Sepsis Flashcards
What are the red flag symptoms of maternal sepsis?
Pyrexia >38 deg C (common but its absence does not rule out sepsis)
• Hypothermia < 36 deg C (a significant finding that may indicate severe infection)
• Persistent tachycardia > 90 beats per minute.
• Tachypnoea (RR > 20 breaths / minute).
• Abdominal or chest pain
• Diarrhoea or vomiting – may indicate exotoxin production (early toxic shock)
• Rash (generalised streptococcal maculopapular rash or purpura fulminans).
Any widespread rash suggests early toxic shock syndrome, especially if conjunctival Hyperaemia or suffusion is present.
• Abdominal / pelvic pain and tenderness (severe lower abdominal pain and
severe ‘after pains’ that require frequent analgesia or do not respond to theusual analgesia are also common important symptoms of pelvic sepsis).
• Extreme patient anxiety/distress
• An abnormal or absent fetal heart may be secondary to sepsis.
What is the management of maternal sepsis within the first hour?
• High flow oxygen to achieve saturation > 94%
• Blood cultures.
• If a staph aureus suspected remove any potentially
infected devices e.g. cannulae
• Intravenous antibiotics.
• IV fluid resuscitation
• Measure lactate and Hb: ensure Hb > 70g / L
• Monitor the hourly urine output (catheterise if organ dysfunction is apparent).
• NSAIDS should be avoided for pain relief in cases of sepsis as they impede the ability of polymorphs to fight GAS infection.
• Measure and fit Graduated Compression Stockings.
• Women suspected of or diagnosed with group A Streptococcus sepsis should be isolated in a single room with ensuite facilities to minimise the risk of
spread to other women. Refer to the GAS Policy
Which investigations are warranted if maternal sepsis is suspected?
- Arterial blood gas measurement (to assess for hypoxia and measurement of
the serum lactate).
• FBC, coagulation, G&S, U&Es, LFT, CRP.
• Obtain blood cultures prior to antibiotic administration provided this does not delay antibiotic administration.
• Culture from other sites as guided by clinical suspicion e.g. MSU, HVS, wound swab, breast milk, stool, respiratory secretions, CSF, placental swabs
and neonatal swabs.
• Amniocentesis for microbiology studies may be warranted if chorioamnionitis
is suspected.
• Take a throat swab if the woman presents with a sore throat / respiratory symptoms (gel swab for bacterial MC &S (Group A streptococcus throat carriage) dry swab for influenza + respiratory viral pathogen PCR.
• Check previous and recent microbiology results as these may indicate the nature of the likely pathogen.
• Imaging studies (USS/CXR, CT scan) to identify / sample any source of infection as appropriate.
• Check the blood glucose
What are the risk factors for uterine inversion?
Fundally located adherent placenta2,3,5 Uterine atony Short umbilical cord 3,5 Primiparity2,5 Macrosomic fetus Arcuate of bicornuate uterus Ehlers – Danos and other syndromes associated with abnormal or ‘weak’ collagen Previous uterine inversion antepartum use of magnesium sulphate4
What causes uterine inversion?
Uterine inversion is almost always caused by applying cord traction before the uterus has contracted
firmly and placental separation has occurred.
What are the symptoms of uterine inversion?
acute lower abdominal pain
severe shock of neurogenic and haemorrhagic origin.
The shock is often out of proportion to the degree of blood loss. Blood loss may not occur if the placenta remains attached.
What is a First degree uterine inversion?
The fundus reaches the internal os
What is a second degree uterine inversion?
The fundus has passed through the cervix but not outside the vagina
What is a third degree uterine inversion?
The fundus is prolapsed outside the vagina
What is a fourth degree uterine inversion?
The uterus, cervix and vagina are completely turned inside out and are visible.
What is an Acute uterine inversion
Occurs within 24 hours of birth
What is an subacute uterine inversion
Occurs after 24 hours and within 30 days
What is a chronic uterine inversion
Occurs after 30 days and is rare.
What is management of a uterine inversion
- CODE BLUE – MEDICAL. Early involvement of senior obstetric and anaesthetic staff reduces mortality.
- Ensure the head of the bed is flat. The woman may remain with her legs bent or in lithotomy.
- Insert two 16 gauge intravenous cannulae. Group and cross-match 4 units of blood and order a
full blood picture. Consider performing coagulation studies. - Commence intravenous fluids
- If not already administered, withhold the oxytocic until uterine replacement is complete.
- Commence monitoring immediately - BP, RR, HR, Sats 15 minutely (more frequently if maternal conditions necessitates).
- Administer oxygen 8-12 L/min via a rebreathing mask. Insert an indwelling catheter without hindering resuscitation. Monitor urine output.
- If the uterus is successfully replaced commence an oxytocic infusion as per PPH therapeutic infusion
regimen. - If the replacement of the uterus is not possible, resuscitate the woman and transfer her to
theatre immediately. - IN THEATRE
10.1 Stabilise the woman and obtain effective anaesthesia.
10.2 Relax the uterus with either:
Glyceryl trinitrate spray 400micrograms – sublingual
OR
Terbutaline 250micrograms – subcutaneous
OR
Intravenous salbutamol up to 250 micrograms
10.3 Replace the uterus - Commence oxytocin therapy following uterine replacement
What is the Clinical Presentation of neonatal sepsis?
Respiratory distress hypotonia, lethargy pyrexia / hypothermia poor skin perfusion poor feeding / intolerance vomiting - possible bile abdominal distension full fontanelles skin lesions eyes umbilicus discharge unexplained jaundice metabolic acidosis high/low PGLs apneoa seizures neutropenia thrombocytopenia - DIC
