Journal of Applied Molecular Cell Biology


ISSN: 2412-2580
Short Key Title: J App Mol Cell Bio
DOI: http://dx.doi.org/10.21065/24122580
Start Year: 2014

PHARMACEUTICAL AND CLINICAL STUDY OF POST-PARTUM PERITONITIS: A CASE STUDY
Alia Anber , Saman Mehak
Faculty of Pharmacy, University of Sargodha, Sargodha 40100 Pakistan
Keywords: Peritonitis, post-partum, laparotomy, medical and pharmaceutical care.
Abstract

Introduction: Peritonitis is the inflammation of peritonitum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localized or generalized, and may result from infection or from a non-infectious process. Case presentation: We present a case of a 21 years-old female patient with postpartum peritonitis who was admitted in the hospital. The diagnosis concluded with intestinal obstruction, fluid leakage along with bacterial and fungal infection. A successful laparotomy was performed. The patient was injected with different antibiotics, supplement and pre-operative and post-operative drugs. The patient is still admitted in the hospital and under observation. Conclusion: The patient is still under observation and is recovering fast after the surgery and medication. Our case report emphasizes that negligence of the physician while diagnosing can lead to severity of the disease and proper medical care is required during delivery to avoid postpartum infections.

Article Information

Identifiers and Pagination:
Year:2016
Volume:3
First Page:1
Last Page:5
Publisher Id:JAppMolCellBio (2016 ). 3. 1-5
Article History:
Received:October, 5, 2015
Accepted:November 21, 2015
Collection year:2015
First Published:January 1, 2016

INTRODUCTION

Peritonitis [1]  is an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs. Peritonitis may be localized or generalized, and may result from infection (often due to rupture of a hollow organ as may occur in abdominal trauma or appendicitis) or from a non-infectious process. Antibiotics are usually administered intravenously.

Cause of peritonitis:[1]

There are two types of causes for peritonitis:

1)       Infected peritonitis:

·         Perforation of part of the gastrointestinal tract is the most common cause of peritonitis. Perforations may be due to ulcers, carcinoma, ingestion of sharp foreign object, ascites and the perforation of hollow viscous mixed bacteria are obtained; mostly Gram-negative (e.g., E. coli) and anaerobic bacteria (e.g., Bacteroides fragilis)[2]

·         Disruption of peritonitis caused by surgical wound, trauma, peritoneal dialysis and chemotherapy. The bacteria usually found are of cutaneous species for example Staphylococcus aureus.

·         Systemic infections like tuberculosis may rarely have a peritoneal localization.

 

2)       Non-infected peritonitis:

·         Leakage of sterile body fluid into the peritoneum such as blood, gastric juice, bile, urine and pancreatic juices. It is important to note that while these fluids are sterile at first, they frequently become infected once they leak out of the organ, leading to infectious peritonitis within 24-48 hours.

·         Sterile abdominal surgery under normal circumstances causes minimal generalized peritonitis.

CASE PRESENTATION

21 years-old, female patient weighing 57kg came to the hospital with a 3 day-history of persistent abdominal pain. The patient had a delivery 4 days before, giving birth to a healthy child, by normal vaginal delivery. The patient had been discharged the following day on oral metronidazole and amoxicillin. The family history shows no significant or serious diseases. Patient has not undergone any surgery in the past, neither shows hypersensitivity to any specific substance. She doesn’t have any complicated disease either. Upon coming to the hospital, 4 days after the delivery, the patient was diagnosed with constipation and was discharged on stool softeners. The patient re-presented in the hospital 2 days later, she had tachycardia with a heart rate of 100 beats per minute. Abdominal examination affirmed distention and tenderness. The patient also complained of fever (38°C), chills, vomiting and nausea accompanied by a loss of appetite and constipation.  She was immediately admitted in the hospital. The patient was monitored for different laboratory tests as follows:

Test

Result

Units

Reference ranges

Creatinine

132

µmol/l

60-125

urea

6.70

µmol/l

3.3-6.7

Renal Function Test

 

Glucose fasting:

Test

Result

Units

Reference ranges

Glucose fasting

7.9

mmol/l

(4.2-6.4)

 

Electrolyte (Na, K, Cl):

Test

Result

units

References range

Sodium

130.4

mmol/l

136-148

Potassium

4.49

mmol/l

3.6-5.2

Chloride

99.9

mmol/l

98-108

 

Urine sugar

Test

Result

Urine sugar

Nil

 

FBC by analyzer:

Test

Result

Units

Reference ranges

HGB

10.2

g/dL

12-15

PLT

369

x19^9/L

150-400

WBC/TLC

14.0

X10^9/L

4-11

 

C-Reactive Protien:

Test

Result

units

Reference ranges

C-Reactive Protien(CPR)

>6

mg/L

Negative: <6

Positive: >6

Test

Result

Units

Reference ranges

Creatinine

81

µmol/l

60-125

urea

7.34

µmol/l

3.3-6.7

RFT:

 

Electrolyte (Na, K, Cl):

Test

Result

units

References range

Sodium

139.5

mmol/l

136-148

Potassium

3.20

mmol/l

3.6-5.2

Chloride

103.6

mmol/l

98-108

 

PT+INR, IMR+PT, APTT:

test

Result

units

Reference range

PT

16

Sec

12-15

INR

1.19

%

 

APTT

36

seconds

30-43

 

Electrolyte with Bicarbonate:

Test

Result

units

References range

Sodium

135

mmol/l

136-148

Potassium

3.91

mmol/l

3.6-5.2

Chloride

107

mmol/l

98-108

Bicarbonate

24.7

mmol/l

22-28

 

In the postpartum period it is important to remember that the clinical signs of peritonism, guarding and rebound tenderness may be diminished or subtle due to abdominal wall laxity[3]. An ultrasound was performed of the pelvis and abdomen to rule out any products of conception. The ultrasound (Fig. 1), revealed an enlarged bulky uterus with a small amount of fluid in the cavity. In addition, abdominal X-ray taken supine showed distended loops of bowel [4] and on erect X-rays fluid levels were visible.

The ultrasound showed enlarged bulky uterus with fluid in the cavity and the erect X-ray revealed fluid levels thus indicating that the patient had a non-infectious peritonitis. This, later, led to the infectious peritonitis.

Cultures taken from the peritoneal fluid grew Streptococcus feacalis indicating a microbial infection in the peritoneum. This was treated by antibiotics mentioned later. Conservative management was advised and patient was referred to a general surgeon who performed a laparotomy[1] (surgery) which is required for a full exploration and lavage of peritoneum.


                                             Figure1. Fluid present anterior to the uterus.

When the patient was admitted in the hospital, a surgery was performed four days later. Nasogastric (NG) tube was used every half hour for feeding. Patient’s surgery was successful although the patient kept suffering from mild fever for 3 days after the surgery. Following medication was administered to the patient:

Pre-operative drugs: RL 1000mL injection IV, once daily, Cefactum injection IV 2g once daily, Dalacin C 600mg IV once daily, Trovas injection IV 100mL once daily, Plabolyte M, IV 1000mL given once.

Post-operative drugs: Parentral administration of drugs:  RL 100mL injection IV once daily, Cefactum injection IV 2g once daily, Dalacin C injection IV 600mg once daily, Trovas injection IV 100mL once daily, Anafortan plus IM injection 4mL, as needed. Oral administration of drugs: Capsule Dalacin C, 300mg, thrice a day, Tablet Panadol, 600mg, daily, Capsule Omega, 20mg, twice a day, Protein sachet, once daily, ORS, as required, Injection normal Saline, 1000mL, once daily.

DISCUSSION

The clinical pattern of peritonitis is one of abdominal pain with nausea, vomiting and sometimes diarrhea or ascites. These symptoms may progress to shock which is fatal. In severe forms an abdominal catastrophe is mimicked and surgical intervention is practically mandatory. The peritoneum has a rich supply of pain fibers and a surface area equal to that of the skin. Any assault on this organ by bacteria or allergen can lead to sudden and drastic shock by a combined neurogenic and plasma losing mechanism.

A 21-year old female patient under study appeared in the hospital, with severe abdominal pain and constipation.  The physician recommended a stool softener to the patient. But, 2 days later the patient re-presented with severe symptoms of vomiting, constipation and persistent abdominal pain upon which physician suggested some laboratory tests and ultrasound. The reports revealed inflammation of the peritoneum for which patient was immediately admitted to the hospital and referred to surgery. The diagnosis led to postpartum peritonitis after knowing that the patient delivered the child in a local, unhygienic maternity home of a village which became a cause of infection during the delivery. On admission to the hospital, the patient was then subjected t proper treatment and surgery was performed.

Atibiotics like cefactum and Delacin were administered to the patient against bacteria causing peritonitis. Cefactum-a cephalosporin (ß- lactum) antibiotic used for certain bacterial infections and are quite active against E. coli and Bacterides fragilis, the common cause of peritonitis. Dalacin C (clindamycin) is also an antibiotic which prevents bacteria like E. coli and staphylococcus and streptococcus from producing their essential proteins. To confirm the susceptibility of drug against bacteria, blood sample of patient was tested. Other than antibiotics, anti-spasmodics like Anafortan plus and Panadol was also administered. For electrolyte balance hypertonic solution with electrolytes with carbohydrates (Plabolyte, and ORS) were used. RL solution (Lactated Ringer’s solution) and Normal Saline solution were injected for resuscitation after blood loss due to the laparotomy performed. To improve the immunity of the patient fish oil capsules (Omega) were used. So this appears to be a rational treatment as the patient is moving towards a rational treatment.

This case reports signifies the fact that such rare yet fatal infection could have been prevented if the delivery was performed under hygienic conditions. The delayed and incorrect diagnosis led to the severity of the disease. This negligence of the medical staff during delivery and poor socio-economic status of the patient’s family resulted in the patient’s sickness. If the patient had been admitted in the hospital and the delivery was performed under hygienic condition then this situation could have been prevented. Other than that, if the physician had checked the patient correctly and diagnosed prior to the disease getting severe than the patient could been prevented from surgery.

 

CONCLUSION:

The patient is still admitted in the hospital and is under observation where her vitals are kept in check. She is recovering from her condition which indicates that the treatment she was subjected to was rational. The antibiotics used worked efficiently. The important point is, postpartum peritonitis is a rare condition [5]. This indicates poor medical care during the delivery of the patient[6] and negligence of the physician in diagnosing the disease. This infection might have led to a shock proving fatal for the patient.[7]

 

RECOMMENDATIONS:

The patient is recommended to continue the treatment with prescribed medication and complete bed rest.

ACKNOWLEDGEMENTS:

We would like to thank Dr. Shakeel D-Pharm, Head Pharmacist, FOH, whose help we gratefully acknowledge.

 

REFERENCES:

1.       Wikipedia. Peritonitis. http://en.wikipedia.org/wiki/Peritonitis (accessed 10 July 2014).

2.       Warren L. Review of Medical Microbiology and Immunology, 12th ed. New York, Chicago, San Francisco, Lisbon, London: McGraw-Hill; 2012. 

3.       Vanessa B, Sascha D, Anna A, Rudi B, Oladapo F. Postpartum pneumoperitoneum and peritonitis after water birth. Journal of Radiology Case Reports 2009; 3(4): 1-4.

4.       Arnold B, Stephen B. Toohey’s Medicine, 15th ed. New York, Toronto, Oxford: Churchill Livingstone;  

5.       Ilin C, Chris VB, Bernard B, Anne S. Population-Based Surveillance for Postpartum Invasive Group A Streptococcus Infections, 1995–2000. Oxford Journals 2002; 35(6): 665-670.

6.       Olivia AS, Alastair RM, Rodney JB. Vernix caseosa peritonitis – no longer rare or innocent: a case series. Journal of Medical Case Reports 2009; 3(60):

Meredith D, Melissa L, Elizabeth RZ, Thomas HT, Chris VB,Stephanie S. Incidence and Severity of Invasive Streptococcus pneumoniae, Group A Streptococcus, and Group B Streptococcus Infections Among Pregnant and Postpartum Women. Oxford Journals 2011; 53(2): 114-123.


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Bibliography

Dr. Bruno Perillo PhD is associated with Istituto di Scienze dell, Alimentazione, Consiglio Nazionale delle Ricerche, via Roma, 52, 83100 Avellino, Italy. He has contributed in book chapter entitled “Analysis of posttranslational modifications in the control of chromatin plasticity observed at estrogen-responsive sites in human breast cancer cells” Methods Mol. Biol. 1204, 59-69. 2014. Whereas, his research work is published in renowned credible journals.  

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