Puerperal sepsis Flashcards
Definition of puerperal sepsis.
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)
Define septic shock.
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)
Describe a screening tool for maternal sepsis.
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.
What is SOFA and omSOFA?
Why is it important?
- 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:
- Respiratory PaO2/FiO2 <400
- Platelets <150
- bilirubin >20
- creatinine >90
- MAP <70
- Altered mental state / drowsy
What are the clinical criteria of septic shock?
- Inotrope support required to maintain MAP ≥65 despite adequate fluid resuscitation
- Tissue hypoperfusion as shown by lactate ≥2 despite adequate fluid resuscitation
What are the first line investigations of sepsis?
- 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
What are the common pathogens responsible for maternal sepsis?
- 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
Group A strep.
- 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
When should you consider leasing with HDU/ICU?
What are the indications for ICU admission?
- 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)
Management of sepsis.
- 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
What is the importance of the “golden Hour”?
- For each hour of delay in administering IV antibiotics in sepsis, the mortality increases by 8%
Fetal assessment in sepsis.
- CTG and USS BPP are poor markers of fetal sepsis
- Abnormal CTG findings should still prompt consideration of timing of delivery
What are the considerations for timing of delivery for maternal sepsis?
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
Treatment of influenza.
- 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
Empiric broad spectrum antibiotics for community and hospital acquired sepsis of unclear source (NZ).
Cefuroxime 1.5g IV Q8H + Metronidazole 500mg IV Q12H + Gentamicin 4-7mg/kg IV (once)
