Maternal Sepsis

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

17. What do you do now?

18. 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

19. 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++.

20. 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

21. 4-7 hours Post-Op01.00 to 04.00 Temp PR BP Urine output <0.5mls/hr RR

22. 4-7 hours Post-Op01.00 to 04.00 Lactate 3.0

23. 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

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

25. 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

26. 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

27. 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