Other conditions + sepsis in pregnancy and postpartum Flashcards
Which autoimmune condition may improve in pregnancy and why?
rheumatoid arthritis due to reduction in T helper 1 cell activity
Why does SLE flare in pregnancy?
Increased T helper 2 activity
What is placenta accreta?
chorionic villi attached to the myometrium (75%)
What is placenta increta?
chorionic villi invade the myometirum (17%)
What is placenta percreta?
chorionic villi invade through the myometrium into the serosa (7%)
Define sepsis
infection + systemic manifestations
Define severe spesis
infection + sepsis induced organ dysfunction or tissue hypoperfusion
Define septic shock
Persistence of hypo perfusion despite adequate fluid resuscitation
Which ethnic groups are at highest risk of sepsis?
black or other ethnic minority
What are the primary organisms to cause toxic shock syndrome?
streptococcus and staphylococcus (exotoxic shock)
What are the potential signs of toxic shock syndrome?
GI symptoms - vomiting/diarrhoea/nausea abdo pain - severe due to necrotising fasciitis Watery vaginal discharge Suffusion of eyes/tongue/mouth - red Generalised rash
Key investigations for sepsis
blood culture before antibiotics, lactate within 6 hours, ABG
What is a concerning lactate level?
> 4mmol/L
If hypotension and/or lactacte >4 - initial management
20ml/kg crystalloid
When would you give a vasopressor in sepsis?
To maintain a mean arterial BP of >65mmHg
In severe sepsis/septic shock, what CVP/central venous saturation are you aiming to maintain?
CVP >/= 8
Central venous O2 >/= 70%
Central venous mixed o2 >/= 60%
What factors prompt transfer to ITU?
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
Most commonly identified organisms leading to mortality in sepsis?
E coli (uti/cerclage/preterm premature rupture of membranes) Group B streptococcus
Limitation of co-amoxiclav treatment of sepsis in pregnancy
Does not cover pseudomonas or MRSA and increased risk of neonatal enterocolitis
Limitation of metronidazole treatment of sepsis in pregnancy
Only covers anaerobes
Limitation of clindamycin treatment of sepsis in pregnancy
excreted renally- potentially nephrotoxic
Limitation of Tazocin treatment of sepsis in pregnancy
Does not cover MRSA
Limitation of gentamicin treatment of sepsis in pregnancy
Requires monitoring, only poses problem to kidneys if renal function is abnormal
What conditions are intravenous immunoglobulins used in sepsis?
streptococcal or stapylococcal invasive systemic infections
Role of intravenous immunogobulin therapy
used for invasive stroptcoccal or staphyloccocal infectins - inhibits tumour necrosis factor release and interleukin release and neutralises exotoxins
What is intravenous immunoglobulin therapy not useful in?
endotoxic shock from gram negative bacteria
When is intravenous immunoglobulin therapy contraindicated?
In congenital IgA deficiency
Neonatal risks of intrauterine sepsis
Cerebral palsy and encephalopathy
What is pyrexia in pregnancy?
> /=38 or 37.5 on two occasion 2 hours apart
Recommended anaesthesia for delivery in maternal sepsis
GA for caesarean section not spinal or epidural
Measures for group A sespsis
Isolation, discussion with paediatrics for neonatal prophylaxis and notifiable disease if invasive group A present
What is the most common site of sepsis in the puerperieum?
postnatal sepsis is most commonly due to genital tract sepsis, uterine infection, endometritis
What common organisms cause sepsis in the puerperium?
group A beta haemolytic strep (streoptococcus pyogenes)
E coli
Staph aureus
streptococcus pneumoniae
MRSA, clostridium strepticum, morganella morganii
What are common causes of postpartum sepsis?
Genital tract most common
Elsewhere - mastitis, uti, pneumonia, skina nd soft tissue, GI and pharyngitis
When should a patient with mastitis be transferred to hospital?
signs of sepsis
no improvement with oral antibiotics in 48 hours
severe or unusual symptoms
High risk organism associated with mastitis
PVL producing MRSA - high risk of transmission in breast milk
High risk organism associated with UTI
ESBL producing coliforms
Clinical signs of PVL associated staphylococcal necrotising pneumonia
Severe haemoptysis and low WCC
Which infection sites are particularly associated with postpartum toxic shock syndrome
soft tissue and skin
Postpartum recurrent abscess formation, particularly labial abscess formation is associated with which oragnism
PVL producing staphylococci
Cardinal sign of necrotising fasciitis
agonising pain
What factors prompt antibiotic treatment of pharyngitis?
3/4 centor criteria - fever, tonsillar exudate, no cough, tender anterior cervical lymphadenotpathy
What are the centor criteria?
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
usual organisms causing regional anaesthesia associated infection
staphyloccocus aureus (+ streptococci)
What would a generalised maculopapular rash indicate post partum with fever?
streptococcal/staphylococcal infection
toxic shock only 10% in streptococcal shock syndrome
What analgesia should be avoided in sepsis?
NSAIDs as they limit polymorph ability to fight GAS
What features in the history increase risk of streptoccocal infection
family history of streptococcal infection i.e. pharyngitis
cellulitis/impetigo/pharynigitis
IV drug use/generalised immunosuppression
What is GI symptoms with fever suggestive of in postpartum period
may be food borne salmonella or camplylobacter but these rarely cause sepsis
Toxic shock syndrome often cause GI symptoms, rash and red conjunctivae
Which organism causes “Q fever”
coxiella burnettii from birthing animals/contaminated dust
What vital signs are suggestive of sepsis postpartum?
HR >90, RR >20, T 38 or <36
systolic <90, MAP <70, systolic BP drop >40
if sepsis develops within 12 hours of delivery, which organism is this suggestive of?
streptococcal infection
Signs of collected pus or infected haematoma?
Rising CRP, swinging pyrexia, high platelet count (thrombocytosis)
Role of clindamycin in sepsis
inhibits endotoxin production, but MRSA may be resistant - use with Tazocin or a carbapenam
Limitations of cefuroxime and metronidazole
increased risk of c diff with cefuroxime
neither provides protection against MRSA, pseudomonas or ESBL
Treatment of c diff
oral metronidazole or vancomycin
Indication for ITU admission
septic shock or signs or organ hypoperfusion
When is GAS prophylaxis advised?
family with close contact - kissing/household contacts
health care workers with respiratory contact - suctioning
Blood results suggestive of sepsis
wcc <4/>12, CRP >7
Hypoxaemia in sepsis/ severe sepsis
Hypoxaemia <40
Severe sepsis <33.3 if no pneumonia, <46.7 if pneumonia
Creatinine in sepsis/severe sepsis (indicating end organ failure)
> 44.2 rise
severe sepsis >176 rise
Coagulation abnormality suggestive of end organ failure
INR >1.5 or APTT >60 seconds
Common organisms causing mastitis sepsis
staph aureus (MSSA) streptococcus
Treatment of mastitis sepsis
fluclox + clindamycin (against endotoxins)
or vanc + clindamycin if pen allergic
Common organisms causing c-section wound or cannulate infection
MRSA
streptococci
Treatment of c-section wound or cannulate infection
fluclox or vanc + clindamycin
Common organisms causing endometritis
gram negative organisms
streptococci
Treatment of postpartum endometritis
Cefotaxime + metronidazole + gent
Gent+ clindamycin + cipro if allergic
Common organisms causing pyelonephritis
gram neg bacteria (e coli)
occasionally staphylococci/streptococci
Treatment of pyelonephritis
cefotaxime + gent
or gent + cipro if allergic
gent + merapenam if ESBLs
Common organisms causing Toxic shock syndrome
staphylococci
streptococi
Treatment of TSS
flucoclox+clindamycin+gent
or vanc + clinda + gent if MRSA
consider Intrevenous immunoglobulin
Common organisms causing severe sepsis with no clear focus
MRSA
Gram negatives including ESBL producers
Anaerobes
Treatment of severe sepsis with no clear focus
mero+clinda+gent
or clinda+gent+metro+cipro if allergic
Signs of TSS staphylococcus
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
Signs of TSS streptococcus
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
