Sepsis

Question 1

Define sepsis, severe sepsis and septic shock

Answer 1

Sepsis = infection + systemic manifestations of infection
Severe sepsis = sepsis + sepsis-induced organ dysfunction or tissue hypoperfusion
Septic shock = persistence of hypoperfusion despite adequate fluid replacement therapy

Question 1

What are the antenatal causes of sepsis

Answer 1

Urinary tract infection → pyelonephritis
Pneumonia
Skin and soft tissue infection
Gastroenteritis
Pharyngitis
Infection related to regional anaesthesia
Chorioamnionitis
PID

Question 2

What are the intrapartum causes of sepsis

Answer 2

Urinary tract infections
Chorioamnionitis

Question 3

What are the postpartum causes of sepsis

Answer 3

Mastitis
Endometritis
Urinary tract infection
Skin and soft tissue infection e.g. LSCS wound
Infection related to regional anaesthesia
Abdominal collection
Infected perineal wounds
Pneumonia
Gastroenteritis
Pharyngitis

Question 4

What are the usual causative organisms for maternal sepsis

Answer 4

Group A beta-haemolytic strep (pyogenes)
E. coli
Peptostreptococcus
Bacteroides
Clostridium perfringens

Note: EARLY presentation of sepsis (<12h post-delivery) is more likely to be streptococcal i.e. GAS

Question 5

What are the risk factors for maternal sepsis

Answer 5

Obesity, BAME
Impaired glucose tolerance/diabetes, Impaired immunity
Hx pelvic infection or GBS infection, GAS infection in close contacts/family members
Amniocentesis or other invasive procedures, Cervical cerclage
Anaemia
Vaginal discharge
Prolonged spontaneous rupture of membranes

Question 6

What are the symptoms of maternal sepsis

Answer 6

Fever or rigors
Abdominal/pelvic pain and tenderness
Rash (Generalised streptococcal maculopapular or purpura fulminans)
Offensive vaginal discharge
- Smelly: anaerobes
- Serosanguinous: streptococcal
Productive cough
Urinary symptoms
PROM or PPROM

Question 7

What is suggested by presence of the following:
Severe abdominal pain and tenderness unrelieved by usual analgesia
Pre-term labour
Nausea and vomiting, diarrhoea
Extreme severe pain out of proportion to clinical signs
Breast engorgement and redness, breasts become hard and painful
Spreading cellulitis or discharge
Abdominal pain + swinging fevers
Foul smelling profuse and bloody discharge, tender bulky uterus on exam

Answer 7

Genital tract sepsis: Severe abdominal pain and tenderness unrelieved by usual analgesia
Severe infection: Pre-term labour
Toxic shock syndrome: Nausea and vomiting, diarrhoea
Necrotising fasciitis: Extreme severe pain out of proportion to clinical signs
Mastitis: Breast engorgement and redness, breasts become hard and painful
Wound infection: spreading cellulitis or discharge
Abdominal collection post-LSCS: abdominal pain + swinging fevers
Endometritis: foul smelling profuse and bloody discharge, tender bulky uterus on exam

Question 8

What are the signs of sepsis on examination

Answer 8

Obs: pyrexia/hypothermia, tachycardia, tachypnoea, hypoxia, hypotension
General: impaired consciousness, oliguria
Abdo exam: ?gastroenteritis
Resp exam: ?pneumonia
Bimanual/speculum: ?chorioamnionitis
Neuro: ?meningitis

Question 9

What investigations should be done for maternal sepsis

Answer 9

Initiate sepsis 6
1. Obtain blood cultures (BEFORE Abx)
2. Administer broad-spectrum antibiotic within one hour of sepsis recognition
3. Measure serum lactate (VBG/ABG) + septic screen
4. Fluids (20ml/kg crystalloid)
5. Administer oxygen
6. Measure urine output

Screen:
bedside: MSU for MC&S, throat swab, sputum culture, high vaginal swab, stool sample
Bloods: blood cultures, Blood gas, CRP/ESR, U&Es
Other: LP, CXR, TVUSS, breast US,
+ CTG

Question 10

What is the management for peri-partum sepsis

Answer 10

Transfer to labour ward
Sepsis 6
- Abx: co-amoxiclav
Consultant review
Mother has invasive group A strep → prophylactic antibiotics administered to the baby
Inform close contacts to seek medical attention if symptom develop
Then delivery baby asap: IOL, augmentation, c-section
Neonatal review
<34 w → steroids + Mg sulphate

Question 11

What is the management for intrapartum sepsis

Answer 11

Sepsis 6
CTG → non-reassuring → emergency CS
Avoid epidural/spinal anaesthesia
<34w → steroids
Neonatal review

Question 12

What are the red flags for admission for maternal sepsis

Answer 12

Pyrexia >38
Sustained tachycardia >90bpm
Breathlessness, RR >20
Abdominal or chest pain
Diarrhoea and/or vomiting
Uterine or renal angle pain and tenderness
Generally unwell or unduly anxious or distressed

Question 13

What is the management for postpartum sepsis

Answer 13

Sepsis 6
Abx: piperacillin/tazobactam OR carbapenem
+ clindamycin

Question 14

What is the specific management for endometritis

Answer 14

1. Admit
2. Fluids + Broad spectrum antibiotics
3. Evacuation or retained products of conception (ERPC) or Dilatation and curettage (DNC)

Question 15

What is the specific management for mastitis

Answer 15

Clinically unwell or no response to oral Abx within 48 hours → admit to hospital
CONTINUE breastfeeding, use manual/electric expression
Firm support with breastfeeding, cabbage leaves, ice bags
Massage of breast toward the nipple
Analgesia
Late mastitis: milk for MC&S + start flucloxacillin

Question 16

What is the prognosis of sepsis in pregnancy

Answer 16

Severe sepsis with acute organ dysfunction has a mortality rate of 20-40%, which increases to 60% if septic shock develops
Those who have had GBS have a 50% risk of having GBS in a future pregnancy

Question 17

What are the symptoms of endometritis

Answer 17

Fever, tachycardia
Midline abdominal pain, uterine tenderness
Excessive or increase in bleeding
Excess, foul-smelling, purulent lochia
Subinvolution of uterus