Chapter 6 – Management of Septicaemia and Septic Shock Antepartum, Intrapartum and Postpartum




Abstract




The incidence of sepsis death is 4.7 per 10 000 maternities.


For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 hour of admission to hospital for anyone with suspected sepsis.


Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency.


Sepsis remains an important cause of maternal morbidity and mortality.





Chapter 6 Management of Septicaemia and Septic Shock Antepartum, Intrapartum and Postpartum


Karin Leslie and Sarah Hammond




Key Facts


Sepsis remains an important cause of maternal morbidity and mortality.


Delays in diagnosis and treatment are often identified as contributory factors in maternal death due to sepsis [1].


Women with sepsis need




  • Early diagnosis



  • Rapid antibiotics



  • Review by senior doctors and midwives


Sepsis remains as one of the leading causes of maternal deaths in the United Kingdom, and approximately 50% of cases may have been avoidable by a different care.Prompt action and effective teamwork can make the difference between survival and death.



The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)


Sepsis Life-threatening organ dysfunction caused by a dysregulated host response to an infection


Septic shock Septic shock is a subset of sepsis in which underlying circulatory and cellular/metabolic abnormalities are profound enough to substantially increase mortality.


The consensus reached by the taskforce in 2016, ‘Sepsis 3’, has significantly changed the way we define sepsis. The definitions of sepsis, septic shock and organ dysfunction had remained largely unchanged for more than two decades prior to this. There has been a move away from earlier definitions that focused on a host’s systemic inflammatory response syndrome (SIRS), as SIRS criteria did not correlate with outcomes.


Septic shock is defined as the need for vasopressors to maintain mean arterial pressure >65 mm Hg after an adequate fluid bolus and a lactate >2 mmol/L. A pragmatic clinical definition outside critical care is a systolic blood pressure <90 mm Hg despite adequate fluid resuscitation.



Introduction


The incidence of sepsis death is 4.7 per 10 000 maternities.


For each maternal sepsis death, approximately 50 women have life-threatening morbidity from sepsis. The rapid progression to severe sepsis highlights the importance of following the international Surviving Sepsis Campaign guideline of early administration of high-dose intravenous antibiotics within 1 hour of admission to hospital for anyone with suspected sepsis.


Signs of severe sepsis in peripartum women, particularly with confirmed or suspected group A streptococcal infection, should be regarded as an obstetric emergency.



Key Pointers



Source of Infection


May be directly a result of pregnancy/delivery or unrelated. The source of infection (Table 6.1) may not be identified in all cases.




Table 6.1 Source of Infection (UKOSS series 2015, 365 cases of life-threatening sepsis)

























Genital tract (chorioamnionitis, endometritis, infected pelvic haematoma) 31%
Urinary tract (pyelonephritis, urinary tract infection) 20%
Wound (surgical site infection) 9%
Respiratory (pneumonia) 5%
Other (endocarditis, breast abscess, meningitis, etc.) 9%
Unknown 26%


Key Organisms





  • Streptococcus: Lancefield Groups A and B



  • Escherichia coli



  • Staphylococcus aureus



  • Coliforms



  • Antibiotic-resistant gram–negative organisms



The causal organism is seldom confirmed microbiologically when treatment is started. Culture-positive ‘sepsis’ is observed in only 30%–40% of cases even when microbiological tests are completed.



Group A Streptococcus




  • There is a 90-fold increase in risk of infection in pregnant or recently pregnant women compared with the non-pregnant population.



  • Infection can rapidly progress to severe sepsis and septic shock.



  • Group A can also cause scarlet fever and necrotising fasciitis.



  • Typically community based.



  • From 5% to 30% of the general population are asymptomatic carriers.



  • Streptococcal sore throat is one of the most common bacterial infections of childhood.



  • Easily spread by person-to-person contact or droplets.



  • Infected individuals generally worked with or had young children.



  • Contamination of the perineum is more likely when a woman or close family member have a sore throat or upper respiratory infection.



  • Advise women regarding hand hygiene before as well as after perineal hygiene.

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May 9, 2021 | Posted by in OBSTETRICS | Comments Off on Chapter 6 – Management of Septicaemia and Septic Shock Antepartum, Intrapartum and Postpartum
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