State the diagnose and define, identify the four risk factors, list 5 signs and symptoms, outline investigations, treatment and management, and discuss preventative measures for Mary's condition.

Diagnosis: Puerperal sepsis (postpartum sepsis).

Explanation:
The patient is a 30-year-old woman, 5 days postpartum after delivery of twins (one stillborn) with history of postpartum hemorrhage (PPH). She presents with fever of $38^\circ$C, abdominal pain, pulse 108 bpm (tachycardia), blood pressure 90/60 mmHg (hypotension), and respiratory rate 28 breaths/min (tachypnea). These vital signs indicate systemic infection and sepsis (SIRS criteria: temperature $>38^\circ$C, heart rate $>100$ bpm, respiratory rate $>20$/min). Risk factors include recent delivery at a small health center (possibly limited hygiene/asepsis), multiple gestation, stillbirth, and PPH (leading to uterine atony, retained products of conception, or tissue trauma favoring bacterial infection).

• Fever $>38^\circ$C
• Lower abdominal pain or uterine tenderness
• Foul-smelling or purulent vaginal discharge (lochia)
• Chills or rigors
• Tachycardia (heart rate $>100$ bpm)

a. IV fluids:
Ringer's lactate or $0.9\%$ normal saline: initial bolus 20 ml/kg body weight over 1 hour, then $100-200$ ml/hour maintenance (adjust based on response, monitor urine output $>30$ ml/hour).

b. Antibiotics: (Broad-spectrum IV covering aerobic/anaerobic organisms per WHO guidelines)

• Ampicillin 2 g IV every 6 hours
• OR Ceftriaxone 1 g IV every 24 hours
• Gentamicin 5 mg/kg IV once daily
• Metronidazole 500 mg IV every 8 hours

• Persistent hypotension (systolic BP $<90$ mmHg) despite IV fluid bolus
• Altered mental status or confusion
• Severe respiratory distress (respiratory rate $>30$/min or difficulty breathing)

puerperal sepsis