Puerperal sepsis Flashcards

1
Q

Definition of puerperal sepsis.

A

Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period. (WHO)

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. (SOMANZ)

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2
Q

Define septic shock.

A

Septic shock is when there is persistent hypoperfusion despite adequate fluid replacement therapy.
(RCOG)

Septic shock is defined as a subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities substantially increase mortality. (SOMANZ)

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3
Q

Describe a screening tool for maternal sepsis.

A

Obstetric modified quick Sepsis-related Organ Failure Assessment (omqSOFA) score.

  • RR ≥25
  • SBP ≤90
  • Altered mentation

Score ≥2 predicts an increased risk of mortality from sepsis.
This should prompt further assessment for sepsis with omSOFA.

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4
Q

What is SOFA and omSOFA?

Why is it important?

A
  • SOFA (sepsis-related organ failure assessment score) is a validated scoring system for assessing risk of mortality due to sepsis
  • It requires clinical findings, vital signs and biochemical test results
  • SOFA ≥2 predicts 10% risk of mortality
  • omSOFA is the obstetric modified tool - not formally validated, but adapted from SOFA
  • omSOFA:
    1. Respiratory PaO2/FiO2 <400
    2. Platelets <150
    3. bilirubin >20
    4. creatinine >90
    5. MAP <70
    6. Altered mental state / drowsy
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5
Q

What are the clinical criteria of septic shock?

A
  • Inotrope support required to maintain MAP ≥65 despite adequate fluid resuscitation
  • Tissue hypoperfusion as shown by lactate ≥2 despite adequate fluid resuscitation
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6
Q

What are the first line investigations of sepsis?

A
  • FBC, U&E, creatinine, LFT, Coagulation screen
  • ABG - lactate, hypoxia, acid-base status
  • Blood cultures - 2 x from different sites, also from any indwelling lines
  • Cultures - MSU, LVS, stool, NP swabs, sputum, placental etc
  • Imaging - CXR +/- CT/USS as indicated
  • Fetal assessment - CTG and/or USS
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7
Q

What are the common pathogens responsible for maternal sepsis?

A
  • E.coli (most common, 2nd commonest cause of mortality)
  • GAS (commonest cause of mortality - 25%)
  • GBS
  • Klebsiella pneumonae (nosocomial)
  • Staph A
  • Strep pneumonae
  • Gram neg/pos anaerobes
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8
Q

Group A strep.

A
  • Gram positive cocci
  • Commonest cause of maternal mortality from sepsis - 25% cases
  • Up to 30% population are asymptomatic carriers on skin and throat
  • Pregnant women have 20 fold increased risk IGAS
    • rheumatic fever, scarlet fever, bacteremia, necrotising fasciitis
  • Rx: benzylpenicillin 1.2g IV Q6H OR amoxicillin 2g IV Q6H AND clindamycin 600mg IV Q8H
  • Inform paeds team
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9
Q

When should you consider leasing with HDU/ICU?

What are the indications for ICU admission?

A
  • Speak to ICU if no improvement in MAP or other indices despite 2L fluid rescusitation

ICU criteria:

  • Cardiorespiratory compromise (MAP < 65 despite adequate fluid resuscitation, worsening hypoxia/tachypnoea/oxygen requirement)
  • Tissue hypoperfusion (lactate ≥2 despite adequate fluid resuscitation, metabolic acidosis, clinical signs poor perfusion, poor placental perfusion)
  • End organ dysfunction (oliguria, rising creatinine, worsening liver derangement, altered mental state)
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10
Q

Management of sepsis.

A
  • Early involvement of obstetric SMO / physician with experience in maternal sepsis
  • First-line investigations
  • IV access and administration of empiric Abs within the 1st hour
  • Once pathogen/source clear change to appropriate antibiotic
  • Fluid resuscitation with crystalloid; 20ml/kg up to maximum 2L STAT.
  • Fluid balance monitoring - consider IDC placement
  • If hypoxia apply oxygen and titrate to saturations
  • Early involvement of ICU if no signs of clinical improvement after 2L IV fluids
  • Close monitoring with MEWS Q15-30 minutes depending on acuity
  • Fetal wellbeing assessment with CTG +/- USS
  • Consideration of steroids if preterm and consideration of preterm delivery
  • Consider timing and mode of delivery, depending on maternal/fetal clinical state, gestation and careful risk/benefit consideration
  • VTE prophylaxis
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11
Q

What is the importance of the “golden Hour”?

A
  • For each hour of delay in administering IV antibiotics in sepsis, the mortality increases by 8%
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12
Q

Fetal assessment in sepsis.

A
  • CTG and USS BPP are poor markers of fetal sepsis
  • Abnormal CTG findings should still prompt consideration of timing of delivery
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13
Q

What are the considerations for timing of delivery for maternal sepsis?

A

The timing of delivery will be determined by:

  • The presence of intrauterine sepsis
  • The nature of the maternal sepsis and response to initial resuscitation efforts
  • The gestation of the pregnancy and fetal status

If intrauterine cause of sepsis:

  • plan for delivery, as associated with increased risks of cerebral palsy, and unlikely to respond well to Abs without source control
  • if pre-viable (<23 weeks) - induce, as fetus unlikely viable and benefits for mother in reducing post-op complciations
  • if viable - consider CS as the fastest MoD, unless progressing well in established labour
  • Consider steroids, but don’t delay delay delivery if emergent

Other site of sepsis:

  • Manage sepsis and monitor fetal wellbeing
  • Aim to optimise sepsis and prolong pregnancy if preterm
  • At term consider delivery

Other indicators for delivery:

  • Worsening fetal or maternal clinical status despite management
  • Pregnancy reducing effectiveness of resuscitative efforts - e.g. ability to ventilate in Respiratory distress
  • Septic shock or end organ dysfunction
  • Maternal cardiac arrest - move to perimortem hysterotomy without delay
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14
Q

Treatment of influenza.

A
  • Manage as sepsis.
  • Tamiflu 75mg po bd for 5 days - start within 48 hours of symptoms
  • If started <2days - 84% reduction in ICU admission in pregnant women
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15
Q

Empiric broad spectrum antibiotics for community and hospital acquired sepsis of unclear source (NZ).

A

Cefuroxime 1.5g IV Q8H + Metronidazole 500mg IV Q12H + Gentamicin 4-7mg/kg IV (once)

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16
Q

NZ empiric antibiotics for genital tract suspected source.

A

Cefuroxime 1.5g IV Q8H + Metronidazole 500mg IV Q12H

If severe sepsis add: Gentamicin 4-7mg/kg IV

OR Amox + gent + met

ADD clindamycin in GAS suspected