What is the appropriate immediate management for a 35‑year‑old woman, post‑lower‑segment cesarean section, who is anuric four hours post‑operatively, has gestational diabetes (normoglycaemic), leukocytosis with neutrophilia, thrombocytopenia, elevated C‑reactive protein, normal liver function tests, and has been switched from piperacillin‑tazobactam plus aminoglycosides (amikacin, gentamicin) to meropenem and teicoplanin?

Immediate Management of Post-LSCS Anuria with Sepsis

This patient requires urgent evaluation for acute kidney injury (AKI) secondary to sepsis and/or surgical complications, with immediate fluid resuscitation, bladder catheter patency verification, and consideration of imaging to exclude bladder injury or ureteral obstruction. 1, 2

Critical Initial Assessment (Within 1 Hour)

Verify urinary catheter patency immediately – flush the catheter to exclude mechanical obstruction, as catheter malfunction is the most common cause of apparent anuria post-cesarean. 3

Assess hemodynamic status and fluid balance:

• Review intraoperative blood loss and fluid administration 3
• Check vital signs for hypotension (suggesting hypovolemia or septic shock) 1
• Examine for signs of hemorrhage or hemoperitoneum 3

Obtain urgent laboratory studies:

• Serum creatinine, BUN, and electrolytes to quantify renal dysfunction 4
• Repeat complete blood count (your TLC 14,700 with 90% neutrophils indicates sepsis, but the platelet count of 1.07 suggests thrombocytopenia requiring urgent attention) 1, 4
• Coagulation profile (PT/INR, aPTT, fibrinogen) given thrombocytopenia 3
• Lactate level (>2 mmol/L indicates shock) 3, 5
• Urinalysis if any urine can be obtained 3

Immediate Fluid Resuscitation

Administer aggressive intravenous crystalloid resuscitation targeting euvolemia, as perioperative fluid management is critical for maternal outcomes after cesarean delivery. 3 Aim for urine output >0.5 mL/kg/hour once catheter patency is confirmed. 1

Urgent Imaging to Exclude Surgical Complications

Order contrast-enhanced CT abdomen/pelvis immediately if the patient remains anuric after catheter verification and initial fluid bolus, to evaluate for: 1, 5

• Bladder injury or intraperitoneal bladder rupture (rare but presents with oliguria/anuria, abdominal distension, and elevated creatinine 4-11 days post-cesarean) 2
• Ureteral injury or obstruction 2
• Intra-abdominal hemorrhage or hematoma 3, 1
• Subfascial/rectus sheath abscess (your rising leukocytosis from baseline ~12,000 to 14,700 with CRP 31 suggests evolving infection) 1

Alternative if CT contraindicated: Bedside ultrasound can assess for hydronephrosis, bladder distension, and free fluid, though CT provides superior characterization. 5

Antibiotic Optimization

Your current regimen of meropenem plus teicoplanin is appropriate for suspected post-cesarean sepsis with broad coverage of aerobic, anaerobic, and resistant organisms. 3, 6

Critical pitfall: The combination of piperacillin-tazobactam, amikacin, AND gentamicin (two aminoglycosides simultaneously) was nephrotoxic and likely contributed to AKI. 6, 7 Aminoglycosides should be avoided or used with extreme caution in the setting of renal dysfunction. 7

Monitor for drug-induced neutropenia – prolonged piperacillin-tazobactam use (which this patient received) can cause leukopenia, though your current leukocytosis suggests active infection rather than drug effect. 7

Differential Diagnosis for Post-Cesarean Anuria

Prerenal causes (most common):

• Hypovolemia from blood loss or inadequate fluid replacement 3
• Septic shock with distributive physiology 1

Intrinsic renal causes:

• Acute tubular necrosis from hypoperfusion or nephrotoxins (aminoglycosides) 6, 7
• Pregnancy-associated atypical hemolytic uremic syndrome (aHUS) – consider if thrombocytopenia worsens, hemolysis develops, or neurologic symptoms appear 4

Postrenal causes (obstructive):

• Bilateral ureteral injury (rare, 0.03% incidence) 2
• Bladder injury with urinary ascites (0.0016-0.94% incidence, presents 4-11 days post-op) 2
• Catheter malfunction 3

Specific Management Based on Findings

If bladder injury confirmed on imaging:

• Insert percutaneous peritoneal drain for urinary ascites 2
• Maintain urethral catheter for complete urinary diversion 2
• Conservative management with dual drainage (urethral + peritoneal) can succeed in selected cases, avoiding immediate surgical repair 2

If subfascial abscess/collection identified:

• Arrange urgent CT-guided percutaneous drainage for collections ≥3 cm 1
• Do not delay drainage based on size alone when systemic infection signs are present 1

If prerenal AKI from hypovolemia:

• Continue aggressive fluid resuscitation targeting MAP >65 mmHg 1
• Monitor urine output hourly 3

Thrombocytopenia Management

Your platelet count of 1.07 (assuming 107,000/µL) requires close monitoring but does not typically require transfusion unless <50,000/µL with active bleeding or <20,000/µL spontaneously. 3 Investigate for:

• Dilutional thrombocytopenia from resuscitation 3
• Consumptive coagulopathy (check fibrinogen, which should be 4-6 g/L in pregnancy; <2 g/L with bleeding requires replacement) 3
• Early thrombotic microangiopathy (check peripheral smear for schistocytes, LDH, haptoglobin) 4

Glucose Control

Maintain tight capillary blood glucose control postoperatively despite normoglycemia now, as your patient has GDM history. 3 Target <140 mg/dL to optimize wound healing and reduce infection risk. 3

Critical Pitfalls to Avoid

• Do not attribute anuria to "normal postoperative oliguria" – zero urine output for 4 hours post-cesarean is never normal and demands immediate investigation 3
• Do not delay imaging if anuria persists after catheter flush and initial fluid bolus 1, 2
• Do not overlook bladder injury – it can present in delayed fashion (up to 11 days) with oliguria, abdominal distension, and rising creatinine 2
• Do not continue aminoglycosides in the setting of AKI – your switch to meropenem/teicoplanin was appropriate 6, 7
• Do not interpret rising leukocytosis as normal postoperative change – progression from 12,000 to 14,700 with CRP 31 indicates evolving infection requiring source control 1

Monitoring and Escalation

• Hourly urine output monitoring once catheter patent 3
• Serial creatinine every 6-12 hours until trending down 4
• Repeat CBC with platelet count every 12 hours 3, 4
• If no improvement within 2-4 hours of resuscitation, proceed urgently to CT imaging 1, 5
• Consider nephrology consultation if AKI persists or worsens despite adequate resuscitation 4