Recognition and Management of Maternal Sepsis: Key Observations and Intervention

1. Recognition and management of maternal sepsis

2. 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.

4. 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

5. 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

6. Australian Maternal Deaths 1972-2014

7. 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

9. 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

10. qSOFA(SOMANZ 2017) (quick sequential organ failure assessment score) • Score 2 or more • Trigger systems assessment

11. omSOFA – systems (SOMANZ) • Assesses cardiorespiratory, haematological, hepatic, renal and neurological impact • Score ≥2 to indicate systems failure

12. 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)

13. 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

14. Risk factors for group A streptococcal sepsis • Working with or having young children • Immediate postnatal period • Winter

15. Ignaz Semmelweiss1818-1865 Hungarian obstetrician 1846 – Head, First Clinic Vienna General Hospital

16. 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

17. Childbed (Puerperal) Fever

18. Causes? • Religious beliefs • Climate • Crowding • Medical students dissected the cadavers of deceased women • Colleague was stuck by a dissection scalpel – promptly died – similar findings

19. Chlorinated Handwash

20. 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

21. 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

23. What should you do next?

24. Initial management • Call for help  • Airway – high-flow O2 • Breathing • Circulation • IV access • IV fluids • Blood tests

25. Management of sepsis

26. Monitoring

27. Investigation

28. Treatment Discuss septic patients with duty anaesthetists and ICU early in their care

29. 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

30. 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

31. 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

33. 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

34. 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)

35. 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

36. 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

37. 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.

38. 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’

39. 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.

40. 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