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Complications of 3rd stage of labour ?
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1- Postpartum Hge 2- Retained Placenta 3- Acute uterine inversion 4- Shock 5- DIC
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Postpartum Hge ? Definition
Incidence
Significance
Pre-requisites for Postpartum Hemostasis Types
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* Definition : - Quantitative Definition : Excessive Bleeding from or into genital tract after delivery of the fetus with blood loss
> 500 cc after vaginal delivery > 1000 cc after cesarean section
Not accurate as :
- Proper estimation maybe difficult/inaccurate - General coniditon depend on both amount & rate of bleeding & maternal health prior to delivery "Anemia / HTN / APH etc .." - Clinical Definition :
Any amount of Bleeding from or into genital tract after delivery of the fetus that affects maternal general condition "Vital signs"
* Incidence :
0.5-4% depending on management of labour
* Significance : One of the leading causes of maternal mortality in Egypt " 34% of all deaths" * Pre-requisites for Postpartum Hemostasis
Blood flow to placental site is 600 ml/min
so excessive blood loss may occur after delivery, postpartum hemostasis depend on :
1- Good myometrial contraction & retraction constricting & occluding opened vessels at placental site
2- No retained placental parts
3- Good coagulation
* Types : 1- Primary PPH :
- Immediate or within first 24 H after delivery - Associated with acute blood loss & is life threatening
2- Secondary PPH :
- After the 1st 24 hours after delivery till end of peurperium " 6 weeks "
- Uncommon / Mild / Chronic = gynecological
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Aetiology of Primary PPH ?
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Due to combined factors as :
A) Atonic PPHge "Placental site" 75-80% :
Failure of uterine contraction & retraction
Risks include : 1- Overdistension : MFP / PHA / Macrosomia
2- Prolonged labour : exhaustion+dehydration
3- Prolonged Anaethesia or tocolytics 4- APH : PP or Accidental Hge
5- Anemia : hypoxia
6- Full bladder & Nervous shock : reflex atony 7- Fibroid
8- Grand Multipara : lax weak muscles
9- Sudden Cessation of uterine stimulants
10- Retained seperated placenta : impair uterine contractions B) Traumatic PPHge "Genital tract lacerations" :
As Ruptured uterus or Vaginal / cervical / perineal lacerations
In difficult or operative VDs C) DIC & Hypofibrinogenemia :
Can occur in Placenta abruptio / Retained IUFD / Amniotic fluid embolism
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Diagnosis of Primary PP Hge ?
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A) Symptoms :
Vaginal bleeding Immediatly or within first 24 H after delivery
B) Signs :
- History of : Risk Factors
Atonic : PHA / MFP etc
Traumatic : Difficult or instrumental delivery
- General Ex : Hypovolemic shock Pallor & Oliguria
Low BP / Rapid weak pulse / subnormal temp
- Abdominal Ex : Uterine size & Consistency
Atonic Revealed or partially/totally concealed
- Uterus : Lax "Soft Doughy"
- FL : High above umblicus if concealed
Below Umblicus if revealed
Traumatic
- Uterus : Firm contracted
- FL : Below umblicus - Vaginal Ex : Preferably under anaethesia
Detect bleeding from vaginal / perineal / cervical laceration
- Explore uterus digitally for retained parts & exclude ruptured uterus
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1- Maternal Mortality : 34% of MMR in Egypt 2- Hemorrhagic shock : Blood loss + DIC 3- Acute renal failure : 2ry to Hypovolemic S.
4- Peurperal sepsis : Low immunity / retained parts / possible manipulations
5- Sheehan's syndrome : Hypopituitaris following PPHge = 2ry Amenorrhea
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A) Prevention :
1- Proper ANC : Identification of risk factors
Previous PPH - Causes of APH "PP & PA" - Anemia - Overdistended uterus "MFP - PHA " - Grandmultipara. 2- Proper Mx of 1st & 2nd Stage of labour : 1st Bladder evacuation & Avoid prolonged sedation
2nd Avoid difficult prolonged labour & unnecessary instrumental delivery
3- Proper Mx of 3rd Stage of labour :
- Delivery of Placenta :
Active Mx reduces PPHge by 50%
or Wait for signs if placental seperation
- Uterine Massage : every 15 mins
- Ecbolics : Continue for 1 H after delivery especially in high risk cases
- Continous observation : Vital signs + Vaginal bleeding in 1st two hours after delivery B) Treatment :
Support life & arrest bleeding by following successive steps in order
1- Anti-Shock Measurments & Blood transfusion whenever necessary.
2- Gentle Uterine Massage :
By placing thumb abdominally over fundus & other fingers of the same hands behind to stimulate uterine contractions
3- Ecbolics : Given with massage - Oxytocin :
- By IV drip not direct IV bolus = serious hypotension & arrhthmia
- Increase freq. & strength of contractions
- Methyl Ergometrin :
- 0.2-0.4 mg IM or IV not more = Coronary spasm
- Causes tetanic uterine contractions
- Mesoprostol :
800-1000 ug rectally or anyroute except IV
4- If Retained Placenta :
Deliver immediately by controlled cord traction or manual removal
5- Vaginal Exploration Under anesthesia : - Detect & Remove undiagnosed retained placental fragmentes
- Detect & Surgically repair any vaginal / cervical lacerations
6- Bimanual Compression of uterus : If bleeding persists = lifesaving till laparotomy
By one hand in vaginal fornix & one hand bending the uterus to kink uterine artery
7- Laparotomy : If bleeding persists
- Subtotal Hysterectomy :
If bleeding is uncontrollable - Bilateral ligation of Anterior division of internal illiac artery or B-Lynch :
If young desiring future fertility but if failed = hysterectomy
8- Associated DIC : FFP / FBT / CryoPTT / Fibrinogen / Platelet Concentrate
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Secondary PPHge ?
Definition Causes
Treatment
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* Definition : Bleeding from or into genital tract after 24 h of delivering the fetus till the end of peurperium * Causes : RIFL + CP
1- Retained placental fragments : MC Dx : US & Tx : Ecbolics or D&C 2- Infection : Seperation of infected sloughs from lower genital tract laceration = Give AB
3- SM Fibroid : Sloughed Necrotic tip
4- Local cause : Polyp / erosion / Cancer Cx
5- Choriocarcinoma : Most dangerous 6- Peurperal inversion or UnDx Chronic * Treatment :
Treatment of the cause
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Retained Placenta ?
Definition
Incidence
Aetiology
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* Definition :
Failure of expulsion of placenta within 30 mins of delivery of fetus * Incidence : 0.5% of all deliveries * Aetiology :
1- Retained Seperated Placenta :
- Atony : Failure of expulsion of seperated P. - Contraction ring : Hour glass deformity of uterus = Incarceration of placenta - Complete Uterine rupture : Passage of placenta to the peritoneal cavity 2- Retained Non-Seperated Placenta :
- Atony : No Shearing mechanism needed for seperation
- Defective Placentation :
- Absent or defective decidual reaction "D.Basalis" = Absence of line of cleavage & MPS layer "Nitabuch's" = CV peneterate uterine muscles.
- More common with : PP - CS scar - SM fibroid
- Classified as : Accreta : Directly Attached to superficial myometrium Increta : Invade myometrium Percreta : Peneterate through myometrium
- May Involve : All cotyledons = Total
Few to several = Partial Single Cotyledon = Focal
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Clinical Picture ofRetained Placenta ?
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* Symptoms :
1- Failure of expulsion of placenta within 30 mins of delivery of fetus
2- Vaginal Bleeding : if entire or part of placenta is separated * Signs :
- General : Shock
Hemorrhagic or even in absence of Hge if retained > 2 hrs "Idiopathic Obs. Shock" - Abdominal : Lax Uterus - Local : Vaginal examination may reveal 1- Hour glass contraction
2- Complete rupture uterus 3- Absent of plane of cleavage
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Complications of Retained Placenta ?
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1- Shock : Hgic or Idiopathic 2- PP Hge 3- Peurperal Sepsis 4- Subinvolution Due to Congestion 5- Retained Parts : Form Placental Polyp giving rise to Choriocarcinoma 6- Complications of : Methods to deliver placenta Perforation / Peurperal sepsis / Inversion / PPHge Anaethesia
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Management of Retained Placenta ?
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A) Uterine Atony :
1- Gentle Uterine Massage :
To stimulate uterine contractions 2- Ergmetrin IM :
To ensure contraction of uterus 3- Brandt Andrew Maneuver :
Deliver Placenta by controlled cord traction & suprapubic presure 4- Crede's Method for retained placenta :
- Steps :
- Fundus is grasped by four fingers behind & thumb in front to squeeza the placenta
- Fundus is then pushed downward & backward to expel placenta
- Adv. & Dis. :
Easy to do but difficult in obese
Do not work with C.ring or Placenta accreta
- Complication : Inversion / Partial seperation / PPHge
So rarely used in modern obstetrics 5- Manual removal of Placenta :
General Anathesia + Bladder evacuation + Complete asepsis
Lt hand On abdomen to steady the fundus
Rt hand Follows the cord to the placenta & pass the hand to its lower edge then seperate placenta completely by a sawing movement from side to side
Grasp Placenta & deliver it
Inspect Placenta for missing fragmenets
Give Ergometrine + Uterine Massage
Complications Perforation / Peurperal sepsis / Retained Parts / PPHge
B) Contraction Ring :
Deep general anaethesia + Manual removal of placenta C) Adeherent Placenta :
Dx at manual removal or by US : loss of retroplacental hypoechoic area +/- invasion
- Simple adhesions or partial accreta :
Manual removal of placenta
- Complete placenta accreta :
1- Abdominal Hysterectomy :
In shock & severe Hge esp. MP 2- Autolysis :
If young & PG = cut the cord shortly from placenta & leave it in situ to undergo autolysis with close observation & AB + Methotrexate
Maybe unsafe
3- Bakri Ballon : inflated at placental site
4- If bladder invasion : HS + Partial Cystectomy D) Rupture Uterus :
Antishock measures to prepare the patient for Laparotomy :
- Placenta : removed from peritoneal cavity - Uterus :
Non Extensive = repair to preserve fertility
Extensive tears & Poor general condition = Subtotal Hysterectomy
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Acute Uterine Inversion ?
Definition
Incidence
Aetiology
Degrees
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* Definition :
Uterus is partially or completely turned inside out after delivery of the neonate * Incidence : 1:2500/6000 * Aetiology :
A) Induced : Manipulations on lax uterus
1- Vigorus fundal pressure "Crede's method"
2-Vigorus Traction on cord esp. with abnormally adherent placenta
3- During manual removal of placenta or CS
B) Spontaneous :
1- Percipitate labour
2- Traction by fetus on very short cord
3- SM Fundal Fibroid
4- Vigorus straining or coughing * Degrees :
1st Degree Depressed uterine fundus that doesn't pass through cervix or reach Int.OS
2nd Degree Fundus protrudes through cervix
3rd Degree Total inversion dragging on the vagina & protruding outside vulva
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Diagnosis of Acute Peurperal Inversion ?
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A) Symptoms :
Pain in lower abdmen
Bleeding from the vagina
Mass Protruding from vulva if 3rd degree
Shock B) Signs :
- General : Profound Shock
Hypovolemic : Massive blood loss
Neurogenic : Traction on peritoneum & Compression of adnexa
- Abdomen : Genralized tenderness
1st & 2nd Fundal Cupping
3rd absent uterus
- Local :
2nd Soft purple mass felt in the vagina
3rd Soft purple mass seen at vulva = inverted uterus covered by congested endometrium
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Management of Acute Peurperal Inversion ?
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A) Prevention : Avoid
1- Vigorous Manipulation on lax uterus
2- Traction on the cord with abnormally adherent placenta
B) Treatment :
1- Anti shock Measurements :
Insert 2 wide bores IV Cannulas
Blood sample for cross matching
Start Ringer Lactate IV infusion or plasma substitutes
Place inverted uterus in the vagina
2- Repositioning : - General anaethesia "Halothane = relax uterus" + Tocolytics as terbutaline or MgSo4
- Uterus is Repositioned manually with the palm of the hand & fingers in the direction of long axis of the vagina
- If placenta is still attached remove it to facilitate repositioning "Controversial"
- When normal configuration is restored stop tocolytics & start oxytocin infusion while maintaining uterus in position till it contracts.
NB : Hydrostatic Pressure
May be used in repositioning the uterus
3- Surgical correction via Laparotomy :
If mentioned procedures failed
4- Hysterectomy is the final option
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Complications of Acute Inversion ?
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1- Postpartum Hge
2- Peurperal Sepsis
3- Shock
4- Subacute : 2ry PPHge & offensive vaginal discharge
5- Chronic : Mass protruding through vagina Diff.Dx : Fibroid & Polyp
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DIC & Hypofibrinogenemia
Changes in Coagulation system with pregnancy
Definition
Etiology
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* Changes in Coagulation system :
In late pregnancy :
- Fibrinogen "Factor I" increase from 200-400 mg/dl to become 350-650 mg/dl
- Factors VII / VIII / IX / X increase in concenteration
- Other factors & platlet count "N = 150000 - 400000 / cmm " = don't change remarkably
* Definition :
- Hematological condition characterized by accelerated fibrin formation & lyses with consumption of coagulation factors & platlets in variable quantities.
- Signs of hypofibrinogenemia develop when fibrinogen level goes below 100 mg/dl.
* Etiology : Pregnancy related cause :
A) Common : 1- Placenta abruptio
2- Massive crystalloid or colloid replacement in cases with mass blood loss
3- Severe PE/Eclampsia or HELLP S
B) Rare : RSAAAAAM
1- Retained dead fetus > 3-4 weeks as missed abortion or IUFD
2- Sepsis : Toxins
3- Amniotic fluid embolism : Proteases
4- Acute fatty liver of pregnancy
5- Adult RDS
6- Acute Hemolytic transfusion reaction
7- Autoimmune diseases
8- Hematological malignencies or solid tumors
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Mechanism of DIC & Hypofibrinogenemia ?
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A) Accelerated Coagulation :
1- Activation of :
- Extrinsic pathway by Thromboplastin from tissue destruction
- Intrinsic pathway by collagen & other tissue components when endothelial integrity is lost
- Factor 10 directly by proteases present in mucin of amniotic fluid or neoplasms
2- Factor 10 Prothrombinase is activated & convert Prothrombin II to Thrombin IIa
3- Thrombin changes Fibrinogen I into fibrin monomeric & polymeric clots
B) Increased Fibrinolysis :
1- Fibrin monomers combine with tPA & plasminogen to release Plasmin
2- Plasmin lyses fibrin monomers & polymers to a serious of FDP including D-dimer
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Diagnosis of Hypofibrinogenemia ?
Clinical Picture
Investigations
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A) Clinical Picture : Hemorrhage
1- Antepartum or Postpartum Hge
2- Purpuric eruptions at pressure sites = TTP & Incoaguable blood
3- Persistant bleeding form venipuncture sites or after catheter insertion
3- Spontaneous Bleeding from gums & nose
4- Generalized oozing in surgical fields B) Investigations : Detect to Fibrinolysis
1- Prolonged BT (1-3 mins) & PT (3-8 mins)
2- Prolonged PT & PTT "Maybe normal"
3- CBC : Low platlet count
4- Low fibrinogen & Antithrombin III
5- FDPs & Fibrin D-dimer "normally absent"
6- Weiner test "Clot observation test" :
5-10 cc of blood in a test tube incubated at 37*
- Normal : Clot within 3-8 mins - Hypofibrinogenemia : Clot formed afte rlonger time & dissolves within 1 hour
- Afibrinogenemia : No clot is formed
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Treatment of Hypofibrinogenemia ?
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1- Must be directed toward underlying cause to reverse Defibirination
2- Fresh Frozen Plasma transfusion : If PT is > 1.5 times from control value
Goal is PT within 2-3 Seconds of control 3- If Fibrinogen < 100 mg/dl
- Cryopercipitate transfusion :
Each unit increases fibrinogen by 10 mg/dl
Give 10 units after every 2-3 units of plasma
- Fibrinogen :
4-10 g IV
3- Platlet Transfursion :
If count < 20000/cmm or clinically significant bleeding with count 20000 : 50000/cmm
Every unit increases count by 10000/cmm so give 1-3 U/10 Kg/day
4- Antifibrinolytics :
Epsilon Amino Caproic acid = 4-6 g IV
Trasylol 2-4 ampules each is 25000 U IV
Not recommneded in obstetric coagulopathy = organ ischemia & infarction unless all above measures fail
NB : Heparin Infusion Is Condemned
When Vascular system integrity is compromised
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Peurperal Pyrexia ?
Definition
Aetiology
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* Definition :
Best defined as : - Temperature of 38*C or higher
- Lasting for 24 H / Recurrs within 24 H
- During first 21 days of peurperium excluding the first 24 H
- Measured by mouth with standard technique at least 4 times daily.
* Aetiology :
1- Peurperal Sepsis : Most common & Serious complication of peurperium = One of the lethal triad for maternal deaths
( PE + PPHge + Peurperal sepsis )
So : any peurperal pyrexia is considered peurperal sepsis till proved otherwise. 2- Breast infection
3- UTI
4- Respiratory tract Infection
5- Thrombophlebitis
6- General causes : typhoid / malaria
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Peurperal Sepsis ?
Definition
Aetiology ( PDF + Route + Organisms )
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* Definition : Wound infection of female genital tract occuring during labour or during the first postpartum 3 weeks excluding 1st 24 H
* Aetiology :
A) PDF :
- General = Decreased Immunity 1- Anemia
2- APH or PPH
3- DM
4- Septic focus
- Local = In Genital tract
1- Lack of aseptic measure
2- Prolonged ROM
3- Prolonged labour with repeated Vaginal Ex
4- Instrumental delivery with lacerations
5- Cercelage sutures
6- Retained Parts of Placenta or Membranes
7- Intrauterine Manipulations "Manual P.Sep."
B) Route :
1- Exogenous : Most Important
Droplet infection from attendants
Usterilized Instruments
2- Endogenous :
By organisms already present in genital tract before delivery eg Vaginitis & Cervicitis
3- Autogenous :
Organisms reach genital tract from remote sites via blood stream eg Tonsilitis /RTI /Caries
C)Organisms :
1- Anaerobic Streptococci "Most Common" :
Non pathogenic but becomes so in the presence of dead tissues = Mild infection
2- GABHS : Virulent = Severe infection
3- Others : Staph. ( Lacerations ) + Non Hemolytic strept. + E.coli + Pseudomonas + C.Welchii
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Pathological types of Peurperal Sepsis ?
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A) Primary Site Infection :
1- Uterus "Endometritis" : MC 1ry site
* Acute Putrid Endometritis "Day 4" :
Mild Infection / Low Virulence "Anaerobic Strept." - Patient resistance Good / Uterus : Subinvoluted + filled with necrotic tissue = necrotic infected discharge + Leucocytic barrier under endo. = limits spread of infection
* Acute Septic Endometritis "Day 2" :
Severe infection / Virulent "GABHS" - Low Patient resistance / Uterus : involuted + lined with pyogenic membrabe with scanty purulent discharge + No Leucocytic barrier
2- Infected Lacerations "Cervical / Vaginal / Perineal" :
- Pathology : appear as ulcers with dirty base + greenish discharge + surrounding edema
B) Secondary Site Infectiom "Local Spread" :
1- Parametritis : Inflammation of pelvic cellular tissue lateral to the uterus
- Route : Lymphatic spread / Direct from tears
- pathology :
- Start as : unilateral mass of exaudate pushing the uterus oppositely, If abcess develops it points above inguinal ligament "MC" / Vagina / Rectum / Bladder / Peri-renal space / Gluteal region " Through GSN" / Thigh "Through OF"
- Heals by fibrosis pulling uterus to same side
2- Salpingo-oophoritis "PID" :
- Route : Lymphatic or vascular from 1ry site
3- Pelvic thrombophlebitis :
- Route : From Parametritis or Uterine wall vessels thrombophlebitis
- Pathology : Extend to pelvic veins / femoral vein / IVC = Partial or complete occlusion
4- Peritonitis :
- Route : Lymphatics of uterine wall / tubal lumen / cervical or vaginal vault lacerations
- Pathology :
1- Generalized Peritonitis
2- Localized Pelvic peritonitis "Pelvic Abcess" :
Effusion collects in cul du sac = tender cystic swelling behind uterus.
C) Generalized Spread :
Severe infection In patients with low resistance = Infected emboli results in Septicemia / Septic shock.
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Clinical Picture of Peurperal Sepsis ?
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* Varies according to Pathological Types :
A) Local Uterine Infections "Endometritis" :
- FHMA + Lower abdominal Pain
- Marked Uterine tenderness
- FL : Putrid = High "Retained" /Septic = Normal
- Discharge : Putrid = offensive or Septic = Scanty Purulent
B) Infected lacerations :
Fever + Local Pain
Wound : hot, red, painful, swollen, covered with purulent exaudate.
C) Parametritis :
- Starts 7-10 Days Post delivery
- Mild fever + tachycardia + Deep seated Pelvic Pain
- Cervical tear with unilateral tender mass in one fornix / Horse shoe induration around cervix with extreme tenderness "Jumping sign"
- If abcess formed : points & drains as above
D) Salpingo-oophoritis :
- 7-10 Days post delivery
- Fever + Rapid pulse + Bilateral Deep Seated Lower abominal Pain
- Tender adnexa & lower abdomen with pain on moving the cervix
E) Pelvic Thrombophlebitis :
- 2nd week post delivery
- Low grade fever "Picket Fence" despite AB
Rapid pulse inconsistant with fever + P.Pain
- Extension to Femoral Vein : Whole limb is edematous white but not tender "Phlegmasia alba dolens" - To IVC : massive edema in both limbs
F) Peritonitis :
- Generalized :
1- Marked FHMA + Tachycardia
2- Generalized abdominal pain & tenderness but gaurdening isn't marked "Lax Muscles"
3- Abdominal distension with shifting dullness
4- Continous vomiting "Adynamic IO" = Dehydration & Detrioration of general cond. - Localized "Pelvic Abcess" :
1- FHMA + Tachycardia
2- Pelvic pain & Lower abominal tenderness
3- Cystic tender mass in cul du sac
4- Tenesmus
G) Septicemia "Most Serious" :
- 1st week post delivery
- High shooting fever with tachycardia out of proportion with pyrexia + Rigors
- Symptoms & Signs of generalized peritonitis
- Late : Skin eruption "Flushing" - Jaundice - renal failure - drowsiness - septic shock
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Diagnosis of Peurperal Pyrexia ?
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A) History of : 1- Infection : In genital tract or body in general 2- Disease : Diabetes & Anemia 3- Delivery : Ask : Mode-Place-Prolonged ROM
B) Examination :
1- General :
Assess extent / Exclude other causes / Discover possible sources outside genital t.
- Vital signs
- Cyanosis or Purpura = Septicemia
- LL = DVT / Chest / Breast / Throat Infection
2- Abdominal :
Tenderness or rigidity / Size of uterus "Subinvoluted" / Renal angles "Pyelonephritis"
3- Local :
- Lochia : amount / nature / odeur
- Infected Lacerations / Uterine size & tenderness / Pelvic Swellings
C) Investigations :
1- Vaginal & Cervical Swabs : For Culture & Sensetivity "Both Aerobic & Anaerobic"
2- Urinary Catheter Specimen : For Complete urine analysis + Culture & Sensetivity
3- Blood Culture & Sensetivity 4- CBC & Blood film "Malaria" 5- Doppler US : DVT 6- Chest Xray : Chest infection
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Prevention of Peurperal Sepsis ?
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A) During Pregnancy :
- Treat any infection in genital tract or any septic focus
- Improve general condition Treat Anemia / DM
B) During Labour :
1- Proper aseptic & anti-septic measures 2- Avoid Unnecessary repeated Vaginal ex.
3- Antibiotics in case of prolonged labour or premature ROM
4- Avoid retained fragments in uterus 5- Proper management of genital lacerations
C) During Peurperium :
1- Main aseptic & antiseptic measures
2- Sitting in bed to promote lochia drainage
3- Respiratory & pelvic ms floor exercises
4- Prevent infected personnel or visitors
5- Isolation of suspected cases
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Treatment of Peurperal Sepsis ?
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A) General Measures : 1- Rest & Isolation 2- Diet : Light nutritive diet with Vitamins, Iron & Plenty of fluids. 3- Observation : Frequent Meas. of Vital Signs
4- Analgesics & Antipyretics = Good Sleep B) Antibiotics :
Combination of the following till C&S results " 1- Cephalosporins : gram +ve
2- Gentamycin : gram -ve 3- Clindamycin / Metronidazole : Anaerobes
C) Promotion of Draiage :
1- Fowler's Position :
Semi-setting with Semi-flexed knees to facilitate accumulation of pus in douglas pouch & facilitate drainge by posterior colpotomy 2- Ergometrin : Stimulate uterine contractions for expulsion of retained parts 3- Removal of retained parts : Under GA 4- Removal of sutures : in infected wounds 5- Surgical Drainage : In pelvic abcess orwhen antibiotics fail to cure
D) Treatment of Complications :
1- Septic Thrombophlebitis & DVT :
Anticoagulatns + Antibiotics + Limb Immobilization till hotness disappear
2- Generalized Perionitis :
- NPO + IV Fluids + Ryle tube for GIT drainage
- Massive IV antibiotics 3- Septic Shock : CB4
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