Infection in pregnancy

Question 1

Discuss BV in pregnancy
-Impact to pregnancy
-When to treat
-Impact of treatment

Answer 1

1. Impact to pregnancy
   -PPROM, PTB
2. When to treat
   -Treat if symptoms as would outside of pregnancy
   -Treat in early pregnancy up to 20/40. May be beneficial for some women with previous PTB
3. Impact of treatment
   -Cochrane reviews finds no improvement in outcomes with treatment

Question 2

Discuss bacterial sepsis in pregnancy
-Incidence
-Mortality rate
-Definition of sepsis
-Definition of septic shock
-Definition of puerperal sepsis

Answer 2

1. Incidence
   -11.4% of maternal deaths in Australia
2. Mortality rate
   -0.8/100,000
   -20-40% if bacterial sepsis
   -60% if bacterial septic shock
3. Definition of sepsis
   -Life threatening organ dysfunction caused by dysregulated host response to infection
   -Infection + systemic manifestation of sepsis
4. Septic shock
   -Underlying circulatory and metabolic abnormalities associated with increased mortality indicated by hypotension with MAP ,65 or lactate >2.0 despite fluid resus
5. Definition of puerperal sepsis
   -Development of sepsis after birth and until 6 weeks PP (Different from WHO def)

Question 3

Discuss scoring systems for sepsis in obstetrics
-omqSOFA
-omSOFA

Answer 3

1. omqSOFA = obstetric modified quick SOFA
   -Use for screening
   -Based on SBP <90, RR>25 and altered mentation
   -A score >2 is considered sepsis
2. omSOFA = obstetric modified SOFA
   -Use if + for sepsis by omqSOFA
   -A score of 2 or change in score of 2 or more is significant
   -Based on PaO2, plt levels, bilirubin, MAP, mental state, Cr

Question 4

Discuss fever in pregnancy
-Impact in early pregnancy
-In late pregnancy
-Neurodevelopmental outcomes

Answer 4

1. Impact in early pregnancy
   -Organogenesis related to height and duration of fever
   -Most strongly associated with neurological defects (neural tube, microcephaly, micropthalmia)
   -Associated with oral clefts and congenital heart anomalies
2. Late pregnancy
   -PTB
3. Neurodevelopment
   -Possible association with autism and developmental delay

Question 5

What are the common bacterial pathogens which cause maternal sepsis and which is the most common cause of maternal death from sepsis.

Answer 5

-E.coli - most common cause of infection
-GAS (Strep pyogenes) - most common cause of maternal death from sepsis
-GBS (Step agalactiae)

Question 6

Discuss GAS in pregnancy (7 points)

Answer 6

1. GAS = streptococcus pyogenes
2. Usually asx carriage on skin or throat
3. Causes 50% of maternal septic deaths in NZ and 25% in AUs
4. 20 x increased risk in pregnancy
5. 1:10 GAS infections healthcare related
6. Treat in isolated room
7. Treat Healthcare workers

Question 7

Discuss management of maternal sepsis (5)

Answer 7

1. Recognise - omqSOFA and omSOFA
2. Resuscitate
   -Maintain airway and oxygenate if required
   -IV access
   -Blood tests and cultures from blood + other sites
   -IVF - crystalloid
3. Respond
   -ABX (cef, Met, Gent or clinda and gent if allergy) within 60mins. DO NOT DELAY
   -Consider IVIG in GAS to neutrolise exotoxins
4. Re-assess
   -Look for deterioration (change in omSOFA)
   -Assess fetal wellbeing depending on gestation
   -Step up to ICU if required
5. Consider VTE prophylaxis with dose adjustment if renal impairment

Question 8

Discuss timing and mode of delivery for maternal bacterial sepsis
-Intrauterine infection (5 points)
-Extrauterine infection (2 points)
-If goes into premature labour (1 point)
-Perimortem CS (3 points)

Answer 8

1. Intrauterine infection
   -Consider delivery regardless of gestation
   -If previable can consider IOL to manage source control
   -Consider mode of delivery based on cervical favourability, chance of neonatal survival, expectation of rapid delivery
   -Consider steroids but don’t delay delivery for this.
   -Risk of cerebral palsy and encephalopathy - 2.4 in intrauterine infection
2. Extrauterine infection
   -Aim to treat maternal sepsis and prolong gestation
   -Consider delivery in term pregnancies if pregnancy is impacting maternal response to infection
3. Premature labour
   -Consider tocolytics for steroids unless intrauterine infection
4. Perimortem CS
   -Perform in event of maternal cardiopulmonary arrest >20 weeks or if uterus palpable above umbilicus
   -Commence immediately. Don’t wait 4 mins, Better outcomes with shorter intervals
   -Associated with better neonatal outcomes

Question 9

What are the risk factors for maternal sepsis (11)

Answer 9

-Obesity
-Impaired glucose tolerance
-Immunosupression
-Anaemia
-Vaginal discharge
-History of pelvic infection
-Hx of GBS infection
-Cervical cerclage
-Invasive procedures (Amnio)
-PROM
-GAS in close family or contacts