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Postnatal Sepsis & Postnatal Problems - Coggle Diagram
Postnatal Sepsis & Postnatal Problems
Sepsis Background
Definitions
Postnatal Sepsis
A life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion, or postpartum period
Sepsis
The presence of infection and the systemic manifestations of the infection
Severe sepsis
Combination of sepsis and sepsis induced-organ dysfunction or tissue hypoperfusion
Septic Shock
Persistent hypoperfusion despite adequate fluid replacement therapy
Epidemiology
19 cases 2014-2016
1 /214 pregnancies
Risk Factors
Obesity
Impaired glucose tolerance / diabetes
Impaired immunity / immunosuppressant medication
Anaemia
Vaginal discharge
Hx pelvic infection
Amniocentesis / invasive procedures
Cervical cerclage
Prolonged SROM
Vaginal trauma , CS, Woun haematoma
Retained products of conception
GAS infection in close contacts
Black or minority ethnic gorup
Major Pathogens
GAS - Strep pyogenes
E. coli
Staph aureus
Strep pneumonia
Clostridium septicum
Morganelle morganii
MRSA
Signs and Symptoms of Postnatal Sepsis
Signs
Tachycardia
Tachypnoea
Hypoxia
Hypotension
Oliguria
Impaired conciousness
Failure to respond to treatment
Diarrhoea
Vomiting
Breast engorgement / redness / rash
Abdominal / pelvic pain and tenderness
Wound infection
Offensive vaginal cahrge
Productive cough
Urinary symptoms
Delay in uteine involution, heavy lochia
Lethary
Reduced appetite
Rigors
Pyrexia or hypothermia
Important Hx Details
Antenatal hx
Postnatal hx
Delivery details
CS
Forceps
Manual removal of placenta
Prolonged rupture of membranes
PPH and continued vaginal bleedinng
Sx
Exposure to ill contacts
PMhx
Infection with multi-resistant organisms
GDM
Comorbidities
Sources to Consider in Unwell PP Pt
Chest
Chest infection
PE
Breast
Mastitis
Breast abcess
Abdomen
Wound infection
Endometritis
UTI
Pyelonephritis
Lower limbs
DVT
Thrombophlebitis
CNS / Epidural / Spinal Site
Abcess
Meningitis
Sepsis Management
Who needs Sepsis 6
Any woman with infection + 1,2 or 3
Immunosuppressed
On treatment with risk of neutropenia - anticancer tx
SIRS Response on IMEWS chart
RR ≥
22
HR ≥
100
Temp
<36 or ≥ 38
WCC
<4
or
> 16.9 x10^9
Bedside glucose
> 7.7mmol/L
in absence of DM
FHR
> 160
bpm
Clinically apparent new onset organ dysfunction due to infection
Signs of acute organ dysfuntion:
Alerted mental state
RR >
30
O2 sats <
90%
SBP <
100
mmHg
HR ≥
130
bpm
Mottled or ashen appearance
Non-blanching rash
Sepsis 6 → 1hr bundle
Take 3
Blood cultures
Before antimicrobial
Consider source control
Blood test including Lactate
Lactate
FBC
U&E
LFT
+/- Coag
Others guided by hx
Urine ouput
Consider catherterisation in pt with severe / septic shock
Give 3
O2
If required
Non rebreather mask with high flow O2
Titrate to 94-98%
88-92% in Chronic lung disease
IV fluid
If deficit
500ml bolus isotonic crystalloid over 15 min
up to 30ml / kg
Reassess for hypovolaemia, euvolaemia, fluid overload
IV antimicrobials
Local guidelines
Other Investigations
Urine dip
MSU C&S
Swab wounds, genital tract
Blood gas, lactate, coag
LFTs
CXR
Throat swab
Nose swab if MRSA status unknown
Remeassure lactate if ≥ 2mmol/L
3 Hour Bundle
Diagnosis and treatment reviewed with blood results / other test results
Sepsis / septic shock diagnosed and documented
Repeat lactate if ≥ 2mmol/L
Assess need for source control
Care escalated to specialist care if required
6 Hour Bundle
Review diagnosis and treatment
Is women responding, stabilising or deteriorating
Pressors
in women with fluid resistance shock
Mainting MAP > 65mmHg
Futher Indications
V/Q scan or CT pulmonary angiogram for PE
USS Doppler legs
USS / CT abdo pelvis
Colour flow Doppler scan of pelvis
Blood film
ECHO
Modified Early Obstetric Warning Score (MEOWS) / IMEWS
Respiratory Rate
Method
Assess for 60 sec following HR
Support across woman's chest
Observe depth and regularity
Document as numerical value
Normal Parameters
11-19 resp / min
Oxygen Saturation
Not routine
Assess if:
Resp rate trigger pink or yellow
Medical / obstetric condition necessitates measurement of O2 sats - HDU / resp disorder
Accuracy
Depends on adequate flow of blood through light probe
In Critical condition may be inaccurate / unobtainable
Documentation
As percentage
Normal Parameters
96-100%
Heart Rate
Method
Palpte radial artery using index finger
Support wrist across chest
Count 30 seconds if regular
60 sec if irregular
In tachy / brady must be done manually
Document numerically
Normal Parameters
60-99bpm
Blood Pressure
Recorded in IMEWS at booking at top of chart
Method
Systolic and diastolic seperate
Correct cuff size - document cuff size
If HTN check with sphygmomanometer
Document as numerical value
Document trend between systolic / diastolic with straight or dotted line
Late Sign of Deterioration
Signifies decompensation
Urinalysis
Required on admission
Frequency following admission depends
Indication
On admission for any reason as baseline
Specific disorders / treatments (HTN, DM)
Clinica symptoms eg dysuria
Frequency
Depending on clinicall assessment and diagnosis
HTN / UTI may require daily urinalysis or more frequent
No risk factors may not require daily
Documenting
Neg
Trace
+
++
+++
++++
AVPU - Neurological Response
Any fall in repsonse is significant
A - Alert and orientated to person, place, time and event
V - Responds to voice / verbal stimuli (post op recovery)
P - Responds to painful stimuli with a purposeful or non -purposeful movement
U - Unresponsive - does not repond to any stimuli
Temperature
Site
Oral
Axilla
Tympanic
According to local guidelines ensuring correct thermometer / equipement
Hypothermia
Significant
May indicate infection
Antipyretics
May mask pyrexia
Normal Parameters
36 - 37.4 °C
Pain Score
Scale of 1-10
0 - no pain
10- extreme pain
Tools
Souces of Sepsis
Endometritis
Epidemiology
More common following CS
30% following abdominal delivery
1-3% following vaginal birth
Presentation
Vaginal bleeding - common cause of 2° PPH
Lower abdo / pelvic pain
Offensive lochia
Pyrexia
Complications
Chronic endometritis
Intrauterine adhesions
Dysmenorrheoa
Subfertility
Risk Factors
Prolonged rupture of membranes
Chorioamniotis
Itrauterine death of fetus
Long labour
Anaemia
Diabetes
Obesity
Immuncompromised
Instrumental delivery
CS
Retained products of conception
Manual removal of placental
Mastitis
Complications
Breast abcesses
Necrotising faciitis
Toxic shock syndrome
Early weaning
Inability to breastfeed in future
Need for resection
Epidemiology
2005-2008 UK 2 womn died of mastitis related sepsis
GAS and S. aureus
Indication for hospital
Clinically unwell
No response to oral abx
Severe or unsual symptoms
Clinical Signs / Symptoms
Hot
Firm
Erythematous
Unilateral swelling
Tender on palpation
Axillary lymphadenopathy
Pyrexia
Infective / non-infective
Investigations
Clinical assessment usually sufficient
Swapping of purulent discharge / milk samples
Likely to be contaminated by skin commensals
Abscess
USS
Treatment
Fluid therapy
Analgesia
Antipyretics
Abx - Augmentin, Flucloxacillin
Continue breastfeeding from affected breast - failure leads to congestion and retention of milk from affected ducts
Breast Abscess
Drainage under US
Breast Abscess
Urinary Tract
Pathogens
E. coli >50%
ESBL producing coliforms - resistant to common abx (cephalosporins / co-amox) may need cabapenems / IV abx such as colistin
S. epidermidis
Proteus
S. faecalis
Klebsiella aerogenes
Pseudomonas aeruginosa
Investigation
MSU
Leucocytes
Protein
Blood
→ Send for culture
Urine C&S
Clinical Signs & Symptoms
Dysuria
Frequency
Loin tenderness
Pyrexia
Risk Factors
Prolonged indwelling catheter
Instrumental delivery
GDM
Prolonged hospital stay
Structural abnormalities of urinary tract (vesico-ureteric reflux)
Neurological conditions - spina bifida, MS
Immunosuppression
Treatment
Analgesia
Rehydration
Abx per local guidelines
Pneumonia
Management
In consultation with resp physician + medical micobiologist
Beta lactam + Macrolide - covers typical and atypical
Presentation
Haemoptysis
Pneumococcal pneumonia
Severe haemoptysis + Low peripheral WCC
Suggest PVL- associated staphylococcal necrotising penumonia
Mortality of 70% in young fit people
Investigation of cause
Sputum sample culutre
Pneumococcal antigen
Skin / Soft Tissue
In suspected bacetrial sepsis - examine for skin / soft tissue infection
Sites
IV cannulae
Injection sites
CS site
Episiotomy wounds
Management
Swap of discharge
Remove indwellin devices if suspected source
Perineal Infection
Clinical Signs and Symptoms
Acute perineal discomfort
Offensive discharge
Painful / unable to sit down a few days after delivery
Swelling, erythema
Pus from suture line
Risk Factors
Instrumental delivery
Midline episiotomy
Episiotomy extension
3rd / 4th degree tear
Vulvovaginal haematoma
Poor sterile technique during perineal repair
Poor postnatal hygiene
Investigation
Swab affected area for culture
Bloods - infection markers
Management
Advise on hygiene ,fluid intake, diet, avoidance of constipation, analgesia
ABx
Cephalosporins
Metronidazole
Co-amoxiclav
Most - heal by secondary intention
If severe wound breakdown - primary intention
Chronic infected lesions - colorectal surgeons (anal fistulae)
Caesarean Wound Infection
Clinical Signs and Symptoms
Erythema
Tenderness
Pus discharge from site
Wound haematoma
Wound dehiscence (opening)
Pain
Risk Factors
Obesity
Diabetes
Emergency CS - prolonged labour, mulit VE, less attention to sterility
MRSA status
Complications
Spreading cellulitis
Necrotising fasciitis
Treatment
Prophylaxis at time of CS
ABx
Cephalosporins
Co-amox
Metronidazole
Large wound haematoma - evacuation, excision, refashioning of wound (if tissue viability a concern)
May need plastic surgeons
Vaccum dressing
Gastroenteritis
Pathogens
Salmonella
Campylobacter
C difficile
Manage symptomatically
Pharyngitis
10% GAS
Most viral
Infection related to Regional Anaethesia
Spinal abcess very rare
Complications
Cauda equina damage
Neural compression
Postnatal Problems
Secondary PPH
Causes
Endometritis
Retained placental tissu
Abnormal involution of placental site
Pseudoaneurysms and ateriorvenous malformation
Management
Resus
Establish cause
Follow algorithm
Investigations
Vaginal swab if pyrexic
Sepsis protocol
US pelvis - exclude retained placental tissue
ABX for endometritis
Surgical evacuation - increased risk of uterine perf - done under US guidanec
Thromboembolic disease
Risk assessment performed following delivery
Investigation and management same as during pregnancy
Psychiatric Problems
Hypertensive Complications
Follow up HTN during pregnancy to ensure full resolution
PET
Educate increased risk of CVD, renal disease
Recommend BP checks with GP
Essential HTN
Pre-conecptual councelling - some antihypertensives c/i in pregnancy
Urinary Retention
Epidemiology
Common after delivery
Usually painful - may not be after epidural
Presentation
Frequency
Stress incontinence
Severe abdominal pain
Investigation
Strict fluid charts
Abdominal palpation
Post micturition US can assess residual volume non-invasively
