Puerperal sepsis

Question 1

Definition of puerperal sepsis.

Answer 1

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)

Question 2

Define septic shock.

Answer 2

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)

Question 3

Describe a screening tool for maternal sepsis.

Answer 3

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.

Question 4

What is SOFA and omSOFA?

Why is it important?

Answer 4

• 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:
  
  1. Respiratory PaO2/FiO2 <400
  2. Platelets <150
  3. bilirubin >20
  4. creatinine >90
  5. MAP <70
  6. Altered mental state / drowsy

Question 5

What are the clinical criteria of septic shock?

Answer 5

• Inotrope support required to maintain MAP ≥65 despite adequate fluid resuscitation
• Tissue hypoperfusion as shown by lactate ≥2 despite adequate fluid resuscitation

Question 6

What are the first line investigations of sepsis?

Answer 6

• 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

Question 7

What are the common pathogens responsible for maternal sepsis?

Answer 7

• 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

Question 8

Group A strep.

Answer 8

• 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

Question 9

When should you consider leasing with HDU/ICU?

What are the indications for ICU admission?

Answer 9

• 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)

Question 10

Management of sepsis.

Answer 10

• 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

Question 11

What is the importance of the “golden Hour”?

Answer 11

• For each hour of delay in administering IV antibiotics in sepsis, the mortality increases by 8%

Question 12

Fetal assessment in sepsis.

Answer 12

• CTG and USS BPP are poor markers of fetal sepsis
• Abnormal CTG findings should still prompt consideration of timing of delivery

Question 13

What are the considerations for timing of delivery for maternal sepsis?

Answer 13

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

Question 14

Treatment of influenza.

Answer 14

• 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

Question 15

Empiric broad spectrum antibiotics for community and hospital acquired sepsis of unclear source (NZ).

Answer 15

Cefuroxime 1.5g IV Q8H + Metronidazole 500mg IV Q12H + Gentamicin 4-7mg/kg IV (once)

Question 16

NZ empiric antibiotics for genital tract suspected source.

Answer 16

Cefuroxime 1.5g IV Q8H + Metronidazole 500mg IV Q12H

If severe sepsis add: Gentamicin 4-7mg/kg IV

OR Amox + gent + met

ADD clindamycin in GAS suspected