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Life Threatening Maternal and Perinatal Infections. Medical Legal Issues in Obstetrics Practice November 19-20, 2009 Ronald S. Gibbs, MD Professor, Department of Obstetrics and Gynecology Associate Dean, Continuing Medical Education. Learning Objectives.
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Life Threatening Maternal and Perinatal Infections Medical Legal Issues in Obstetrics Practice November 19-20, 2009 Ronald S. Gibbs, MD Professor, Department of Obstetrics and Gynecology Associate Dean, Continuing Medical Education
Learning Objectives At the completion of this presentation, in the learner’s practice, she/he will • Know how to recognize sepsis early in the course. • Know how to institute effective therapy promptly. • Know when surgical intervention is needed. • Know how and when to screen for Group B Streptococci (GBS) among pregnant women. • Know which antibiotics to use for GBS prophylaxis among women who can not receive penicillin.
The Obstetrician Gynecologist and Sepsis • Most OBGYNs see sepsis infrequently or rarely. • Patient survival depends upon early critical decision making. • Sepsis/infections are important causes of death among OBGYN patients.
Causes of Pregnancy-Related Death: Livebirth in U.S. For Livebirth, N = 797, 1987-1990, Berg et al (CDC), O&G 1996;88:1-7
Recent Definitions Describing Sepsis and Related Conditions From Sweet RL & Gibbs RS "Infectious Diseases of the Female Genital Tract," 5th ed 2009.
Epidemiology of Sepsis, 1979 to 2000, United States Martin GS et al. NEJM 2003; 348:1546-54
Clinical Manifestation of Sepsis Temperature instability Altered sensorium: Combativeness, confusion, disorientation, impaired judgment. Flushing, peripheral vasodilation Pulmonary: ARDS (in 25-50% with septic shock):tachypnea, dyspnea, stridor, cyanosis, pulmonary edema Cardiac: Tachycardiaarrhythmiaischemia, even MI
Clinical Manifestation of Sepsis Hematologic: DIC, thrombocytopenia, spontaneous bleeding. Abdominal/pelvic: Intestinal obstruction, evisceration, jaundiceperitonitis and abscess Wound: Cellulitis, abscess, necrotizing fasciitis, Meleney’s gangrene, myonecrosis. Renal: Oliguria, anuria, pyuria
***Hypovolemia ***Hypovolemia ***Hypovolemia *Pulmonary Embolism *Amniotic Fluid Embolism *Diabetic Ketoacidosis *Cardic Tamponade *Aortic Dissection *C. difficile Colitis *Hemorrhagic Pancreatitis *Infected Vascular Catheter *Cardiogenic Shock Differential Diagnosis of Sepsis
Management of Sepsis • Admission to ICU (unless to OR first) • Support the organ systems • Eradicate the infection • Most common avoidable errors leading to death: • Failure to use appropriate antibiotic • Failure to institute appropriate drainage
Evidence-Based Management of Severe Sepsis and Septic Shock • Dellinger RP, Levy MM, Carlet JM. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med 2008;36:296-327.
Management of Sepsis: Surgical Eradication of Infection This is the critical decision of the obstetrician gynecologist: • When to operate and • What procedure to do.
2002 GBS Prevention Guidelines • Recommend screen based approach only. • Change alternative antibiotics for penicillin allergic patients. • More specific recommendations for clinical scenarios.
2002 GBS Screen Based Approach • All pregnant women should be screened at 35-37 weeks’ gestation for vaginorectal GBS colonization. At time of labor or ROM, intrapartum chemoprophylaxis (IPC) should be given to pregnant women identified as GBS carriers. (A-II)
2002 GBS Screen Based Approach • If result of GBS culture not known at time of labor, give IPC if: • < 37 weeks’ gestation or • ROM 18 hours or • T 100.4F ( 38.0C) (A-II)
2002 GBS Screen Based Guidelines • Specimen Collection • Distal vagina and anorectum • Collected by patient or provider (B-II) • No speculum • Transport medium acceptable • Label “GBS culture”
2002 GBS Screen Based Approach • Laboratory Processing • Inoculate into selective broth medium. (eg LIM or Trans-Vag) (A-II) • Methods provided for susceptibility to clinda/erythro for GBS from penicillin allergic women. • Labs “should report results to site of delivery and provider.”
2002 GBS Screen Based Approach • Inform patients of results and recommended intervention. • In absence of GBS bacteriuria, do not treat GBS genital colonization before intrapartum period. (D-I)
2002 GBS Screen Based Guidelines • Penicillin G: Drug of choice. • Ampicillin: Alternative. • For penicillin allergy: • Clindamycin/erythromycin no longer drugs of choice.
2002 GBS Screen Based Guidelines • Patients with PCN allergy, not at high risk for anaphylaxis: • Cefazolin, 2gm IV then 1gm every 8 hours until delivery. (B-III)
2002 GBS Screen Based Guidelines • Patients with PCN allergy at high risk for anaphylaxis: • GBS susceptible: Clinda, 900 mg IV q 8h OR Erythro, 500 mg IV q 6h • GBS resistant to Clinda or Erythro or unknown susceptibility: Vancomycin, 1 gm IV q 12h (C-III)
2002 GBS Guidelines- CDC Summary:If GBS isolate is resistant to EITHER erythromycin OR clindamycin and patient has high risk allergy to penicillin, then use vancomycin.
CDC Guidelines on GBSPossible Changes in 2010 • Recommendations of antibiotic selection in patients who cannot take penicillin. • Dose of penicillin. • Management of premature rupture of membranes. • Others.
References • Sweet RL & Gibbs RS “Infectious Diseases of the Female Genital Tract,” 5th ed 2009. • Martin GS et al, The epidemiology of sepsis in the United States from 1979 through 2000.NEJM 2003; 348:1546-54 • Dellinger RP, Carlet JM, et al. Surviving Sepsis Campaign International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med 2008;36:296-327. • CDC. Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC, MMWR 2002; 51 (No. RR-11): 1-24.