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Pathology in pregnancy > Other conditions + sepsis in pregnancy and postpartum > Flashcards

Other conditions + sepsis in pregnancy and postpartum Flashcards

1
Q

Which autoimmune condition may improve in pregnancy and why?

A

rheumatoid arthritis due to reduction in T helper 1 cell activity

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2
Q

Why does SLE flare in pregnancy?

A

Increased T helper 2 activity

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3
Q

What is placenta accreta?

A

chorionic villi attached to the myometrium (75%)

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4
Q

What is placenta increta?

A

chorionic villi invade the myometirum (17%)

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5
Q

What is placenta percreta?

A

chorionic villi invade through the myometrium into the serosa (7%)

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6
Q

Define sepsis

A

infection + systemic manifestations

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7
Q

Define severe spesis

A

infection + sepsis induced organ dysfunction or tissue hypoperfusion

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8
Q

Define septic shock

A

Persistence of hypo perfusion despite adequate fluid resuscitation

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9
Q

Which ethnic groups are at highest risk of sepsis?

A

black or other ethnic minority

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10
Q

What are the primary organisms to cause toxic shock syndrome?

A

streptococcus and staphylococcus (exotoxic shock)

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11
Q

What are the potential signs of toxic shock syndrome?

A 
GI symptoms - vomiting/diarrhoea/nausea
abdo pain - severe due to necrotising fasciitis
Watery vaginal discharge
Suffusion of eyes/tongue/mouth - red
Generalised rash
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12
Q

Key investigations for sepsis

A

blood culture before antibiotics, lactate within 6 hours, ABG

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13
Q

What is a concerning lactate level?

A

> 4mmol/L

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14
Q

If hypotension and/or lactacte >4 - initial management

A

20ml/kg crystalloid

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15
Q

When would you give a vasopressor in sepsis?

A

To maintain a mean arterial BP of >65mmHg

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16
Q

In severe sepsis/septic shock, what CVP/central venous saturation are you aiming to maintain?

A

CVP >/= 8
Central venous O2 >/= 70%
Central venous mixed o2 >/= 60%

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17
Q

What factors prompt transfer to ITU?

A 
Septic shock (hypotension not responding to fluid resuscitation) or lactate >/= 4 - needs ionotropes
Acute renal failure requiring dialysis
hypothermia
reduced consciousness
multi-organ failure
uncorrected acidosis
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18
Q

Most commonly identified organisms leading to mortality in sepsis?

A 
E coli (uti/cerclage/preterm premature rupture of membranes)
Group B streptococcus
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19
Q

Limitation of co-amoxiclav treatment of sepsis in pregnancy

A

Does not cover pseudomonas or MRSA and increased risk of neonatal enterocolitis

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20
Q

Limitation of metronidazole treatment of sepsis in pregnancy

A

Only covers anaerobes

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21
Q

Limitation of clindamycin treatment of sepsis in pregnancy

A

excreted renally- potentially nephrotoxic

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22
Q

Limitation of Tazocin treatment of sepsis in pregnancy

A

Does not cover MRSA

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23
Q

Limitation of gentamicin treatment of sepsis in pregnancy

A

Requires monitoring, only poses problem to kidneys if renal function is abnormal

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24
Q

What conditions are intravenous immunoglobulins used in sepsis?

A

streptococcal or stapylococcal invasive systemic infections

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25
Q

Role of intravenous immunogobulin therapy

A

used for invasive stroptcoccal or staphyloccocal infectins - inhibits tumour necrosis factor release and interleukin release and neutralises exotoxins

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26
Q

What is intravenous immunoglobulin therapy not useful in?

A

endotoxic shock from gram negative bacteria

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27
Q

When is intravenous immunoglobulin therapy contraindicated?

A

In congenital IgA deficiency

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28
Q

Neonatal risks of intrauterine sepsis

A

Cerebral palsy and encephalopathy

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29
Q

What is pyrexia in pregnancy?

A

> /=38 or 37.5 on two occasion 2 hours apart

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30
Q

Recommended anaesthesia for delivery in maternal sepsis

A

GA for caesarean section not spinal or epidural

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31
Q

Measures for group A sespsis

A

Isolation, discussion with paediatrics for neonatal prophylaxis and notifiable disease if invasive group A present

32
Q

What is the most common site of sepsis in the puerperieum?

A

postnatal sepsis is most commonly due to genital tract sepsis, uterine infection, endometritis

33
Q

What common organisms cause sepsis in the puerperium?

A

group A beta haemolytic strep (streoptococcus pyogenes)
E coli
Staph aureus
streptococcus pneumoniae
MRSA, clostridium strepticum, morganella morganii

34
Q

What are common causes of postpartum sepsis?

A

Genital tract most common

Elsewhere - mastitis, uti, pneumonia, skina nd soft tissue, GI and pharyngitis

35
Q

When should a patient with mastitis be transferred to hospital?

A

signs of sepsis
no improvement with oral antibiotics in 48 hours
severe or unusual symptoms

36
Q

High risk organism associated with mastitis

A

PVL producing MRSA - high risk of transmission in breast milk

37
Q

High risk organism associated with UTI

A

ESBL producing coliforms

38
Q

Clinical signs of PVL associated staphylococcal necrotising pneumonia

A

Severe haemoptysis and low WCC

39
Q

Which infection sites are particularly associated with postpartum toxic shock syndrome

A

soft tissue and skin

40
Q

Postpartum recurrent abscess formation, particularly labial abscess formation is associated with which oragnism

A

PVL producing staphylococci

41
Q

Cardinal sign of necrotising fasciitis

A

agonising pain

42
Q

What factors prompt antibiotic treatment of pharyngitis?

A

3/4 centor criteria - fever, tonsillar exudate, no cough, tender anterior cervical lymphadenotpathy

43
Q

What are the centor criteria?

A 
criteria used to stratify risk of bacterial infection in pharyngitis and therefore need for antibiotics.  Criteria include
tonsillar exudate
no cough
tender anterior cervical lymphadenopathy
fever
3/4 = antibiotics advised
44
Q

usual organisms causing regional anaesthesia associated infection

A

staphyloccocus aureus (+ streptococci)

45
Q

What would a generalised maculopapular rash indicate post partum with fever?

A

streptococcal/staphylococcal infection

toxic shock only 10% in streptococcal shock syndrome

46
Q

What analgesia should be avoided in sepsis?

A

NSAIDs as they limit polymorph ability to fight GAS

47
Q

What features in the history increase risk of streptoccocal infection

A

family history of streptococcal infection i.e. pharyngitis
cellulitis/impetigo/pharynigitis
IV drug use/generalised immunosuppression

48
Q

What is GI symptoms with fever suggestive of in postpartum period

A

may be food borne salmonella or camplylobacter but these rarely cause sepsis
Toxic shock syndrome often cause GI symptoms, rash and red conjunctivae

49
Q

Which organism causes “Q fever”

A

coxiella burnettii from birthing animals/contaminated dust

50
Q

What vital signs are suggestive of sepsis postpartum?

A

HR >90, RR >20, T 38 or <36

systolic <90, MAP <70, systolic BP drop >40

51
Q

if sepsis develops within 12 hours of delivery, which organism is this suggestive of?

A

streptococcal infection

52
Q

Signs of collected pus or infected haematoma?

A

Rising CRP, swinging pyrexia, high platelet count (thrombocytosis)

53
Q

Role of clindamycin in sepsis

A

inhibits endotoxin production, but MRSA may be resistant - use with Tazocin or a carbapenam

54
Q

Limitations of cefuroxime and metronidazole

A

increased risk of c diff with cefuroxime

neither provides protection against MRSA, pseudomonas or ESBL

55
Q

Treatment of c diff

A

oral metronidazole or vancomycin

56
Q

Indication for ITU admission

A

septic shock or signs or organ hypoperfusion

57
Q

When is GAS prophylaxis advised?

A

family with close contact - kissing/household contacts

health care workers with respiratory contact - suctioning

58
Q

Blood results suggestive of sepsis

A

wcc <4/>12, CRP >7

59
Q

Hypoxaemia in sepsis/ severe sepsis

A

Hypoxaemia <40

Severe sepsis <33.3 if no pneumonia, <46.7 if pneumonia

60
Q

Creatinine in sepsis/severe sepsis (indicating end organ failure)

A

> 44.2 rise

severe sepsis >176 rise

61
Q

Coagulation abnormality suggestive of end organ failure

A

INR >1.5 or APTT >60 seconds

62
Q

Common organisms causing mastitis sepsis

A 
staph aureus (MSSA)
streptococcus
63
Q

Treatment of mastitis sepsis

A

fluclox + clindamycin (against endotoxins)

or vanc + clindamycin if pen allergic

64
Q

Common organisms causing c-section wound or cannulate infection

A

MRSA

streptococci

65
Q

Treatment of c-section wound or cannulate infection

A

fluclox or vanc + clindamycin

66
Q

Common organisms causing endometritis

A

gram negative organisms

streptococci

67
Q

Treatment of postpartum endometritis

A

Cefotaxime + metronidazole + gent

Gent+ clindamycin + cipro if allergic

68
Q

Common organisms causing pyelonephritis

A

gram neg bacteria (e coli)

occasionally staphylococci/streptococci

69
Q

Treatment of pyelonephritis

A

cefotaxime + gent
or gent + cipro if allergic
gent + merapenam if ESBLs

70
Q

Common organisms causing Toxic shock syndrome

A

staphylococci

streptococi

71
Q

Treatment of TSS

A

flucoclox+clindamycin+gent
or vanc + clinda + gent if MRSA
consider Intrevenous immunoglobulin

72
Q

Common organisms causing severe sepsis with no clear focus

A

MRSA
Gram negatives including ESBL producers
Anaerobes

73
Q

Treatment of severe sepsis with no clear focus

A

mero+clinda+gent

or clinda+gent+metro+cipro if allergic

74
Q

Signs of TSS staphylococcus

A 
1 Fever >/=39
2 Macular rash
3 Desquamation
4 Systolic BP <90
5 Multisystem involvement (3 or more):
  GI sx.
  severe myalgia
  mucous membranes - i.e. conjunctival suffusion
  Renal- creatinine x 2 normal limit
  heam - thrombocytopenia
  liver - bili x 2 normal limit
  CNS- reduced consciousness
4/5 = probable
5 = confirmed
75
Q

Signs of TSS streptococcus

A

GAS from sterile site (blood/CSF/peritoneum/tissue) or non-sterile site (vagina/throat/sputum)

and multiorgan involvement

either hypotension or two or more the following:

renal - creat >176
heam - thrombocytopaenia or DIC
liver - raised AST/ALT or bili x2 upper limit
skin - generalised macular rash (desqumation in 10%)
ARDS
Soft tissue necrosis

Probable - signs + GAS from non sterile site
Definite - signs + GAS from sterile site

Pathology in pregnancy (9 decks)

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