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Obstetric sepsis presentation by Dr. ranjana khanna.

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Vikram Khanna

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OBSTETRIC SEPSIS Dr Ranjana Khanna - Prayagraj Dr Sujata Dalvi - Mumbai
Obstetric sepsis presentation by Dr. ranjana khanna.
Dr Sujata Dalvi Consultant Obstetrician & Gynaecologist Mumbai Gleneagles / Saifee / Bhatia / St Elizabeth Hospitals Hon Clinical Associate Nowrosjee Wadia Maternity Hospital Treasurer Mumbai Obstetrics & Gynaecological Society (MOGS) Associate Editor of JOGI (Journal of Ob Gyn of India) President Mumbai Menopause Society Imm Past Secretary AMOGS (Association of Maharashtra Ob Gyn Societies)
Panelists Dr Komal Chavan Dr Rahul Mayekar Dr Preeti Lewis Dr Pradnya Changede Dr Prema Kania Dr Pradnya Supe Dr Reena Wani Dr Tarini Taneja
DEFINITION WHO defines Obstetric sepsis as Organ failure caused by infection during pregnancy, childbirth, post abortion or post-partum period Third most prevalent reason for maternal mortality Physiological changes in pregnancy may mimic beginning of sepsis which makes definitive diagnosis difficult RCOG Greentop guidelines say that SEPSIS ----infection + systemic manifestations of infection. SEVERE SEPSIS---- sepsis+ sepsis induced organ dysfunction/ tissue hypoperfusion SEPTIC SHOCK----persistence of tissue hypoperfusion despite fluid replacement
Clinical response arising from a nonspecific insult, including >=2 of the following: o Temperature >= 38属C or <=36属C o HR >= 90 beats/min o Respirations >= 20/min, PC02< 32 o WBC count>=12,000/mm3 or <=4,000/mm3 or >10% immature neutrophils (Band Forms) SIRS with a presumed or confirmed infectious process Severe sepsis with persistent refractory hypo tension Sepsis with >=1 sign of organ failure o Cardiovascular o Renal o Respiratory o Hepatic o Hematologic/ DIC o CNS o Metabolic acidosis What is Sepsis? A spectrum of body response and changes SIRS Systemic Inflammatory Response Syndrome Bone RC, et al. Chest 1992;101:1644 Opal SM,et al. Crit Care Med 2000;28:S81; Levy M, et al. Crit Care Med 31:2003
ETIOLOGY OF OBSTETRIC SEPSIS Septic abortion PROM / PPROM Chorioamnionitis Postpartum endometritis Wound sepsis RTI UTI Necrotising fasciitis Acute appendicitis / pancreatitis / cholecystitis
What are the risk factors for Obstetric Sepsis?
RISK FACTORS FOR OBSTETRIC SEPSIS Obesity Impaired glucose tolerance/diabetes Impaired immunity/ on immunosuppressive medication Anaemia Vaginal discharge H/O Pelvic infection H/O gr B streptococcal infection Amniocentesis/ other invasive procedures Cervical cerclage PROM GAS infection in close contacts / family members Black or other minority ethnic gr origin
What is the pathophysiology of obstetric sepsis?
PATHOPHYSIOLOGY Common organisms involved are.. Ecoli Klebsiella Group A beta haemolytic streptococcus GBS Staphylococcus Bacteroids N.Gonorrhoea C.Trachomatis Cl. Welchi Mycoplasma hominis H.Influenzae
MECHANISM These inflammatory mediators Endothelial dysfunction Increased vascular permeability Myocardial suppression Activation of coagulation cascade leading to DIC
EVOLUTION OF SEPSIS In Early Stages of Sepsis Released Vasoactive Mediators cause: Vasodilation Platelet Aggregation Capillary Plugging Endothelial Damage resulting in o Cellular Hypoxia o Lactic Acidosis o Worsening of Tissue Perfusion In Late Stages of Sepsis Poor tissue perfusion causes: Decreased Vascular resistance Decreased cardiac output Vasoconstriction Further decrease in tissue perfusion End organ damage Many cytokines cause global myocardial dysfunction, which results in septic shock
What Should Prompt recognition of Obstetric Sepsis Clinical signs suggesting sepsis includes .pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness &failure to respond to tt. But these signs may not always be present & are not related to severity of sepsis. Regular observations of P/R, B.P, R/R Temp should be recorded on MODIFIED EARLY OBSTETRIC WARNING SCORES ( MEOWS ) chart. Disease progression may be more rapid than non-pregnant state. Sepsis may cause Abdominal pain & tenderness. Severe infection may result in Preterm Labour. Toxic shock syndrome may produce confusing symptoms eg NVD, severe pain, watery discharge, rash.
What are the four pillars of sepsis?
Four pillars of septic shock management 1. Early recognition of shock state and identification of source of infection 2. Resuscitation and rapid establishment of tissue reperfusion 3. Providing support to failing organs 4. Source control including early adequate antibiotics and drainage/ debridement
Prognosis in OBSTETRIC SEPSIS SOFA score in Obstetrics..assesses the degree of organ system dysfunction of a patientThis score has a score for six major organs of the body.respiratory, cardiovascular, hepatic, coagulation, CNS, renal ..Each organ received a score ranging from 0 (normal ) to 4 ( most abnormal ) with minimum SOFA score of 0 & maximum of 24 qSOFA score in pregnancy evaluates presence of 3 clinical criteria: systolic BP <100.respiratory rate>22 & altered mental status
Red flag symptoms of sepsis High temperature New onset of confusion or altered mental state
SEPSIS SIX CARE BUNDLE GIVE 3 1OXYGENTitrate O2 to saturations of 94-98% or 88- 92% in chronic lung disease. FLUIDS Start IV fluid resuscitation if hypovolaemia500 ml bolus of isotonic crystalloids over 15 min & 30ml/kg reassessing signs of hypovolaemia. ANTIMICROBIALSIV antibiotics according to local guidelines.
TAKE 3 CULTURESTake blood cultures before starting antibiotics & consider source control. BLOODSLactate measurement , FBC ,U&E , LFT ,coag factors. URINE OUTPUTAssess urine output & cathetrise.. GOLDEN HOUR OF SEPSIS---stresses the relation between timely initiation of antibiotics & outcome each hour delay in Tt reduces sepsis survival by 7.6%.
Golden Hour of Sepsis Golden hour of sepsis is the idea that starting antibiotic treatment promptly can improve outcomes For each hour that treatment is delayed, sepsis survival decreases by 7.6% The golden hour refers to early recognition, early administration of antibiotics, and early reversal of shock state
Incidence Sepsis leading cause of maternal mortality morbidity Pregnancy related sepsis 11 % 25 40 % maternal deaths - worldwide Global National WHO 4.4 % (puerperal sepsis alone in live births) Severe sepsis acute organ dysfunction (MM 20 to 40 % - up to 60% if septic shock develops)
Why is pathophysiology different in pregnancy during sepsis ?
Pathophysiology - Sepsis In Pregnancy Maternal Immune system adaptation for development of fetus may impair maternal system to fight infection Physiological Hyperventilation due to pregnancy may cause respiratory alkalosis may not be able to buffer metabolic acidosis caused by sepsis Some of the physiological changes may mimic early septic changes making diagnosis little difficult
Investigations CULTURESTake blood cultures before starting antibiotics & consider source control BLOODSLactate measurement , FBC ,U&E , LFT ,RFTs, coag profile USG Abdomen / Pelvis MRI Chest / Cardiac evaluation
Role of Bio Markers ??
Bio markers Identify patients at early stage Differentiate sepsis from non-inflammatory pathologies Severity of condition Guiding treatment Total WBC Count CRP (C reactive protein) Procalcitonin levels WBC & CRP (non-specific for inflammation) PCT (specific for bacterial infection) Elevated Lactate levels poor prognosis
Antibiotics ??
Choice of Antibiotics Broad spectrum preferred start ASAP Depend upon culture report change Gram positive / negative / anaerobes If no improvement addition of higher antibiotics Occasionally Fungal infection Resistance to antibiotics ??
Management Bundle of Care approach ??
Bundle of Care approach Resuscitation bundle within first 6 hours associated with reduced mortality from sepsis Early recognition Essential investigations / monitoring (culture UO inv) Essential treatment (O2 IV Fluids Antibiotics) Sepsis 6 O2, blood culture, antibiotics, IV Fluids, lactate Hb, UO All within first 1 hour
Management IV Fluids Crystalloids primary choice Initial 30 ml/kg ----- later 20 ml/kg No improvement Sr lactate levels / hypotension Shift to ICU Broad spectrum antibiotics Remove sepsis Plan for Birth with ICU support
Monitoring Patient ??
Monitoring Patient Maternal Fetal monitoring Examinations Investigations Central venous line ICU USG NST Discuss Birth plan ICU in charge / Anaesthetist / NN / Colleagues
Role of Surgical Therapy ?
Surgical therapy Retained products I & D abscess Debridement necrotic tissue Pelvic mass removal SOS Hysterectomy To remove source of infection
Delivery ??
Delivery of Fetus Decision complex Source of infection gestational age fetal well- being - maternal well being Treat maternal status first stabalize Fetal monitoring (gestational age) Deliver where ?
Transfer to ICU ??
Indications ICU transfer Cardio-vascular Respiratory Renal GI liver related Neurological Miscellaneous
Managing Maternal Sepsis High degree of suspicion Quick detect maternal deterioration (bed side) Implement sepsis bundle immediately Fluid resuscitation Antibiotics Investigations (lactate) O2 UO neck-line Once stabilized find source of infection Anticipate prevent adverse pregnancy outcome
SEPTIC ABORTION Septic abortion is a serious infection of the uterus that occurs during, shortly before, or after an abortion or miscarriage. It is uncommon but may be life threateningfatality rate 0.4-0.6/100000 first trimester pregnancy losses.S/SRise in temp.,leukocytosis, lower abdominal tenderness,cervical tenderness & purulent vaginal discharge. Infection goes from endometrium---myometrium---parametrium---peritoneum. Cause is polymicrobial
Septic Abortion ?? GRADE 1.Infection localised to uterus. GRADE 2.Infection spreads beyond uterus to parametrium, tubes, ovaries, pelvic peritoneum. GRADE 3Generalised peritonitis, endotoxic shock, jaundice, acute renal failure Preventive Measures: Access to effective & acceptable contraception Access to safe legal abortion Appropriate medical management of abortion
Take Home Message Sepsis leading cause maternal mortality / morbidity Pregnant women more susceptible Physiological changes mimic changes delays diagnosis & optimal treatment Identification pathogens with proper antibiotics main key Removal of source of infection important
Obstetric sepsis presentation by Dr. ranjana khanna.
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Obstetric sepsis presentation by Dr. ranjana khanna.

  • 1. OBSTETRIC SEPSIS Dr Ranjana Khanna - Prayagraj Dr Sujata Dalvi - Mumbai
  • 3. Dr Sujata Dalvi Consultant Obstetrician & Gynaecologist Mumbai Gleneagles / Saifee / Bhatia / St Elizabeth Hospitals Hon Clinical Associate Nowrosjee Wadia Maternity Hospital Treasurer Mumbai Obstetrics & Gynaecological Society (MOGS) Associate Editor of JOGI (Journal of Ob Gyn of India) President Mumbai Menopause Society Imm Past Secretary AMOGS (Association of Maharashtra Ob Gyn Societies)
  • 4. Panelists Dr Komal Chavan Dr Rahul Mayekar Dr Preeti Lewis Dr Pradnya Changede Dr Prema Kania Dr Pradnya Supe Dr Reena Wani Dr Tarini Taneja
  • 5. DEFINITION WHO defines Obstetric sepsis as Organ failure caused by infection during pregnancy, childbirth, post abortion or post-partum period Third most prevalent reason for maternal mortality Physiological changes in pregnancy may mimic beginning of sepsis which makes definitive diagnosis difficult RCOG Greentop guidelines say that SEPSIS ----infection + systemic manifestations of infection. SEVERE SEPSIS---- sepsis+ sepsis induced organ dysfunction/ tissue hypoperfusion SEPTIC SHOCK----persistence of tissue hypoperfusion despite fluid replacement
  • 6. Clinical response arising from a nonspecific insult, including >=2 of the following: o Temperature >= 38属C or <=36属C o HR >= 90 beats/min o Respirations >= 20/min, PC02< 32 o WBC count>=12,000/mm3 or <=4,000/mm3 or >10% immature neutrophils (Band Forms) SIRS with a presumed or confirmed infectious process Severe sepsis with persistent refractory hypo tension Sepsis with >=1 sign of organ failure o Cardiovascular o Renal o Respiratory o Hepatic o Hematologic/ DIC o CNS o Metabolic acidosis What is Sepsis? A spectrum of body response and changes SIRS Systemic Inflammatory Response Syndrome Bone RC, et al. Chest 1992;101:1644 Opal SM,et al. Crit Care Med 2000;28:S81; Levy M, et al. Crit Care Med 31:2003
  • 7. ETIOLOGY OF OBSTETRIC SEPSIS Septic abortion PROM / PPROM Chorioamnionitis Postpartum endometritis Wound sepsis RTI UTI Necrotising fasciitis Acute appendicitis / pancreatitis / cholecystitis
  • 8. What are the risk factors for Obstetric Sepsis?
  • 9. RISK FACTORS FOR OBSTETRIC SEPSIS Obesity Impaired glucose tolerance/diabetes Impaired immunity/ on immunosuppressive medication Anaemia Vaginal discharge H/O Pelvic infection H/O gr B streptococcal infection Amniocentesis/ other invasive procedures Cervical cerclage PROM GAS infection in close contacts / family members Black or other minority ethnic gr origin
  • 10. What is the pathophysiology of obstetric sepsis?
  • 11. PATHOPHYSIOLOGY Common organisms involved are.. Ecoli Klebsiella Group A beta haemolytic streptococcus GBS Staphylococcus Bacteroids N.Gonorrhoea C.Trachomatis Cl. Welchi Mycoplasma hominis H.Influenzae
  • 12. MECHANISM These inflammatory mediators Endothelial dysfunction Increased vascular permeability Myocardial suppression Activation of coagulation cascade leading to DIC
  • 13. EVOLUTION OF SEPSIS In Early Stages of Sepsis Released Vasoactive Mediators cause: Vasodilation Platelet Aggregation Capillary Plugging Endothelial Damage resulting in o Cellular Hypoxia o Lactic Acidosis o Worsening of Tissue Perfusion In Late Stages of Sepsis Poor tissue perfusion causes: Decreased Vascular resistance Decreased cardiac output Vasoconstriction Further decrease in tissue perfusion End organ damage Many cytokines cause global myocardial dysfunction, which results in septic shock
  • 14. What Should Prompt recognition of Obstetric Sepsis Clinical signs suggesting sepsis includes .pyrexia, hypothermia, tachycardia, tachypnoea, hypoxia, hypotension, oliguria, impaired consciousness &failure to respond to tt. But these signs may not always be present & are not related to severity of sepsis. Regular observations of P/R, B.P, R/R Temp should be recorded on MODIFIED EARLY OBSTETRIC WARNING SCORES ( MEOWS ) chart. Disease progression may be more rapid than non-pregnant state. Sepsis may cause Abdominal pain & tenderness. Severe infection may result in Preterm Labour. Toxic shock syndrome may produce confusing symptoms eg NVD, severe pain, watery discharge, rash.
  • 15. What are the four pillars of sepsis?
  • 16. Four pillars of septic shock management 1. Early recognition of shock state and identification of source of infection 2. Resuscitation and rapid establishment of tissue reperfusion 3. Providing support to failing organs 4. Source control including early adequate antibiotics and drainage/ debridement
  • 17. Prognosis in OBSTETRIC SEPSIS SOFA score in Obstetrics..assesses the degree of organ system dysfunction of a patientThis score has a score for six major organs of the body.respiratory, cardiovascular, hepatic, coagulation, CNS, renal ..Each organ received a score ranging from 0 (normal ) to 4 ( most abnormal ) with minimum SOFA score of 0 & maximum of 24 qSOFA score in pregnancy evaluates presence of 3 clinical criteria: systolic BP <100.respiratory rate>22 & altered mental status
  • 18. Red flag symptoms of sepsis High temperature New onset of confusion or altered mental state
  • 19. SEPSIS SIX CARE BUNDLE GIVE 3 1OXYGENTitrate O2 to saturations of 94-98% or 88- 92% in chronic lung disease. FLUIDS Start IV fluid resuscitation if hypovolaemia500 ml bolus of isotonic crystalloids over 15 min & 30ml/kg reassessing signs of hypovolaemia. ANTIMICROBIALSIV antibiotics according to local guidelines.
  • 20. TAKE 3 CULTURESTake blood cultures before starting antibiotics & consider source control. BLOODSLactate measurement , FBC ,U&E , LFT ,coag factors. URINE OUTPUTAssess urine output & cathetrise.. GOLDEN HOUR OF SEPSIS---stresses the relation between timely initiation of antibiotics & outcome each hour delay in Tt reduces sepsis survival by 7.6%.
  • 21. Golden Hour of Sepsis Golden hour of sepsis is the idea that starting antibiotic treatment promptly can improve outcomes For each hour that treatment is delayed, sepsis survival decreases by 7.6% The golden hour refers to early recognition, early administration of antibiotics, and early reversal of shock state
  • 22. Incidence Sepsis leading cause of maternal mortality morbidity Pregnancy related sepsis 11 % 25 40 % maternal deaths - worldwide Global National WHO 4.4 % (puerperal sepsis alone in live births) Severe sepsis acute organ dysfunction (MM 20 to 40 % - up to 60% if septic shock develops)
  • 23. Why is pathophysiology different in pregnancy during sepsis ?
  • 24. Pathophysiology - Sepsis In Pregnancy Maternal Immune system adaptation for development of fetus may impair maternal system to fight infection Physiological Hyperventilation due to pregnancy may cause respiratory alkalosis may not be able to buffer metabolic acidosis caused by sepsis Some of the physiological changes may mimic early septic changes making diagnosis little difficult
  • 25. Investigations CULTURESTake blood cultures before starting antibiotics & consider source control BLOODSLactate measurement , FBC ,U&E , LFT ,RFTs, coag profile USG Abdomen / Pelvis MRI Chest / Cardiac evaluation
  • 26. Role of Bio Markers ??
  • 27. Bio markers Identify patients at early stage Differentiate sepsis from non-inflammatory pathologies Severity of condition Guiding treatment Total WBC Count CRP (C reactive protein) Procalcitonin levels WBC & CRP (non-specific for inflammation) PCT (specific for bacterial infection) Elevated Lactate levels poor prognosis
  • 29. Choice of Antibiotics Broad spectrum preferred start ASAP Depend upon culture report change Gram positive / negative / anaerobes If no improvement addition of higher antibiotics Occasionally Fungal infection Resistance to antibiotics ??
  • 31. Bundle of Care approach Resuscitation bundle within first 6 hours associated with reduced mortality from sepsis Early recognition Essential investigations / monitoring (culture UO inv) Essential treatment (O2 IV Fluids Antibiotics) Sepsis 6 O2, blood culture, antibiotics, IV Fluids, lactate Hb, UO All within first 1 hour
  • 32. Management IV Fluids Crystalloids primary choice Initial 30 ml/kg ----- later 20 ml/kg No improvement Sr lactate levels / hypotension Shift to ICU Broad spectrum antibiotics Remove sepsis Plan for Birth with ICU support
  • 34. Monitoring Patient Maternal Fetal monitoring Examinations Investigations Central venous line ICU USG NST Discuss Birth plan ICU in charge / Anaesthetist / NN / Colleagues
  • 35. Role of Surgical Therapy ?
  • 36. Surgical therapy Retained products I & D abscess Debridement necrotic tissue Pelvic mass removal SOS Hysterectomy To remove source of infection
  • 38. Delivery of Fetus Decision complex Source of infection gestational age fetal well- being - maternal well being Treat maternal status first stabalize Fetal monitoring (gestational age) Deliver where ?
  • 40. Indications ICU transfer Cardio-vascular Respiratory Renal GI liver related Neurological Miscellaneous
  • 41. Managing Maternal Sepsis High degree of suspicion Quick detect maternal deterioration (bed side) Implement sepsis bundle immediately Fluid resuscitation Antibiotics Investigations (lactate) O2 UO neck-line Once stabilized find source of infection Anticipate prevent adverse pregnancy outcome
  • 42. SEPTIC ABORTION Septic abortion is a serious infection of the uterus that occurs during, shortly before, or after an abortion or miscarriage. It is uncommon but may be life threateningfatality rate 0.4-0.6/100000 first trimester pregnancy losses.S/SRise in temp.,leukocytosis, lower abdominal tenderness,cervical tenderness & purulent vaginal discharge. Infection goes from endometrium---myometrium---parametrium---peritoneum. Cause is polymicrobial
  • 43. Septic Abortion ?? GRADE 1.Infection localised to uterus. GRADE 2.Infection spreads beyond uterus to parametrium, tubes, ovaries, pelvic peritoneum. GRADE 3Generalised peritonitis, endotoxic shock, jaundice, acute renal failure Preventive Measures: Access to effective & acceptable contraception Access to safe legal abortion Appropriate medical management of abortion
  • 44. Take Home Message Sepsis leading cause maternal mortality / morbidity Pregnant women more susceptible Physiological changes mimic changes delays diagnosis & optimal treatment Identification pathogens with proper antibiotics main key Removal of source of infection important