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Recognition and management of maternal sepsis. You are working on the postnatal ward and take routine observations on Amanda who had a normal vaginal birth yesterday of baby Riley, who weighed 3.24 kg.
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You are working on the postnatal ward and take routine observations on Amanda who had a normal vaginal birth yesterday of baby Riley, who weighed 3.24 kg. • Amanda is normally fit and well and now has three children. Her other children are 4 and 2 years old. She is breastfeeding well.
What is the likely cause of her Observations? Temp 37.5-380c RR 21-25 rpm HR 100-120 bpm SaO2 94% in room air
Sepsis • Sepsis is now the leading cause of direct maternal deaths in the UK • The onset of life-threatening sepsis in pregnancy or the puerperium can be insidious, with extremely rapid clinical deterioration, particularly where it is due to streptococcal infection • In many of the deaths women had a short duration of illness, and in some cases were moribund by the time they presented to hospital
Recognition • Clinical observations (heart rate, blood pressure, respiratory rate and temperature) should be taken early and regularly in women with suspected sepsis • Plotting clinical observations on a maternity early warning chart may help in the recognition of sepsis
Signs of sepsis • Tachycardia (HR > 100 bpm) • Raised respiratory rate (RR > 24) • High or low temp (> 38oC or < 35oC) • Hypotension (systolic BP < 90 mmHg) • Low oxygen saturations (less than 95% on air) • Poor peripheral perfusion (cap refill > 2 seconds) • Clamminess • Confusion • Rash or mottled skin
qSOFA(SOMANZ 2017) (quick sequential organ failure assessment score) • Score 2 or more • Trigger systems assessment
omSOFA – systems (SOMANZ) • Assesses cardiorespiratory, haematological, hepatic, renal and neurological impact • Score ≥2 to indicate systems failure
Symptoms of sepsis • Diarrhoea • Vomiting • Abdominal pain • Rash • Sore throat • Sputum • Vaginal discharge • Wound infection • Dysuria • Low urine output (less than 0.5 ml/kg/hr)
Group A streptococcus • The most common cause of maternal death from infection in the UK • Community-based infection • 5–30% asymptomatic carriers on throat or skin • streptococcal sore throat: one of most common bacterial infections of childhood • All maternal deaths either had, or worked with, young children
Risk factors for group A streptococcal sepsis • Working with or having young children • Immediate postnatal period • Winter
Ignaz Semmelweiss1818-1865 Hungarian obstetrician 1846 – Head, First Clinic Vienna General Hospital
Vienna General Hospital • Maternity units set up to reduce high infanticide rates • Free for socio-economically disadvantaged • But – allowed training of doctors and midwives • Clinic 1 – doctors • Clinic 2 – midwives • Alternating days
Causes? • Religious beliefs • Climate • Crowding • Medical students dissected the cadavers of deceased women • Colleague was stuck by a dissection scalpel – promptly died – similar findings
A Hero? • “Doctors are gentlemen, and gentlemen’s hands are always clean” • Fever must be due to ‘uncleanliness of the bowel’ – purging is required • Other units refused to follow suit • Louis Pasteur & Joseph Lister finally confirmed the germ theory disease and antisepsis. • Died after being beaten in an asylum • Infected wounds causing sepsis
Additional risk factors for sepsis • Retained products of conception • Manual removal • Prolonged ruptured membranes • Caesarean section • Premature labour • Obesity • Following an invasive intrauterine procedure (e.g. amnio, CVS) • Cervical suture • Impaired immunity • Diabetes mellitus • Fetal demise • Water birth
Initial management • Call for help • Airway – high-flow O2 • Breathing • Circulation • IV access • IV fluids • Blood tests
Treatment Discuss septic patients with duty anaesthetists and ICU early in their care
Sepsis in Labour Differentiate between GBS prophylaxis… • IV Benzylpenicillin 3 g loading dose, 1.8 g 4hrly • (penicillin allergy) IV Clindamycin 900 mg 8hrly …and sepsis management (eHandbook) • IV Amoxycillin 2 g, then 1 g 6hrly AND • IV Gentamycin 5 mg/kg dailyAND • IV Metronidazole 500 mg every 12 hours • (penicillin allergy) IV Clindamycin 900 mg 8hrly
Sepsis in Labour • Abnormal CTG • May be due to sepsis • Fetal scalp sampling may be falsely reassuring • May transmit infection • Consider delivery if abnormal CTG w sepsis • Epidural • Contraindicated in sepsis
Prompt IV antibiotic treatment • High-dose broad-spectrum IV antibiotic therapy in accordance with known patient allergies, should be given ASAP • Administration should not be delayed for the results of microbiological testing • If possible, take blood cultures prior to antibiotics, but the commencement of antibiotic treatment should not be delayed. • A microbiologist should be contacted early for advice • If already extremely ill, deteriorates or does not improve within 24 hours of treatment, then additional or alternative IV antibiotics such as tazocin should be used
SOMANZ Guidelines Community acquired: • amoxicillin 2 g IV Six-hourly PLUS • gentamicin 4–7 mg/kg IV§ PLUS • metronidazole 500 mg IV 12-hourly Hospital acquired • piperacillin 4 g + tazobactam 0.5 g IV 8hrly • AND consider gentamicin 4–7 mg/kg IV
Lactate • Indicates organ hypo-perfusion • Can be a sign of viscus injury • Linked to mortality 0-2.5 mmol/L 4.9%, 2.5-4.0 mmol/L 9.0% >4.0 mmol/L 28.4% (n=1278 ED admissions w sepsis. Shapiro AnnEmMed 2005)
Fluid resuscitation • Hypotension and/or an elevated serum lactate level (> 4 mmol/l) should be treated with IV fluid bolus • Give an initial minimum fluid challenge of 20 ml/kg IV crystalloid • A 75 kg septic patient should be given at least 1500 ml of intravenous crystalloid stat • If there is no improvement in the hypotension and/or the serum lactate level following the fluid bolus, the patient should be transferred to intensive care
Surviving Sepsis Campaign (SSC) UK • Consensus guidelines on the definition and management of sepsis developed in 2004 • Implementation of the ‘resuscitation bundle’ within the first 6 hours associated with reductions in mortality from sepsis • RCOG has adopted the same treatment principles within guidance on maternal sepsis
Surviving Sepsis Campaign:‘the resuscitation bundle’ Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emergency Medicine Journal. 2011 May 19;28(6):507–12.
Sepsis Six • Developed in the UK in an attempt to simplify the Surviving Sepsis Campaign guidance and improve uptake • Implementation of the Sepsis Six has been associated with reduced mortality and an increase in the implementation of the full SSC ‘resuscitation bundle’
Sepsis Six • Give 100% O2 • Take blood cultures • Give IV broad-spectrum antibiotics • Give IV fluid therapy • Measure lactate and haemoglobin • Measure hourly urine output (catheter) All within the FIRST HOUR Daniels R, Nutbeam T, McNamara G, Galvin C. The sepsis six and the severe sepsis resuscitation bundle: a prospective observational cohort study. Emergency Medicine Journal. 2011 May 19;28(6):507–12.
Summary • Be aware of sepsis and bewaresepsis • If sepsis is suspected in the community, urgent referral is indicated • The onset of life-threatening sepsis can be insidious, with extremely rapid clinical deterioration • High-dose IV antibiotics ASAP • Fluid resuscitation • Measure lactate • Early liaison with microbiology and intensive care