Medical Complications In Pregnancy
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Medical Complications In Pregnancy

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Medical complications in pregnancy...

Medical complications in pregnancy...

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    Medical Complications In Pregnancy Medical Complications In Pregnancy Presentation Transcript

    • MEDICAL CONDITIONS COMPLICATING PREGNANCY
    • DIABETES MELLITUS
    • DEFINITION OF TERMS
      • OVERT DIABETES
      • - those known to have diabetes mellitus
      • before pregnancy
      • GESTATIONAL DIABETES
      • - those diagnosed during pregnancy
    • CLASSIFICATION DURING PREGNANCY
      • CLASS ONSET FBS 2-HR PP GL THERAPY
      • A1 Gestational <105 mg/dl <120 mg/dl Diet
      • A2 Gestational >105 mg/dl >120 mg/dl Insulin
    • CLASSIFICATION DURING PREGNANCY
      • CLASS AGE/ONSET DURATION VASCULAR THERAPY
      • (Years) DISEASE
      • B Over 20 < 10 None Insulin
      • C 10 – 19 10 – 19 None Insulin
      • D Before 10 > 20 Benign Insulin
      • Retinopathy
      • F Any Any Nephropathy Insulin
      • R Any Any Proliferative Insulin
      • Retinopathy
      • H Any Any Heart Insulin
    • GESTATIONAL DIABETES
      • carbohydrate intolerance of variable severity with onset or first recognition during pregnancy
      • disorder of late gestation
      • disorder induced by pregnancy:
      • from exagerrated physiological changes
      • in glucose metabolism
      • Type 2 DM unmasked during pregnancy
      • A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:
      • A. take a 50 gm glucose challenge test as soon as possible
      • B. order for 50 gm glucose challenge test at 24-28 weeks
      • C. take a 100 gm oral glucose tolerance test as soon as possible
      • D. order for a 100 gm oral glucose tolerance test at 24-28 weeks
    • WHO to screen ?
    • GDM - SCREENING
      • RISK FACTORS
      • Age over 30
      • Family Hx of DM
      • Prior macrosomic, malformed or stillborn infant
      • Obesity
      • Hypertension
      • Glucosuria
    • WHEN to screen ?
    • RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM
      • LOW RISK
      • Blood glucose testing not routinely required if all of the ff characteristics are present:
      • Member of ethnic grp w/ low prevalence of GDM
      • No known DM in 1 st degree relative
      • Age less than 25 yrs
      • Weight normal before pregnancy
      • No Hx of abnormal glucose metabolism
      • No Hx of poor obstetrical outcome
    • RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM
      • AVERAGE RISK
      • Perform blood glucose testing at 24-28 wks:
      • Hispanic
      • African
      • Native American
      • South or East Asian origin
    • RECOMMENDED SCREENING STRATEGY BASED ON RISK ASSESSMENT FOR DETECTING GDM
      • HIGH RISK
      • Perform blood glucose testing as soon as feasible . If normal, repeat at 24-28 wks or at any time pt has SSx suggestive of hyperglycemia:
      • Marked obesity
      • Strong family Hx of type 2 DM
      • Prior gestational diabetes
      • Glucosuria
    • HOW to screen ?
    • GDM - SCREENING
      • 50-g GLUCOSE CHALLENGE TEST
      • > 140 mg/dl or > 130 mg/dl
      • – proceed to 100 gm 3 Hr Oral Glucose Tolerance Test
    • GDM - SCREENING
      • 100-gm ORAL GLUCOSE TOLERANCE TEST (OGTT)
      • TIME NDDG CARPENTER & COUSTAN
      • (1979) (1989)
      • Fasting 105 95
      • 1 hour 190 180
      • 2 hours 165 155
      • 3 hours 145 140
      • GDM is dxed with 2 or > abn values.
      • A 23 yr old markedly obese primigravida at 12 weeks gestation seeks consultation for her first prenatal check-up. She denies any family history of diabetes mellitus. As part of prenatal work-up, you would:
      • A. take a 50 gm glucose challenge test as soon as possible
      • B. order for 50 gm glucose challenge test at 24-28 weeks
      • C. take a 100 gm oral glucose tolerance test as soon as possible
      • D. order for a 100 gm oral glucose tolerance test at 24-28 weeks
    • GDM - ADVERSE EFFECTS
      • MACROSOMIA
      • Excessive fat deposition on shoulders/trunk
      • Predisposes to shoulder dystocia
      • Maternal hyperglycemia  transfer of excess glucose to fetus  stimulate fetal insulin secretion which is a potent growth factor
      • HYPOGLYCEMIA at birth
    • MACROSOMIA Pathogenesis
      • Fetal effects of persistent maternal fasting hyperglycemia include:
      • A. macrosomia
      • B. postterm pregnancy
      • C. oligohydramnios
      • D. hypoglycemia
    • GDM - MANAGEMENT
      • Type A1 – diet alone
      • Type A2 – diet + insulin
      • DIET
      • Goals: 1. to provide the necessary nutrients for
      • mother and fetus
      • 2. to control glucose levels
      • 3. to prevent starvation ketosis
      • EXERCISE
      • upper body cardiovascular training
      • Recommended postpartum follow-up for patients with gestational diabetes consists of:
      • A. daily blood sugar monitoring
      • B. fasting blood sugar on day of discharge
      • C. 50 gm glucose challenge test 1 week postpartum
      • D. 75 gm oral glucose tolerance test 6 weeks postpartum
    • GDM - PROGNOSIS
      • 50% risk of developing overt DM w/in 20 yrs
      • Evaluate with 75-gm OGTT – 6-12 wks pp
      • TIME NO DIABETES IMPAIRED DIABETES
      • GL. TOL.
      • Fasting < 115 < 140 >/= 140
      • ½, 1, 1-½ All < 200 1 value >/= 200 1 value >/=200
      • 2 hr < 140 140 – 199 >/= 200
      • If 75-g OGTT is normal – take FBS yearly
      • Recommended postpartum follow-up for patients with gestational diabetes consists of:
      • A. daily blood sugar monitoring
      • B. fasting blood sugar on day of discharge
      • C. 50 gm glucose challenge test 1 week postpartum
      • D. 75 gm oral glucose tolerance test 6 weeks postpartum
    • OVERT DIABETES
      • Pregestational diabetes
      • Known diabetics before pregnancy
      • The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):
      • A. 100 – 190 – 170 – 130
      • B. 90 – 195 – 140 – 120
      • C. 95 - 180 - 155 - 140
      • D. 130 - 170 - 160 - 135
    • OVERT DIABETES
      • DIAGNOSIS DURING PREGNANCY
      • RBS >200 mg/dl + Sx: polyuria, polydipsia, wt loss
      • Fasting glucose > 125 mg/dl
      • Strong likelihood in pts with:
      • strong family Hx of DM
      • previous large infants
      • persistent glucosuria
      • unexplained fetal losses
      • The diagnosis of overt diabetes is most probable in the gravida with which of the ff OGTT results (Fasting-1hr-2hr-3hr post glucose load – mg/dl):
      • A. 100 – 190 – 170 – 130
      • B. 90 – 195 – 140 – 120
      • C. 95 - 180 - 155 - 140
      • D. 130 - 170 - 160 - 135
    • OVERT DIABETES
      • EFFECTS ON FETUS
      • ABORTION – poor glycemic control
      • HbA1c > 12%
      • persistent pre-prandial glucose level > 120 mg/dl
      • MALFORMATIONS
      • Type 1 – 5-10% incidence
      • from poorly controlled DM preconceptionally and in early pregnancy
    • OVERT DIABETES
      • EFFECTS ON FETUS
      • UNEXPLAINED FETAL DEATH
      • HYDRAMNIOS
      • from fetal polyuria
      • RESPIRATORY DISTRESS
      • from prematurity
      • HYPOGLYCEMIA
      • from hyperplasia of fetal B-islet cells
    • OVERT DIABETES
      • EFFECTS ON FETUS
      • HYPOCALCEMIA
      • HYPOBILIRUBINEMIA
      • prematurity
      • polycythemia with hemolysis
      • CARDIAC HYPERTROPHY
      • INHERITANCE OF DM
      • Diabetic Mother – 1-3% risk
      • Diabetic Father – 6%
      • Diabetic Father and Mother – 20 % risk
    • OVERT DIABETES
      • EFFECTS ON MOTHER
      • DIABETIC NEPHROPATHY
      • inc. when HbA1c > 10%
      • microalbuminuria  overt proteinuria
      •  HPN  end-stage renal dse
      • DIABETIC RETINOPATHY
      • after 7 yrs – 50% chance of dev.
      • after 20 yrs – 90%
      • DIABETIC NEUROPATHY
    • OVERT DIABETES
      • EFFECTS ON MOTHER
      • PREECLAMPSIA
      • not related to glucose control
      • KETOACIDOSIS
      • result of: hyperemesis gravidarum
      • use of B sympathomimetic drugs
      • (tocolytics)
      • infections
      • use of corticosteroids
      • INFECTIONS – 80%
    • OVERT DIABETES MANAGEMENT
      • PRECONCEPTION
      • HbA1c – expresses an ave. of circulating
      • glucose for the past 4-6 wks
      • - assess metabolic control
      • - > 10% - inc. risk for malformations
      • Folate – 400 ug/day
      • - to decrease neural tube defects
    • OVERT DIABETES MANAGEMENT
      • PREGNANCY
      • Blood glucose monitoring
      • Precise fetal age determination
      • LMP, FH, FHT, U/S
      • Well established EDC – to assess accurately
      • macrosomia, hydramnios, FGR
      • Diet
      • Insulin
    • PULMONARY DISORDERS
    • NORMAL CHANGES IN PREGNANCY
    • PULMONARY TUBERCULOSIS
    • TUBERCULOSIS
      • Organism: Mycobacterium tuberculosis
      • DIAGNOSIS
      • Symptoms: cough w/ minimal sputum
      • low-grade fever
      • hemoptysis
      • weight loss
    • TUBERCULOSIS
      • DIAGNOSIS
      • Lab: Chest Xray
      • cavitations
      • mediastinal lymphadenopathy
      • extent of dse may be masked by lung compression
      • Sputum exam – acid-fast bacilli
      • Recommended initial treatment of active tuberculosis during pregnancy is:
      • A. INH, Ethambutol, Rifampin
      • B. INH, Ethambutol, Pyrazinamide, Rifampin
      • C. INH, Rifampin, Streptomycin
      • D. INH only
    • TUBERCULOSIS
      • MANAGEMENT
      • Isoniazid + Rifampicin + Ethambutol for a minimum of 9 months (WHO: + Purazinamide x 6 months)
      • EFFECT ON PREGNANCY
      • Preterm delivery
      • Low birthweight
      • Perinatal death
      • Neonatal tuberculosis – rare, fatal
      • Route: hematogenous
      • aspiration of inf secretion at del unlikely if Rxed
      • Recommended initial treatment of active tuberculosis during pregnancy is:
      • A. INH, Ethambutol, Rifampin
      • B. INH, Ethambutol, Pyrazinamide, Rifampin
      • C. INH, Rifampin, Streptomycin
      • D. INH only
    • URINARY TRACT DISORDERS
      • Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:
          • A. Urinalysis: glucose +
          • B. mild right hydronephrosis on ultrasound
          • C. serum creatinine – 1.2 mg/dl
          • D. Urinalysis: protein - trace
    • NORMAL CHANGES IN PREGNANCY
      • Increased renal size
      • Dilatation of pelves, calyces and ureters
      • - not to be mistaken for obstructive uropathy
      • - predispose to serious upper urinary tract infections
      • Increased GFR and RPF
      • - Serum creatinine and urea nitrogen decrease
    • DIAGNOSTIC TESTS
      • Urinalysis
      • glucosuria
      • orthostatic proteinuria
      • Serum creatinine
      • > 0.9 mg/dl – suspect intrinsic renal dse
      • Ultrasonography
      • Intravenous pyelography
      • if indicated, one-shot pyelogram
      • Cystoscopy
      • Renal Biopsy (?)
      • Which of the ff laboratory values is not normal during pregnancy and suggests an underlying renal disease:
          • A. Urinalysis: glucose +
          • B. mild right hydronephrosis on ultrasound
          • C. serum creatinine – 1.2 mg/dl
          • D. Urinalysis: protein - trace
    • URINARY TRACT INFECTION
      • Acute Uncomplicated Cystitis is most likely in this case:
      • A. A 26-year-old G1P0 with fever,
      • dysuria and flank pains
      • B. A 35-year-old G3P2 with hematuria
      • and colicky right flank pain
      • C. An 18-year-old G3P0020 with
      • dysuria, urinary frequency & yellow-
      • green vaginal discharge
      • D. A 28-year-old G2P1 with dysuria and
      • urinary urgency
    • URINARY TRACT INFECTIONS
      • ASYMPTOMATIC BACTERIURIA
      • DIAGNOSIS
      • Clean-voided specimen containing >100,000 org/ml
      • MANAGEMENT
      • Nitrofurantoin (or Ampicillin, Amoxycillin, Cephalosporin)
      • If untreated, 25% develop acute Sxtic infection.
    • URINARY TRACT INFECTION
      • CYSTITIS AND URETHRITIS
      • DIAGNOSIS
      • Symptoms: dysuria
      • urgency
      • urinary frequency
      • Lab: UA – pyuria, bacteriuria, hematuria
      • MANAGEMENT
      • Ampicillin (or Sulfonamides,Nitrofurantoin, Cephalosporin)
    • URINARY TRACT INFECTION
      • ACUTE PYELONEPHRITIS
      • Leading cause of septic shock during pregnancy (endotoxemia)
      • More common after mid-pregnancy
      • Uslly right-sided
      • Uslly an ascending infection from lower UTI
    • URINARY TRACT INFECTION
      • ACUTE PYELONEPHRITIS
      • DIAGNOSIS
      • Symptoms: fever
      • shaking chills
      • aching pain – lumbar areas
      • P.E.: costovertebral angle tenderness
      • Lab: UA – leukocytes in clumps
      • Urine culture – E. coli 77%
      • Klebsiella pneumoniae 11%
      • Enterobacter / Proteus 4%
    • URINARY TRACT INFECTION
      • ACUTE PYELONEPHRITIS
      • MANAGEMENT
      • Hospitalization
      • Urine and blood cultures
      • CBC, Serum creatinine, and electrolytes
      • Rpt in 48 hrs
      • Chest Xray – if w/ dypnea or tachypnea
      • Monitor V/S, urine output (FBC)
      • IV crystalloid to establish UO to 30 ml/hr or >
    • URINARY TRACT INFECTION
      • ACUTE PYELONEPHRITIS
      • MANAGEMENT
      • Antimicrobial therapy
      • Ampicillin + Gentamycin
      • or Cephalosporins
      • Intravenous
      • Change to po when afebrile – 7-10 days
      • Urine culture 1-2 wks after completion of Rx
      • 30-40% - recurrent infection
      • Acute Uncomplicated Cystitis is most likely in this case:
      • A. A 26-year-old G1P0 with fever,
      • dysuria and flank pains
      • B. A 35-year-old G3P2 with hematuria
      • and colicky right flank pain
      • C. An 18-year-old G3P0020 with
      • dysuria, urinary frequency & yellow-
      • green vaginal discharge
      • D. A 28-year-old G2P1 with dysuria and
      • urinary urgency
    • THYROID DISORDERS
    • NORMAL CHANGES IN PREGNANCY
      • Moderate thyroid enlargement
      • - glandular hpl and vascularity
      • Inc. uptake of radioiodine by maternal thyroid
      • Inc. total serum thyroxine and triiodothyronine
      • Inc. thyroid binding globulin
    • HYPERTHYROIDISM
      • DIAGNOSIS:
      • Tachycardia
      • Thyromegaly
      • Failure to gain weight despite normal or increased food intake
      • Marked elevation of plasma thyroxine
      • Elevated sleeping pulse rate
      • exophthalmos
    • GRAVE’S DISEASE
      • Most common cause of thyrotoxicosis in pregnancy
      • Autoimmune process associated with thyroid stimulating antibodies
      • Autoantibodies mimic thyrotropin and stimulate thyroid function
      • A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:
      • She must discontinue PTU because it is associated with leukopenia.
      • Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.
      • PTU does not cross the placenta.
      • Thyroid storm is a common complication in pregnant women with Graves disease.
    • GRAVE’S DISEASE
      • MANAGEMENT
      • Medical
      • Propylthyouracil / Methimazole
      • readily cross placenta & induce
      • fetal hypothyroidism & goiter
      • dose depends on total serum
      • thyroxine level which should
      • be in upper N range for preg
      • A 37 yr old G2P1 12 weeks gestation presents for her first prenatal check-up. She had been diagnosed with Grave’s disease and maintained on propylthiouracil. Currently, she is euthyroid. Which of the ff statements is appropriate in counseling this patient:
      • She must discontinue PTU because it is associated with leukopenia.
      • Infants born to mothers on PTU may develop goiter and be clinically hypothyroid.
      • PTU does not cross the placenta.
      • Thyroid storm is a common complication in pregnant women with Graves disease.
    • GRAVE’S DISEASE
      • MANAGEMENT
      • Surgical – Subtotal Thyroidectomy
      • after thyrotoxicosis is under control or pt nearly euthyroid
      • done in 2 nd tri or early 3 rd tri
      • elective
      • Indications:
      • 1. women who cannot adhere to
      • medical Rx
      • 2. women in whom drug therapy is toxic
    • GRAVE’S DISEASE
      • EFFECT ON PREGNANCY
      • Higher incidence of preeclampsia
      • heart failure
      • EFFECT ON NEONATE
      • Neonatal thyrotoxicosis
      • fr transplacental passage of maternal thyroid stimulating ab
    • HYPOTHYROIDISM
      • DIAGNOSIS
      • Absence of normal rise in serum thyroxine
      • Increased thyrotropin level
      • Uncommon in pregnancy because associated with infertility
    • HYPOTHYROIDISM
      • EFFECT ON PREGNANCY
      • Inc. incidence of abortion, SB, LBW
      • preeclampsia
      • placental abruption
    • HYPOTHYROIDISM
      • EFFECT ON NEONATE
      • Usually healthy
      • Simple Colloid goiter w/o hypothyroidism – no effect
      • Severe hypothyroidism sec. to maternal radioiodine Rx during pregn  destruction of fetal thyroid  cretinism
    • HYPOTHYROIDISM
      • MANAGEMENT
      • Thyroid hormones
      • dose adjusted so that serum thyrotropin level is w/in N range
      • Thyroid function tests showing an elevated serum thyrotropin, normal serum thyroxine and normal triiodothyronine in an asymptomatic woman at 14 weeks gestation is diagnostic of:
          • A. Hypothyroidism
          • B. Hyperthyroidism
          • C. Subclinical hypothyroidism
          • D. Subclinical hyperthyroidism
    • PUERPERAL INFECTION
    • 10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis
    • PUERPERAL MORBIDITY
      • temperature 38 C or higher, the temperature to occur on any 2 of the 1 st 10 days postpartum, exclusive of the first 24 hrs, and to be taken by mouth by a standard technique at least 4x daily
      • JOINT COMMITTEE ON MATERNAL WELFARE
    • Differential Diagnosis of Puerperal Fever
      • Genital tract infection
      • Respiratory complications
      • Pyelonephritis
      • Breast Engorgement
      • Bacterial Mastitis
      • Thrombophlebitis
      • Incisional wound abscess
    • Respiratory Complications
      • - seen within the 1 st 24 hours
      • - in women delivered by cesarean section
      • - use of general anesthesia
      • Atelectasis
      • Aspiration pneumonia
      • Bacterial pneumonia
    • Pyelonephritis
      • SSx: bacteriuria / pyuria
      • costovertebral angle tenderness
      • spiking temperature
      • Clinical Dx: Urinalysis
      • U/S
      • Rx: Antibiotics
    • Breast Engorgement
      • 15 % of all postpartum women
      • Fever rarely goes > 39 C
      • Fever – not longer than 24 hrs
    • Thrombophlebitis
      • SSx:
      • painful swollen leg
      • calf / femoral angle tenderness
      • Mgt: Heparin
    • Uterine Infection
      • Infection involving the decidua, myometrium and parametrial tissues
      • Metritis with Pelvic
      • Cellulitis
    • Uterine Infection
      • The route of delivery is the single most significant risk factor for the development of postpartum uterine infection.
      • Incidence of Metritis:
      • ff C/S 13 – 50%
      • ff vaginal delivery 1.3 – 2.6%
    • Risk Factors for Metritis
      • Prolonged labor
      • Prolonged membrane rupture
      • Multiple cervical examination
      • Use of internal fetal monitoring
      • Intraamniotic infection
      • Bacterial colonization of lower genital tract
      • Group B streptococcus Mycoplasma hominis
      • Chlamydia trachomatis Gardnerella vaginalis
    • Bacteria Responsible for Genital Tract Infections
      • Aerobes
      • Grp A, B and D streptococci
      • Enterococcus
      • Gram (-) bacteria – E. coli, Klebsiella and Proteus sp
      • Staphylococcus aureus
      • Gardnerella vaginalis
      • Anaerobes
      • Peptococcus sp Clostridium sp
      • Peptostreptococcus sp Fusobacterium sp
      • Bacteroides fragilis Mobiluncus sp
      • Others
      • Mycoplasma sp Chlamydia trachomatis Neisseria gonorrhea
    • Clinical Course
      • Fever
      • Chills
      • Abdominal pain / tenderness
      • Foul-smelling lochia
      • B hemolytic streptococci – scanty odorless lochia
      • Leukocytosis – 15,000 – 30,000/cu mm
    • Treatment
      • BROAD SPECTRUM ANTIBIOTICS
      • Clindamycin + Gentamycin
      • most widely studied regimen
      • 90 – 97% efficacy
      • plus ampicillin – if enterococcal infection suspected
      • Aztreonam – if with renal insufficiency
    • Causes of Persistent Fever Despite Antibiotic Rx
      • Wound infection
      • Peritonitis
      • Parametrial phlegmon
      • Pelvic abscess
      • Septic Thrombophlebitis
    • Wound Infection
      • 3 – 5% post C/S
      • 2% - with prophylactic antibiotics
      • SSx: fever
      • erythema, wound discharges
      • Rx: antibiotics
      • surgical drainage
    • Risk Factors for Wound Infection
      • Obesity
      • Diabetes
      • Corticosteroid therapy
      • Immunosuppression
      • Anemia
      • Poor hemostasis with hematoma formation
    • Peritonitis
      • Route: lymphatics
      • SSx: severe abdominal pain
      • bowel distension – ileus
      • Rx: antibiotics
      • fluid and electrolyte replacement
      • decompression
      • surgery – bowel lesion
      • uterine incisional necrosis
    • Parametrial Phlegmon
      • Dx: parametrial induration
      • unilateral
      • uterus fixed on
      • one side
      • Rx: antibiotics
      • surgery – uterine incisional necrosis
    • Pelvic Abscess
      • Dx: fluctuant broad ligament mass
      • Rx: Drainage
      • Colpotomy
    • Septic Thrombophlebitis
      • Route: hematogenous
      • Pathogenesis:
      • placental site infection 
      • thrombosed myometrial vs
      • SSx: enigmatic fever
      • lower abd’l / flank pain
      • tender mass beyond the cornu
    • Infections of Perineum, Vagina and Cervix
      • Rx: Drainage
      • Antibiotics
      • Analgesics
      • Foleybag catheter
      • Repair
    • 10 days post cesarean section, a 23 yr old primipara complains of fever of 3 days duration associated with hypogastric pain. Temp – 40 C. Breasts are slightly tender. Pelvic exam shows tenderness over the area of the uterus and parametria. The most likely consideration is: A. Breast engorgement B. Acute pyelonephritis C. Metritis with pelvic cellulitis D. Septic pelvic thrombophlebitis
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