Obstetrical tetanus - Clinicals, Diagnosis, and Management

Obstetrics

Clinicals - History

Fact Explanation
A predisposing condition Tetanus is a syndrome caused by the powerful exotoxin of a Gram‐positive bacillus, Clostridium tetani. This is a saprophytic bacterium with a natural habitat of soil, but can also be isolated from stools of domestic animals and humans. It is a motile, spore‐forming obligate anaerobe. Contact with surfaces which contain the spores of this bacteria will cause infection with it. (i.e. suboptimally cleansed surgical instruments, illegally attempted abortions, penetrating injuries with rusty soil covered objects) Tetanus has been reported following a myriad of injuries, including intravenous and intramuscular injections, acupuncture, ear piercing, and even from toothpicks, and also following chronic otitis media. A predisposing condition
Tetanus is a syndrome caused by the powerful exotoxin of a Gram‐positive bacillus, Clostridium tetani. This is a saprophytic bacterium with a natural habitat of soil, but can also be isolated from stools of domestic animals and humans. It is a motile, spore‐forming obligate anaerobe. Contact with surfaces which contain the spores of this bacteria will cause infection with it. (i.e. suboptimally cleansed surgical instruments, illegally attempted abortions, penetrating injuries with rusty soil covered objects) Tetanus has been reported following a myriad of injuries, including intravenous and intramuscular injections, acupuncture, ear piercing, and even from toothpicks, and also following chronic otitis media.
Spasm of muscles The incubation period is about 24 hours. Spasm are the first clinical feature to manifest, and the spasm of jaw muscles or lock-jaw (trismus) is the first to be seen. The spasms are painful, can spread in to other muscle groups such as neck. chest, back and abdomen. Later whole body goes into spasms, which is also known as ophisthotonos. Spasm of muscles
The incubation period is about 24 hours. Spasm are the first clinical feature to manifest, and the spasm of jaw muscles or lock-jaw (trismus) is the first to be seen. The spasms are painful, can spread in to other muscle groups such as neck. chest, back and abdomen. Later whole body goes into spasms, which is also known as ophisthotonos.
Acute difficulty in swallowing Due to laryngeal obstruction and spasm. There can be drooling of saliva too. Acute difficulty in swallowing
Due to laryngeal obstruction and spasm. There can be drooling of saliva too.
Acute difficulty in breathing Due to spasm of respiratory muscles. Acute difficulty in breathing
Due to spasm of respiratory muscles.
No fever Patients usually have no fever. No fever
Patients usually have no fever.
Profuse sweating Due to autonomic neurotoxicity. Profuse sweating
Due to autonomic neurotoxicity.

Clinicals - Examination

Fact Explanation
A recent wound The site where the Clostridium bacteria entered. In most cases a wound is not found. A recent wound
The site where the Clostridium bacteria entered. In most cases a wound is not found.
Rigidity Local rigidity (i.e. lock-jaw, facial muscles causing the typical facial expression ‘risus sardonicus’) or truncal rigidity can be observed. (i.e. opisthotonos) Rigidity
Local rigidity (i.e. lock-jaw, facial muscles causing the typical facial expression ‘risus sardonicus’) or truncal rigidity can be observed. (i.e. opisthotonos)
Neck stiffness Manifestation of muscle spasm. Neck stiffness
Manifestation of muscle spasm.
Episodic muscle spasms Due to stimuli like light, noise. These tonic contractions have a convulsion‐like appearance affecting agonist and antagonist muscle groups together. Episodic muscle spasms
Due to stimuli like light, noise. These tonic contractions have a convulsion‐like appearance affecting agonist and antagonist muscle groups together.
Tachycardia and hypertension Unless complicated by shock. Due to sympathetic overdrive. Tachycardia and hypertension
Unless complicated by shock. Due to sympathetic overdrive.

Investigations - Management

Fact Explanation
12 lead Electrocardiogram It's common to have cardiac arrhythmias in tetanus due to sympathetic overactivity. 12 lead Electrocardiogram
It's common to have cardiac arrhythmias in tetanus due to sympathetic overactivity.
Lung function tests Truncal tetanus is very commonly associated with respiratory failure due to respiratory muscle spasms. Lung function tests
Truncal tetanus is very commonly associated with respiratory failure due to respiratory muscle spasms.
Renal function tests i.e. serum creatinine, serum urea, serum electrolytes. Tetanus can cause acute renal failure. Renal function tests
i.e. serum creatinine, serum urea, serum electrolytes. Tetanus can cause acute renal failure.
Obstetric ultrasound scan To confirm the wellbeing of the fetus as well as to assess the gestational age and exclude structural anomalies. The fetus can be immunized through trans-placental route. Obstetric ultrasound scan
To confirm the wellbeing of the fetus as well as to assess the gestational age and exclude structural anomalies. The fetus can be immunized through trans-placental route.

Management - Supportive

Fact Explanation
Patient education Educate the mother and the family about the infection, immunization and prevention, along with the trans-placental immunity of the fetus following maternal infection. Patient education
Educate the mother and the family about the infection, immunization and prevention, along with the trans-placental immunity of the fetus following maternal infection.
Wound excision The offending or suspicious wound should be excised with a margin of healthy tissue. The wound is not usually sutured but kept open and dressed with antiseptics. Wound excision
The offending or suspicious wound should be excised with a margin of healthy tissue. The wound is not usually sutured but kept open and dressed with antiseptics.
Management of respiratory distress Some patients might need intensive care. Respiratory muscle spasm is managed with sedatives and diazepam. In severe cases artificial ventilation might be necessary. Management of respiratory distress
Some patients might need intensive care. Respiratory muscle spasm is managed with sedatives and diazepam. In severe cases artificial ventilation might be necessary.
Managing the pregnancy and delivery Tetanus in pregnancy affects the female just like it would a non-pregnant female. Apart from tetanus, the pregnancy and delivery also should be managed accordingly. i.e. nutrition, weight management, folic acid supplements, monitoring of labor. Managing the pregnancy and delivery
Tetanus in pregnancy affects the female just like it would a non-pregnant female. Apart from tetanus, the pregnancy and delivery also should be managed accordingly. i.e. nutrition, weight management, folic acid supplements, monitoring of labor.

Management - Specific

Fact Explanation
Metronidazole The drug of choice was procaine penicillin, but it potentiate the effects of toxin, and the recovery period is longer, so in the drug of choice is now metronidazole. Metronidazole
The drug of choice was procaine penicillin, but it potentiate the effects of toxin, and the recovery period is longer, so in the drug of choice is now metronidazole.
Tetanus immune globulin (TIG) They are Anti-tetanus antibodies. For prophylaxis and against neonatal tetanus. The immunoglobulins bind to circulating antigens and neutralize them. It provides temporary passive immunization. Tetanus immune globulin (TIG)
They are Anti-tetanus antibodies. For prophylaxis and against neonatal tetanus. The immunoglobulins bind to circulating antigens and neutralize them. It provides temporary passive immunization.
Magnesium sulphate Intravenous magnesium sulphate is the first line treatment option for severe tetanus spasms. The drug inhibits the afferent and efferent nerve impulses. Magnesium sulphate
Intravenous magnesium sulphate is the first line treatment option for severe tetanus spasms. The drug inhibits the afferent and efferent nerve impulses.
Diazepam For very severe cases, to provide muscle relaxation and sedation. Diazepam
For very severe cases, to provide muscle relaxation and sedation.

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