12) Postnatal Care - Sepsis in pregnancy and postpartum

Question 1

Definition of sepsis

Answer 1

Infection + SIRS

Question 2

Definition of severe sepsis

Answer 2

Sepsis + organ dysfunction/hypoperfusion

Question 3

Mortality rate associated with severe sepsis

Answer 3

20-40%

Question 4

Definition of septic shock

Answer 4

Hypoperfusion despite fluid resuscitation

Question 5

Mortality rate associated with septic shock

Answer 5

60%

Question 6

Risk factors for sepsis in pregnancy

Answer 6

Maternal:

• Obesity
• Diabetes
• Immunosuppression
• Anaemia
• Vaginal discharge
• Pelvic infection
• GBS infection
• GAS in close contacts
• BAME

Obstetric:

• Amniocentesis/other invasive procedures
• Cervical cerclage
• Prolonged SROM

Postnatal:
Vaginal trauma
Caesarean section
Wound haematoma
RPOC

Question 7

When should Abx given?

Answer 7

Broad spectrum within 1 hour of recognition of severe sepsis.

Question 8

What fluid resuscitation?

Answer 8

If hypotension/lactate >4 then an initial minimum 20mL/kg crystalloid.

Question 9

Target MAP if using vasopressors

Answer 9

65mmHg

Question 10

Target central venous pressure

Answer 10

8mmHg

Question 11

Target central venous O2 sats and target mixed venous O2 sats

Answer 11

Central venous >70%

Mixed venous 65%

Question 12

When should lactate be done?

Answer 12

Within 6 hours of suspected severe sepsis

Question 13

When should blood cultures be done?

Answer 13

Prior to Abx (but don’t delay waiting for results)

Question 14

What lactate value indicates tissue hypoperfusion?

Answer 14

4

Question 15

Most common organisms in pregnant women dying of sepsis

Answer 15

E. Coil

Group A Strep

Question 16

What organisms does co-amoxiclav not cover?

Answer 16

MRSA and pseudomonas

Question 17

What organisms does metronidazole cover?

Answer 17

Anaerobes only

Question 18

What does Clindamycin do?

Answer 18

Covers most Gram +vets and also anaerobes. Switches off exotoxins production.

Question 19

What does tazocin/meropenem not cover?

Answer 19

MRSA

Question 20

What does gentamicin not cover?

Answer 20

Strep & Anaerobes.

Question 21

When can intravenous immunoglobulin be used?

Answer 21

Severe invasive strep or staph infection if other therapies have failed.

Question 22

What constitutes maternal pyrexia in labour?

Answer 22

Temp >38 or >37.5 on 2 occasions 2 hours apart

Question 23

When to do continuous CTG in labour?

Answer 23

Presence of maternal pyrexia or sepsis

Question 24

Notification/contacts for GAS

Answer 24

Invasive GAS notifiable. Household contacts should seek medical attention if symptoms develop - may warrant antibiotic prophylaxis. Healthcare workers exposed to respiratory secretions should be considered for Abx prophylaxis.

Question 25

What percentage of pharyngitis is caused by GAS?

Answer 25

10%

Question 26

What are the Centor criteria for antibiotics in pharyngitis?

Answer 26

Fever
Tonsillitis exudate
No cough
Tender anterior cervical lymphadenopathy

Question 27

Red flag triggers for sepsis

Answer 27

Pyrexia > 38
HR > 90
RR > 20
Abdo/chest pain
Diarrhoea/vomiting
Uterine/renal angle pain + tenderness
Generally unwell/unduly anxious/upset

Question 28

Diagnostic criteria for staphylococcal toxic shock

Answer 28

(Probable = 4/5 criteria met, Confirmed=all 5 criteria met)

1. Fever >= 39.9
2. Diffuse macular erythroderma
3. Desquamation (10-14d after onset of illness)
4. Hypotension (systolic < 90mmHg)
5. Three or more of the following systems involved:
   - GI - vomiting/diarrhoea
   - Muscular - myalgia or elevated CK
   - Mucous membranes - vaginal/oropharyngeal/conjunctival hyperaemia
   - Renal - Cr 2 x ULN
   - Hepatic - Bilirubin 2 x ULN
   - Haematological - Platelets <100
   - CNS - disorientation or altered consciousness

Question 29

Criteria for diagnosis of streptococcal toxic shock syndrome

Answer 29

Probable - meets clinical case definition plus isolation from no-sterile site (throat, vagina, sputum)

Definite - meets clinical case definition plus isolation from sterile site (blood, CSF, peritoneal fluid, tissue biopsy)

1. Hypotension
2. Two or more of:
   - Renal impairment Cr >176
   - Coagulopathy platelets <100 or DIC
   - Liver (ALT/AST/Bili 2 x ULN)
   - ARDS
   - Generalised erythematous macular rash (10%) - may desquamate
   - Soft tissue necrosis (nec fas, myositis, gangrene)

Question 30

Guideline diagnostic criteria for sepsis: Temperature.

Answer 30

> 38

<36

Question 31

Guideline diagnostic criteria for sepsis: HR

Answer 31

> 100

Question 32

Guideline diagnostic criteria for sepsis: RR

Answer 32

> 20

Question 33

Guideline diagnostic criteria for sepsis: Fluid balance

Answer 33

Positive fluid balance >20ml/kg over 24 hours

Oliguria <0.5ml/kg/hr for at least 2 hours

Question 34

Guideline diagnostic criteria for sepsis: Glucose

Answer 34

Plasma glucose >7.7 (in the absence of diabetes)

Question 35

Guideline diagnostic criteria for sepsis: WCC

Answer 35

> 12
<4
Normal but with >10% immature forms

Question 36

Guideline diagnostic criteria for sepsis: CRP

Answer 36

> 7

Question 37

Guideline diagnostic criteria for sepsis: Blood pressure

Answer 37

Systolic <90
MAP <70
Systolic pressure decrease >40

Question 38

Guideline diagnostic criteria for sepsis: Lactate

Answer 38

4

Question 39

Guideline diagnostic criteria for sepsis: Arterial oxygen

Answer 39

PaO2/FiO2<40kPa (severe if <33.3 in absence of pneumonia or 26.7 in presence of pneumonia)

Question 40

Guideline diagnostic criteria for sepsis: Creatinine

Answer 40

Rise of >44.2

overall >176 (Severe)

Question 41

Guideline diagnostic criteria for sepsis: Coagulation

Answer 41

INR >1.5, APTT >60s

Question 42

Guideline diagnostic criteria for sepsis: Platelets

Answer 42

<100

Question 43

Guideline diagnostic criteria for sepsis: Bilirubin

Answer 43

> 70

Question 44

Guideline diagnostic criteria for sepsis: Bowels

Answer 44

Ileus