Maternal Sepsis

Question 1

What are the ANTENATAL risk factors for maternal sepsis?

Answer 1

Obesity
IGT / Diabetes
Immunocomprised patients
Anaemia
Previous pelvic infection
Minority ethnic group
GAS infection in close contacts / family members
(RCOG Guideline)

+ Developing world

Question 2

What are the Intrapartum risk factors for developing maternal sepsis?

Answer 2

Abnormal vaginal discharge
PROM
Vaginal trauma / OASIS injury
CS
Wound haematoma
Retained placenta

Question 3

What is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed?

Answer 3

IVIG

RCOG

Question 4

How does IVIG help in staphylococcal / streptococcal infection

Answer 4

• immunomodulatory effect
• neutralises the superantigen effect of exotoxins
• inhibits production of tumour necrosis factor and interleukins
• main contra-indication to IVIG: congenital deficiency of IgA
• little evidence of benefit in Gram-negative (endotoxin related) species

Question 5

Fever in the embryonic period of pregnancy may be associated with… (3)

Answer 5

• neural tube defects, oral clefts and congenital heart anomalies

Question 6

Maternal death from sepsis is most commonly caused by what organism?

Answer 6

Group A streptococcal infection

Question 7

What is the most common cause of maternal bacterial infection?

Answer 7

E. Coli

Question 8

What is the definition of sepsis?

Answer 8

Life-threatening organ dysfunction caused by dysregulated host response to infection

Question 9

What is the definition of septic shock?

Answer 9

Subset of sepsis in which profound circulatory, cellular and metabolic abnormalities substantially increase mortality

Question 10

What are the elements involved in assessing organ dysfunction for the SOFA score?

Answer 10

• Coagulation
• Platelet count
• Liver function (Bilirubin)
• Cardiovascular system: MAP or presence and dose of inotropes and/or vasopressors
• Neurological system: GCS
• Renal function: Creatinine and urine output
• Respiration: partial pressure of arterial oxygen / fraction of inspired oxygen

Each parameter is scored from 0-4, using the worst available result for the day of assessment

Question 11

Pregnant and postpartum women have a ___ fold increase in the incidence of invasive GAS infection compared with non-pregnant women

Answer 11

20-fold!

Reasons are unclear

Question 12

In pregnancy, GAS can present with non-specific symptoms such as

Answer 12

• fever
• sore threat
• vomiting
• diarrhoea

Question 13

How does Listeria present?

Answer 13

• fever
• flu-like symptoms
• headache
• vomiting
• diarrhoea

Question 14

Non-infectious conditions that can mimic sepsis

Differential diagnosis

Answer 14

• Acute Pulmonary Embolus
• Amniotic fluid embolism
• Acute Fatty Liver of Pregnancy
• Adverse drug reactions / fever
• Acute liver failure - drug related, viral
• Acute adrenal insufficiency
• Acute pituitary insufficiency
• Autoimmune conditions
• Concealed haemorrhage
• Disseminated malignancy
• Pelvic thrombosis
• Transfusion reactions

Question 15

In sepsis, mortality can increase by ___% for each hour’s delay in administering antibiotics

Answer 15

8%

Question 16

What are the common organisms in puerperal sepsis?

Answer 16

GAS - Strep pyogenes
E. Coli
S. Aureus
S. Pneumonia
MRSA
Clostridium septic I’m
Morganella Morganii

Question 17

What is the cardinal feature of Necrotising fasciitis?

Answer 17

Agonising pain

Question 18

With pneumonia, what does severe haemoptysis and lower WBC count suggest?

Answer 18

PVL associated staphylococcal necrotising pneumonia
Panton-Valentine-Leukocidin

Mortality rate >70% in young, healthy people

Question 19

A serum lactate >2 is associated with

Answer 19

Increased mortality in pregnancy

Question 20

A serum lactate >4 is associated with

Answer 20

Tissue hypoperfusion

Question 21

Fever in later pregnancy may be associated with

Answer 21

Fetal death
PTL
IUGR
Autism spectrum disorder and Developmental Delay

Note: the offspring of mothers who took anti-pyretic medications had a lower risk of Autism

Question 22

What is the recommended antibiotic treatment for undifferentiated puerperal sepsis?

Answer 22

NZ: Cefuroxine + Metronidazole + Gentamicin

If risk of MRSA: Vancomycin
If risk of Multi-resistant organisms: Meropenem
If risk of GAS: Clindamycin

Question 23

What is the recommended antibiotic treatment for Group A Sepsis?

Answer 23

Clindamycin 600mg IV q8h

+ consider Immunoglobulin

Question 24

What type of medication is oseltamavir?

How does it work?

Answer 24

Neuraminidase inhibitor

Neuraminidase: promotion of release of viruses from infected particles

Neuraminidase inhibitor: Aggregation of the viral particles at the host cell surface, and a reduction in the amount of virus released to infect other cells

Reduces risk of death from Influenza and 84% reduction in ICU admissions

Question 25

Define puerperal sepsis

Answer 25

Infection of the genital tract any time between rupture of membranes and the 42nd day postpartum in which two or more of the following are present

• fever
• pelvic pain
• abnormal vaginal discharge
• abnormal small / foul odour of discharge
• delay in the rate of reduction of the size of the uterus

Question 26

For what infection should NSIADs be avoided?

Answer 26

Group A strep
The impede the ability of polymorphism to fight GAS

RCOG