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MRCOG Part 2 > Infections/Sepsis in Pregnancy - including GBS GT36, Bacterial Sepsis in/following pregnancy GT64a, b > Flashcards

Infections/Sepsis in Pregnancy - including GBS GT36, Bacterial Sepsis in/following pregnancy GT64a, b Flashcards

1
Q

What is the incidence of Early Onset GBS disease in the UK?

A

0.5/1000 Births

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2
Q

If GBS was detected in a previous pregnancy what is the likelihood of carriage in a subsequent pregnancy?

A

50%

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3
Q

If GBS was detected in a previous pregnancy - what is the risk estimate of disease (EOGBS) in this pregnancy?

A

1/700-1/800
If has third trimester screening and swab is positive for GBS then risk is 1/400
If swab negative then risk is 1/5000

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4
Q

If a woman has pyrexia in labour, and an unknown GBS carrier status, what is the risk of EOGBS?

A

5.3/1000

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5
Q

What is the risk of EOGBS in preterm deliveries?

What is the mortality rate?

A

2-3/1000

Mortality rate is 20-30%

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6
Q

What is the antibiotic recommendation for intrapartum antibiotics to prevent EOGBS?

A

Benzylpenicillin 3g then 1.5g 4 hourly
If penicillin allergic then cefuroxime (1.5g loading dose followed by 750mg 8hourly)
OR Vancomycin 1g every 12hours
(Clindamycin no longer recommended due to resistance rate in UK of 16%).

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7
Q

What % of EOGBS were identified on day 1?

A

89-94%

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8
Q

How do babies with EOGBS present?

A

80% sepsis
12% meningitis
8% pneumonia
1% focal

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9
Q

How should well babies at risk of EOGBS whose mothers did not receive adequate IAP be observed?

A

Assessed for clinical indicators of neonatal infection and have vital signs checked @ 0,2,4,6,8,10,12 hours

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10
Q

In which triennium was sepsis the leading cause of direct maternal deaths in the UK? And which microbe was responsible for death in 13 women?

A

2006-8

GAS

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11
Q

What is the mortality rate of severe sepsis with acute organ dysfunction?
And if septic shock develops?

A

Severe sepsis - 20-40%

Septic shock - 60%

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12
Q

What is the definition of sepsis?

A

Infection plus systemic manifestations of infection

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13
Q

What is the definition of severe sepsis?

A

Sepsis + sepsis-induced organ dysfunction or tissue hypoperfusion

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14
Q

What is the definition of septic shock?

A

Persistence of hypoperfusion despite adequate fluid replacement therapy

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15
Q

What are the risk factors for maternal sepsis in pregnancy?

A 
Obesity
DM/impaired glucose tolerance
Impaired immunity/medication
Anaemia
Vaginal discharge
History of pelvic infection
History of group B streptococcal infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged SROM
GAS in close contacts
Black/minority ethnic
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16
Q

When should lactate be measured in suspicion of severe sepsis and at what level is indicative of tissue hypoperfusion?

A

Within 6 hours

Lactate >=4

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17
Q

Within what time scale should IVAbx be administered when there is recognition of severe sepsis?

A

1 hour

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18
Q

What are the parameters for fluid resuscitation in severe sepsis/septic shock if lactate =>4 or there is hypotension?

A

Crystalloid 20ml/kg initially
If does not respond vasopressors to maintain MAP >65mmHg

If septic shock: CVP >8mmHg
Central venous SpO2 >=70%
Mixed venous SpO2 >= 65%

19
Q

What are the indications for transfer to ICU?

A

CV - Hypotension or raised lactate despite fluid resus (ie
need vasopressors)
Resp - Pulmonary oedema, ventilation, airway support
Renal - Dialysis
Neuro - Decreased GCS
Other - Multiorgan failure, uncorrected acidosis,
hypothermia

20
Q

What are the most commonly identified organisms implicated in maternal death?

A
  • Lancefield group A beta-haemolytic Streptococcus
  • E Coli (esp urosepsis, PPROM, cerclage)

Less commonly anaerobes -
- Peptostreptococcus
- Bacteroides spp
(Clostridium perfringens)

21
Q

What are the limitations of co-amoxiclav when treating sepsis in pregnancy?

A

No MRSA or Pseudomonas cover

Risk of NEC to neonates

22
Q

What are the limitations of metronidazole when treating sepsis in pregnancy?

A

Only covers anaerobes

23
Q

What are the actions of clindamycin?

A

Covers most strep and staph including many MRSA
Switches off exotoxin production
Not nephrotoxic/renally excreted

24
Q

What are the limitations of Tazocin/carbapenems when treating sepsis in pregnancy?

A

Covers all except MRSA

Renal sparing compared to aminoglycosides

25
Q

How does IVIG work in treatment of severe sepsis?
which bacteria is it effective against?
When is it contraindicated?

A

Immunomodulatory
Neutralises superantigen effect of exotoxins in staph/strep
Inhibits production of TNF and interleukins

Contraindicatied in congenital deficiency of IgA

26
Q

What prophylaxis should be considered when a mother is found to have invasive group A streptococcal infection peripartum?

What is the antibiotic regime as per the HPA?

A
  • Notifiable disease!
  • Baby administered with prophylactic abx
  • Close household contacts - seek advice if symptoms devlop
  • Healthcare workers exposed to respiratory secretions consider for prophylaxis
  • Penicillin V qds 10/7 or azithromycin 500mg OD 5/7
27
Q

What are the 5 clinical findings in staphylococcal toxic shock?

A
  1. Temp >= 39.9
  2. Diffuse macular erythroderma
  3. Desquamation 10-14 days after onset (palms/soles)
  4. BP <90mmHg systolic
  5. > =3 systems affected: GI, muscular, mucous membranes, renal, hepatic, haematological, CNS
28
Q

What are the common pathogens causing sepsis in the purperium?

A
  • GAS (Streptococcus pyogenes)
  • Escherichia coli
  • Staphylococcus aureus
  • Streptococcus pneumoniae
  • Meticillin-resistant S. aureus (MRSA)
  • Clostridium septicum
  • Morganella morganii
29
Q

What are the rates of MRSA carriage and infection in mothers in the puerperium in the US?

A

2.1%

30
Q

What % of coliform bacteria are ESBL-producing in the UK?

A

12%

Cause many co-amoxiclav and cephalosporin resistant UTIs - may need carbapenems

31
Q

What are the other sources of puerperial sepsis outside of the genital tract?

A
  • Mastitis (can become necrotising!)
  • UTI
  • Pneumonia
  • Skin/soft tissue infection
  • Gastroenteritis (may be 2dry to TSS if diarrhoea..)
  • Pharyngitis (10% GAS)
  • Spinal abscess (regional anaesthetic)
    • Usu Staph aureus (Strep, gram neg rods, sterile
      specimens in 15% each)
32
Q

Which analgesics should be avoided in sepsis and why?

A

NSAIDs

Impede ability of polymorphs to fight GAS infection

33
Q

What organism is found by contact with aborting sheep or infected birds, or washing contaminated clothing?

A

Chlamydophila psittaci

34
Q

What causes Q fever?

A

Coxielli burnetti

Inhaling particles from birthing animals or infected dust

35
Q

What are the likely orgaisms and suggested empirical treatment in:
Mastitis

A

MSSA, Strep
Flucloxacillin + clindamycin
(Vanc and clinda if allergic or if MRSA; also teic and clinda)

36
Q

What are the likely orgaisms and suggested empirical treatment in:
C-section wound/cannula site infection

A

MSSA, Strep
Flucloxacillin + clindamycin
(Vanc and clinda if allergic or if MRSA; also teic and clinda)

37
Q

What are the likely organisms and suggested empirical treatment in:
Endometritis

A

Gram neg anaerobes, Strep
Shot of gent, Cefotaxime + Metronidazole
(Gent + Clinda + Cipro if allergic)

38
Q

What are the likely orgaisms and suggested empirical organisms in:
Acute Pyelonephritis

A

Gram neg bacteria, some Staph/Strep occasionally
Cefotaxime and shot of gent
(Gent and cipro if allergic)

If ESBL-producing - Gent and meropenem

39
Q

What are the likely orgaisms and suggested empirical organisms in:
Toxic Shock Syndrome

A

Staph, Strep
Fluclox (Vanc if MRSA), clinda, gent (shot)

Any regime must have clinda or linezolid (antitoxin)

40
Q

What are the likely orgaisms and suggested empirical organisms in:
Severe sepsis, no focus

A

MRSA, Strep, Gram negs (ESBL, pseudomonas, anaerobes)

Meropenem + Clinda + gent (shot
If allergy to penicillin, no meropenem)
- Clinda + Gent + metronidazole + cipro

41
Q

What is the NNT with intrapartum antibiotics to prevent 1 case of neonatal death secondary to GBS?

A

5882

42
Q

what type of infections are associated with coliform bacteria?

A

urinary sepsis, PPROM, cerclage

43
Q

what is the clinical case definition of streptococcal sepsis?

A

hypotension + 2 or more of following:

  1. renal impairment (Cr>176)
  2. coagulopathy- plts <100
  3. Liver involvement
  4. ARDS
  5. generalised erythematous rash
  6. soft tissue necrosis
44
Q

which bacterial infections merit antibiotic prophylaxis for family/staff that have come into close contact with the infected?

A
  1. meningococcus (neisseria meningitides)

2. Group A Strep

MRCOG Part 2 (97 decks)

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