1 / 27

Maternal Sepsis

Maternal Sepsis. Dr S Knowles National Maternity Hospital Holles Street Dublin. Day 1. 38 year old Para 2 pregnant woman Gestation 21+6 weeks Presented to a maternity hospital with a history of Abdominal pains/tightenings Vaginal bleeding during afternoon

rcarrillo
Download Presentation

Maternal Sepsis

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Maternal Sepsis Dr S Knowles National Maternity Hospital Holles Street Dublin

  2. Day 1 • 38 year old Para 2 pregnant woman • Gestation 21+6 weeks • Presented to a maternity hospital with a history of • Abdominal pains/tightenings • Vaginal bleeding during afternoon • She reported vaginal spotting during the morning.

  3. Obstetric history • 1999 Emergency caesarean section for fetal distress at 40+5 weeks gestation • liveborn male infant 3.09Kg • 2009 Emergency caesarean section at 26+5 weeks gestation following preterm rupture of membranes 5 days previously and maternal pyrexia • liveborn male infant 750g • neonatal death at 6 days of age.

  4. Current Pregnancy • Blood group O Rh+; Rubella immune; HIV, hepatitis B and syphilis negative • Weight 71.6Kg; BMI 25.7 • Presented at 6, 6+5, 8 and 13 weeks gestation with vaginal bleeding – scan’s confirmed viable pregnancy. • Attended the high-risk clinic for preterm birth at 10, 14, 16, 18, 19, 20 weeks gestation • MSU normal • Chlamydia trachomatis/NeisseriagonorrhoeaeDNA not detected; • HVS: no bacterial vaginosis, scanty Candida; Group B Streptococcus detected. • Cervical length monitored every 2 weeks • Cervical length 1 cm (short) at 19+6 weeks gestation. • Cervical cerclage inserted 20 weeks gestation. • Presented 20+3 weeks gestation, passing small vaginal clots – scan confirmed viable pregnancy. Admitted to antenatal ward. Bleeding stopped, no pains. Good fetal movement felt.

  5. Past Medical History • Left oophorectomy (cyst) 2006 • Tummy tuck 2011 • Cigarettes 2/day • No known drug allergies

  6. Examination on Admission • Temp 35.5oC; PR 101bpm; BP 146/86; RR 17; O2 sats 97% • Pain score 6/10 • Urinalysis: ++blood; +leucocytes • Transabdominal ultrasound: • fetus active; fetal heart 155bpm • liquor volume normal • placenta posterior upper

  7. Admit for observation

  8. Day 2 • Gestation 22 weeks. • 06.55 hours • Preterm pre-labour rupture of membranes (PPROM) • Pains ceased. • Vitals normal. • Scan: oligohydramnios and fetal heart present.

  9. What tests / investigations?

  10. Day 2: PPROM • Cervical suture removed. • HVS and suture sent for C+S. • FBC: • WCC 13.3 x 109/L; 80% neutrophils. • Hb 11.5g/dl • Platelets 215 x 109/L • Not in labour. • Fetal heart heard. • MEWS normal • Rx oral erythromycin as prophylaxis for preterm, prelabour rupture of membranes (PPROM) • Monitor vitals every 4 hours

  11. Day 3 • Gestation 22+1 weeks • Blood stained vaginal loss continues • Not in labour • Fetal heart heard • MEWS normal • Continue 4 hourly observations

  12. Day 4 • Gestation 22+2 weeks • 08.30 • Patient reports reduced fetal movements • Scan confirmed intrauterine fetal death • Induction of labour with vaginal mifepristone • MEWS normal

  13. Day 4: Induction of Labour • 13.05 • Patient feels cold • Temperature 38.1oC • PR 95 • RR 16 • BP 120/63 What would you do next?

  14. Bloods • FBC • WCC 22.3 x 109/L; neutrophils 19.71 x 109/L • Hb 12.0g/dl • Platelets 231 x 109/L • CRP: 42.3 mg/L • Septic work-up obtained • Blood cultures • MSU and HVS • Broad spectrum antibiotics • Benzylpenicillin 3g initially followed by 1.5g every 4 hours + • Gentamicin 240mg once daily + • Metronidazole 500mg every 8 hours. • IV fluids • Oxytocin commenced to speed up delivery

  15. Day 4 Continues • 20.00 • Not easy to induce. Not in labour; cervix 2cm. • Foul smelling liquor observed. • Persistent pyrexia and new onset tachycardia • O2 sats 98% • CRP = 68.3 mg/L • FBC: • WCC 23.4 x 109/L; neutrophils 20.62 x 109/L • Hb 12.4g/dl • Platelets 211 x 109/L • See MEWS

  16. What do you do now?

  17. Consultant Obstetrician contacted Microbiologist regarding antibiotic therapy which was commenced 7 hours previously • Change to: • Meropenem 2g 8 hourly • Gentamicin (increase dose to 360mg from 240mg; weight 71.6Kg at booking) • To theatre for delivery as not in labour • Source control

  18. Theatre • 20.52 • Temperature 40.3oC • PR 138 • BP 95/40 • RR 25 • Lactate 1.6 • Cervix 2 cm. • Dilatation and evacuation of uterus, pus++.

  19. HDU: 2 hours Post-Op23.00 Temp • Tachypnoea 35 • Lactate 3.0 • urine output 660 mls/hr • FBC • WCC 2.5 x 109/L • Hb 11.5g/dl • Platelets 136 x 109/L • APTT 39.6; ratio 1.5 • Total bilirubin 17 PR BP RR

  20. 4-7 hours Post-Op01.00 to 04.00 Temp PR BP Urine output <0.5mls/hr RR

  21. 4-7 hours Post-Op01.00 to 04.00 Lactate 3.0

  22. What do you do now? 7 hours post-op Rx meropenem and gentamicin Blood pressure persistently borderline <90/60mm/Hg Tachypnoea Lactate remains 3.0 Urine output poor <0.5mls/kg per hour x 3 hours

  23. What was done…………. • Fluid bolus • Discuss with microbiology • Add vancomycin and clindamycin

  24. HDU Course • Remained in HDU x 48 hours gradually improving • Lactate • 2.5, 1.6, 1.9, 2.0, 1.6 • Good urine output • Lochia normal • Abdomen soft • Alert and orientated Temp PR BP RR

  25. Microbiology • Blood cultures negative • Placenta, vaginal swab and swab from fetus • E. coli • Resistant to co-amoxiclav • Susceptible to cefotaxime, gentamicin, ciprofloxacin, meropenem • E. faecalis • Susceptible to amoxycillin and vancomycin • Antibiotic therapy switched to IV cefotaxime + IV amoxycillin • Discharged on Day 10 of admission

  26. Key Points • Risk factors for maternal sepsis include • Preterm delivery (<37 weeks gestation) • Prolonged rupture of membranes (>18 hours) • Presence of foreign body e.g. cervical cerclage • Hypotension is a late finding in a young person with sepsis • Polymicrobial infections and negative blood cultures occur with sepsis • E. coli is the most common cause of maternal sepsis • Delivery (source control) is essential to cure chorioamnionitis

More Related