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Maternal Medicine - RANZCOG Q > Sepsis > Flashcards

Sepsis Flashcards

1
Q

Risk factors for sepsis

A

Obesity
Impaired glucose tolerance / diabetes
Impaired immunity/ immunosuppressant medication
Anaemia
Vaginal discharge
History of pelvic infection
History of group B streptococcal infection
Amniocentesis and other invasive procedures
Cervical cerclage
Prolonged spontaneous rupture of membranes
GAS infection in close contacts / family members
Of black or other minority ethnic group origin

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2
Q

Indications for transfer to ICU?

A

Cardiovascular:
Hypotension or raised serum lactate persisting despite fluid resuscitation, suggesting the need for
inotrope support

Respiratory:
Pulmonary oedema
Mechanical ventilation
Airway protection

Renal:
Renal dialysis

Neurological:
Significantly decreased conscious level

Miscellaneous:
Multi-organ failure
Uncorrected acidosis
Hypothermia

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3
Q

Most common organisms?

A

Streptococcus and E coli

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4
Q

Profile of the following antibiotics and their limitations:

Cefuroxime

A

Class: cephalosporin
Coverage: Gram +ve/-ve
MOA: Inhibit cell wall synthesis

Limitations: association with C. difficile. Doesn’t provide any MSRA, Pseudomonas or ESBL cover

Pregnancy: Safe

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5
Q

Profile of the following antibiotics and their limitations:

Augmentin

A

Class: penicillin with addition of clavulanic acid
Coverage: Gram +ve/-ve
MOA: Inhibit cell wall synthesis (bactericidal)

Limitations: Does not cover MRSA or Pseudomonas

Pregnancy: Possible association in 1st trimester with cleft palate, in 3rd trimester concern about increased risk of NEC in preterm babies

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6
Q

Profile of the following antibiotics and their limitations:

Metronidazole

A

Only covers anaerobes

Safe in pregnancy although cochrane review found increased risk of adverse outcomes when used in the first trimester to treat BV/trich

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7
Q

Profile of the following antibiotics and their limitations:

Tazocin and carbapenems

A

Piperacillin–tazobactam Covers all except MRSA and are renal sparing (in contrast to aminoglycosides).
(Tazocin) and carbapenems

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8
Q

Profile of the following antibiotics and their limitations:

Gentamicin

A

Class: aminoglycoside
Coverage: Gram -ve
MOA: Inhibit protein synthesis

Limitations: nephrotoxic if AKI/CKD, serial doses need serum levels monitoring

Pregnancy: Safe

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9
Q

Profile of the following antibiotics and their limitations:

Clindamycin

A

Class: Lincosamide
Coverage: Gram +ve and anaerobes
MOA: Inhibit protein synthesis (bacteriostatic)

Covers most streptococci and staphylococci, including many MRSA, and switches off exotoxin production
with significantly decreased mortality. Not renally excreted or nephrotoxic.

Pregnancy: Safe

Limitations: associated with colitis and C diff.

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10
Q

Profile of the following antibiotics and their limitations:

Doxycycline

A

Class: tetracycline
Coverage: Gram +ve/-ve
MOA: Inhibit protein synthesis (bacteriostatic)

Pregnancy: Causes staining and dental hypoplasia therefore should not be given to pregnant women. Very limited course if no suitable alternative if breastfeeding

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11
Q

Profile of the following antibiotics and their limitations:

Co-trimoxazole

A

Sulfamethoxazole and trimethoprim

Class: Sulfamethoxazole- sulfonamide
Trimethoprim- folate antagonist
Coverage: Gram +ve/-ve
MOA: Folate antagonist- therefore affects bacterial DNA synthesis

Pregnancy: TP: avoid in the first trimester as antifolate
Sulfonamides should be avoided in the 3rd trimester due to risk of kernicterus in newborn

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12
Q

Profile of the following antibiotics and their limitations:

Erythromycin

A

Class: macrolide
Coverage: Gram +ve
MOA: Inhibit protein synthesis
May also have some anti-inflammatory effects

Pregnancy: Safe

Other drugs within macrolide class:

  • Azithromycin- lower serum concentration but higher tissue. Better gram negative cover. Can be used for chlamydia. Has a long half life.
  • Clarithromycin- greater activity than erythromycin with higher tissue levels
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13
Q

Another drug that can be used for severe strep/staph sepsis requiring intensive care?

A

IVIG

IVIG has an immunomodulatory effect, and in staphylococcal and streptococcal sepsis it also
neutralises the superantigen effect of exotoxins, and inhibits production of tumour necrosis factor
(TNF) and interleukins

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14
Q

Risks to the fetus of maternal sepsis

A
  • Increased risk of neonatal encephalopathy and cerebral palsy
  • Preterm delivery
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15
Q

When to consider delivery?

A

Attempting delivery in the setting of maternal instability increases the maternal and fetal mortality rates unless the source of infection is intrauterine.

The decision on mode of delivery should be individualised by the consultant obstetrician with consideration of severity of maternal illness, duration of labour, gestational age and viability

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16
Q

Definition of sepsis

A

life-threatening organ dysfunction caused by

a dysregulated host response to infection

17
Q

What scoring system is recommended by SOMANZ?

A

omqSOFA score

SOFA score: Sequential (sepsis-related) Organ Failure Assessment score (SOFA) has been shown to be useful in identifying those patients with a suspected
infection who are likely to have a prolonged ICU stay or die in hospital.
q- quick
om- obstetrically modified

18
Q

omq-SOFA score?

A
  • systolic blood pressure of 90 mmHg or less
  • respiratory rate of 25/min or greater
  • altered mentation (any state other than ‘Alert’ on maternal observation charts).
19
Q

om-SOFA score?

A

Looking at end organ dysfunction in the following groups:

  • Respiration: parameters related to hypoxia
  • Coagulation: low platelets
  • Liver: Raised bilirubin
  • Cardiovascular: hypotension
  • Central nervous system: reduced AVPU score
  • Renal: evidence of AKI
20
Q

Definition of septic shock

A
  • Vasopressors required so maintain systolic BP

- Lactate >2 despite adequate fluid resuscitation

21
Q

Effects of maternal fever in early pregnancy?

A

Association with NTD, oral clefts

Weak association with congenital heart defects

Association with ASD and developmental delay- particularly if antipyretics weren’t used

No effect of maternal fever was seen on the risk
of miscarriage, stillbirth or preterm labour

22
Q

Non-infectious conditions that can mimic sepsis in pregnancy

A 
PE
AFE 
Pancreatitis 
Acute fatty liver of pregnancy 
Adverse drug reactions, 
Acute liver failure
Acute adrenal insufficiency 
Acute pituitary insufficiency 
Autoimmune conditions 
Concealed haemorrhage 
Disseminated malignancy 
Pelvic thrombosis 
Transfusion reactions
23
Q

First line management?

A

Within 1 hour: Sepsis 6+2:

  • Blood cx and cx other potential sources e.g. urine
  • Serum lactate and bloods
  • Strict measurement of fluid balance
  • Antibiotics
  • IVF
  • O2 to maintain sats >94%
  • Assess fetal state and consider delivery/evac of RPOC
  • Consider thromboprophylaxis
24
Q

In severe sepsis how much can mortality be increased by each hour of delay in antibiotics?

A

8%

25
Q

SOMANZ antibiotic recommendations for sepsis of unknown origin?

A

Community:

  • Oz: amox + gent + metronidazole
  • NZ: cef + met + gent

Hospital:

  • Oz: taz + gent + metronidazole
  • NZ: same

If at risk of GAS: add in clindamycin 600mg IV

If at risk of MDR organism: add in meropenem

26
Q

Treatment of flu in women that are systemically unwell?

A

Use of Oseltamavir within 48 hours of presentation reduced ICU admissions by 84%

27
Q

Anaesthesia in the context of maternal infection?

A

Avoid spinal/epidural as risk of infectious complication is increased

28
Q

Definition of chorioamnionitis?

A

Acute inflammation of the membranes and chorion of the placenta

More common when membranes ruptured. Can occur without- then more commonly due to ureaplasma/mycoplasma. Haematogenous spread from listeria.

29
Q

Risk factors for chorio?

A 
Longer duration of membrane rupture, 
prolonged labor, 
nulliparity, 
internal monitoring of labor, 
multiple vaginal exams, 
meconium-stained amniotic fluid, 
smoking, alcohol or drug abuse, 
immune-compromised states, 
epidural anaesthesia, 
colonization with GBS, 
bacterial vaginosis, 
sexually transmissible genital infections 
vaginal colonization with ureaplasma
30
Q

Diagnosis of chorio?

A

Clinical features: fever, uterine fundal tenderness, maternal or fetal tachycardia and purulent or foul amniotic fluid

Histopathological features

Microbiologic - ie swabs confirming infection

31
Q

Pathogenesis of chorio?

A
  1. passage of infectious organisms to the chorioamnion and/or umbilical cord of the placenta
    • Either ascending, haematogenous, via fallopian tubes, or from procedure e.g. amnio
  2. Maternal and fetal inflammatory response
  3. Fetal response may affect cerebral white matter and therefore increase risk of cerebral palsy
  4. The inflammatory response may produce clinical chorioamnionitis and/or lead to prostaglandin release, ripening of the cervix, membrane injury and labour at term or premature birth at earlier gestational ages
32
Q

Maternal complications of chorioamnionitis?

A

Increased risk of:

  • CS
  • Postpartum endometritis/abscess
  • PPH (due to inefficient uterine contraction from inflammation)
  • Severe sepsis
33
Q

Fetal/neonatal complications of chorioamnionitis?

A 
Preterm birth
Perinatal death 
Cerebral palsy/developmental delay 
Neonatal sepsis 
IVH

Maternal Medicine - RANZCOG Q (5 decks)

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