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Maternal Sepsis

Maternal Sepsis. Max Brinsmead PhD FRANZCOG May 2012. What is Sepsis?. A life-threatening bacterial infection Usually endogenous in origin That is, arising from commensal organisms But in the wrong place Usually blood-borne & therefore generalised Can give rise to septic shock

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Maternal Sepsis

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  1. Maternal Sepsis Max Brinsmead PhD FRANZCOG May 2012

  2. What is Sepsis? • A life-threatening bacterial infection • Usually endogenous in origin • That is, arising from commensal organisms • But in the wrong place • Usually blood-borne & therefore generalised • Can give rise to septic shock • That is, inadequate perfusion of tissues • Multiple organ failure and death • It is important because it kills a large number of women

  3. Antecedents to Maternal Sepsis • Spontaneous Miscarriage • Usually incomplete • Unsafe Termination of Pregnancy • Use of nonsterile instruments • With or without traumatic damage • These result in Septic Abortion • Delivery at Term (or Pre Term) • Often with prolonged labour, Fetal Death • Or unsafe obstetric practices • But can occur spontaneously • This is called Puerperal Sepsis

  4. Risk factors for Antepartum Sepsis • Obesity • Diabetes • Anaemia • Immunospression • Urinary tract infection • Vaginal discharge/History of pelvic infection • Amniocentesis & cervical cerclage • Prolonged rupture of membranes • History of GBS infection • Family with Gp A Streptococcal infection

  5. Organisms Involved • Gram Negatives • E Coli • Klebsiella • Salmonella • Proteus • Pseudomonas • Gram Positives • Streptococci Gp B • Streptococci Gp A • Staphylococci • Clostridia • Anaerobic Organisms • Bacteroides • Streptococci • Peptostreptococci • These are all commensal in the bowel (and vagina) but seriously pathogenic in the higher genital tract and Blood

  6. The Septic Cascade

  7. Clinical Features • Initially • Tachypnoea & Tachycardia • Fever, warm extremities and flushing • Then • Hypotension • Hypothermia • Poorly perfused extremities • Pre terminal • Jaundice = Liver failure • Pulmonary oedema = Heart failure • Oliguria = Renal failure • Loss of consciousness = Brain failure

  8. Diagnosis • Requires high index of suspicion • Especially in high risk individual • Beware of unusual pain/tenderness any site • Widespread macular rash occurs with toxic shock syndrome • Be aware that progress can be very rapid • Diagnosis can be enhanced by use of a MEOWS • This is the Modified Early Obstetric Warning Chart • Measures of serum lactate useful • Lactate >4 mmol/L are diagnostic • +/- Arterial oxygen saturation

  9. Management • Infusion of large volumes of fluid - URGENTLY • At least 20 ml/Kg • Broad Spectrum Antibiotics • After taking blood for cultures • Penicillin or Cephalosporin for Gram positives • Gentamicin or equivalent for Gram negatives • Metronidazole or Clindamycin for Anaerobes • Must be IV and must be in large doses and URGENTLY • Transfuse for anaemia • Less than 7.0 G/dl • Give oxygen • Monitor BP, JVP and Urine Output

  10. A Word about Antibiotics • Requirements may vary depending upon the possible primary site of infection • And clinical circumstances... • MRSA = methicillin resistant Staph aureus • ESBL = extended-spectrum beta lactamase (producing) • Consult with local Microbiologist or Guidelines

  11. Management 2 • Surgery Required • To empty the uterus • To debride necrotic tissue • To drain abscesses • Sometimes to “clear the pelvis” • IV gamma globulins for Gram +ve exotoxins • The use of vasoactive agents e.g. Dopamine or Nor Adrenaline to raise BP is a measure of desperation • When the mortality will exceed 50% • Treat Renal, Lung and Heart Failure as required • Early involvement of multidisciplinary care is desirable • Isolation and/or treatment of contacts may be required

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