Sepsis in Pregnancy, Bacterial Flashcards
Which women are at risk of sepsis in pregnancy?
Risk factors for maternal sepsis in pregnancy as identified by confidential Enquiries into Maternal Deaths
1 - Obesity
2 - Impaired glucose tolerance / diabetes
3 - Impaired immunity/ immunosuppressant medication
4 - Anaemia
5 - Vaginal discharge
6 - History of pelvic infection
7 - History of group B streptococcal infection
8 - Amniocentesis and other invasive procedures
9 - Cervical cerclage
10 - Prolonged spontaneous rupture of membranes
11 - GAS infection in close contacts / family members
12 - Of black or other minority ethnic group origin
What should prompt recognition of sepsis in the pregnant woman?
- All HCP aware of symptoms & signs of maternal sepsis and critical illness & of rapid, potentially lethal course of severe sepsis and septic shock. Suspicion of significant sepsis should trigger an urgent referral to secondary care.
- Clinical signs suggestive of sepsis include one or more of following: 1 - pyrexia, 2 - hypothermia, 3 - tachycardia, 4 - tachypnoea, 5 - hypoxia, 6 - hypotension, 7 - oliguria, 8 - impaired consciousness and 9 - failure to respond to treatment. - These signs, including pyrexia, may not always be present and not necessarily related to severity of sepsis.
- Regular observations of all vital signs (temp, pulse, BP & RR) recorded on Modified Early Obstetric Warning Score (MEOWS) chart.
- All staff taking observations have annual training in use of MEOWS chart.
Clinical features suggestive of sepsis in pregnancy
1 - Fever or rigors
2 - Diarrhoea or vomiting - may indicate exotoxin production (early toxic shock)
3 - Rash (generalised streptococcal maculopapular rash or purpura fulminans)
4 - Abdominal /pelvic pain and tenderness
5 - Offensive vaginal discharge (smelly suggests anaerobes; serosanguinous suggests streptococcal infection)
6 - Productive cough
7 - Urinary symptoms
What are the appropriate investigations when sepsis is suspected?
- Blood cultures are the key investigation and should be obtained prior to antibiotic administration; however, antibiotic treatment should be started without waiting for microbiology results.
- Serum lactate: within six hours of suspicion of severe sepsis in order to guide MX. ≥4 mmol/l = tissue hypoperfusion.
- Any relevant imaging studies should be performed promptly in an attempt to confirm source of infection.
Tasks to be performed within the first six hours of the identification of severe sepsis. Modified from
the Surviving Sepsis Campaign Resuscitation ‘Bundle’ (group of therapies)3
- Obtain blood cultures prior to antibiotic administration
- Administer broad-spectrum antibiotic within one hour of recognition of severe sepsis
- Measure serum lactate
- If hypotension and/or a serum lactate >4mmol/l:initial minimum 20ml/kg of crystalloid or an equivalent. Apply vasopressors for hypotension if not responding to initial fluid resuscitation to maintain MAP > 65mmHg
- If persistent hypotension despite fluid resuscitation (septic shock) and/or lactate >4mmol/l
a. Achieve CVP of ≥8mmHg
b. Achieve central venous oxygen saturation (ScvO2) ≥ 70% or mixed venous oxygen saturation (ScvO2) ≥ 65%
Who should be involved in the collaborative care of women with sepsis?
- If sepsis suspected, regular frequent observations & MEOWS chart recommended. urgent referral to critical care team in severe or rapidly deteriorating cases, & involvement of consultant obstetrician.
- expert advice of consultant microbiologist or infectious disease physician should be sought urgently when serious sepsis is suspected.
Indications for transfer to ICU.
Cardiovascular
1 -Hypotension or
2 -raised serum lactate persisting despite fluid resuscitation, suggesting need for inotrope support
Respiratory
3 - Pulmonary oedema
4 - Mechanical ventilation
5 - Airway protection
6 - Renal Renal: dialysis
7 - Neurological: Significantly decreased conscious level
Miscellaneous
8 - Multi-organ failure
9 - Uncorrected acidosis
10 - Hypothermia
What are the commonly identified organisms, including hospital acquired infection?
- most common organisms identified in pregnant dying from sepsis: Lancefield group A beta-haemolytic Streptococcus and E.Coli.
- Mixed infections with both Gram-positive and Gram-negative organisms are common, especially in chorioamnionitis.
- Coliform infection is particularly associated with urinary sepsis, preterm premature rupture of membranes, and cerclage.
- Anaerobes as Clostridium perfringens (cause of gas gangrene) less common nowadays, with peptostreptococcus & Bacteroides spp. predominating.
What empirical and specific antimicrobial therapy should be used to treat the woman?
- Administration of intravenous broad spectrum antibiotics is recommended within one hour of suspicion
of severe sepsis, with or without septic shock. - If genital tract sepsis is suspected, prompt early treatment with a combination of high-dose broadspectrum I/V antibiotics may be lifesaving.
Antimicrobial choices and limitations of antimicrobial.
Co-amoxiclav: Does not cover MRSA or Pseudomonas, & concern increase in the risk of necrotising enterocolitis in neonates exposed in utero.
Metronidazole: Only covers anaerobes.
Clindamycin: Covers most streptococci & staphylococci, including many MRSA, & switches off exotoxin production with significantly decreased mortality. Not renally excreted or nephrotoxic.
Piperacillin–tazobactam (Tazocin) and carbapenems: Covers all except MRSA and are renal sparing (in contrast to aminoglycosides).
Gentamicin (as a single dose of 3–5mg/kg):
Poses no problem in normal renal function but if doses given regularly serum levels must be monitored.
What is the role of intravenous immunoglobulin (IVIG)?
IVIG is recommended for severe invasive streptococcal or staphylococcal infection if other therapies
have failed.
How should the fetus be monitored and when and how should the baby be delivered?
- In critically ill pregnant, birth: consider if it would be beneficial to mother or baby or both. decision on timing and mode of birth by senior obstetrician following discussion with woman if her condition allows.
- If preterm delivery anticipated, “cautious consideration” to antenatal corticosteroids for fetal lung maturity in woman with sepsis.
- During intrapartum period, continuous electronic fetal monitoring is recommended. Changes in CTG, as changes in baseline variability or new onset decelerations, must prompt reassessment of maternal MAP, hypoxia and acidaemia.
- Epidural/spinal anaesthesia avoided with sepsis & GA usually required for CS.
What prophylaxis should be considered for the neonate, other family members and healthcare workers?
- Local & national guidelines followed in consultation with local health protection unit or lead for communicable disease control.
- When mother found to have invasive group A streptococcal infection in peripartum period, neonatologist informed & prophylactic antibiotics administered to baby.
- Close household contacts of women with group A streptococcal infection: warned to seek medical attention should symptoms develop, & situation may warrant antibiotic prophylaxis.
- Healthcare workers: exposed to respiratory secretions of women with group A streptococcal infection should be considered for antibiotic prophylaxis
What infection control issues should be considered?
- Group A β-haemolytic Streptococcus and MRSA are easily transmitted via hands of healthcare workers and via close contact in households. Local infection control guidelines should be followed for hospital–specific isolation and contact precautions.
- Invasive group A streptococcal infections are notifiable & infection control team & consultant for communicable diseases should be informed.
