderness, leucocytosis and raised
C-reactive protein.
The fetus is also affected as shown by the fetal tachycardia.
Chorioamnionitis is a significant cause of both fetal and maternal morbidity and mortality,
and should be treated as an obstetric emergency.
Management should be instigated immediately. Initial microbial specimens should be
obtained from high vaginal swab and maternal blood cultures.
Intravenous broad-spectrum antibiotic should be commenced to cover both anaerobic and
aerobic organisms. Intravenous fluids should be commenced to counter the effects of vasodilatation and pyrexia, and because the woman is unable to drink adequately. Paracetamol
should be given regularly for the pyrexia and abdominal discomfort.
The baby needs delivery by induction of labour – women with chorioamnionitis often labour
rapidly. Risks of caesarean section in the presence of infection are significant in terms of
bleeding, uterine atony and disseminated intravascular coagulopathy. However continuous
CTG should be employed and immediate caesarean section performed if it deteriorates.
Steroids (to prevent potential respiratory distress syndrome) are contraindicated in this
woman as they may increase the severity of infection.
After delivery, the baby will need to be reviewed by the paediatrician and given a septic screen
and course of intravenous antibiotics.
KEY POINTS
• Chorioamnionitis is a significant cause of fetal and maternal morbidity and must
be managed aggressively with antibiotics and induction of labour.
• An uncomplicated fetal tachycardia should be managed with fluids and paracetamol to the mother, with antibiotics if infection is suspected.
• Delivery should be expedited if any more suspicious CTG features develop.
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