Transcript Ovarian Tumours

Maternal Sepsis
Max Brinsmead MB BS PhD
May 2015
What is Sepsis?
A life-threatening bacterial infection
Usually endogenous in origin
• That is, arising from commensal organisms
• But in the wrong place
Usually blood-borne & therefore generalised
Can give rise to septic shock
• That is, inadequate perfusion of tissues
• Multiple organ failure and death
It is important because it kills a large number of
women
Antecedents to Maternal Sepsis
Spontaneous Miscarriage
• Usually incomplete
Unsafe Termination of Pregnancy
• Use of nonsterile instruments
• With or without traumatic damage
These result in Septic Abortion
Delivery at Term (or Pre Term)
• Often with prolonged labour, Fetal Death
• Or unsafe obstetric practices
• But can occur spontaneously
This is called Puerperal Sepsis
Risk factors for Antepartum
Sepsis
Obesity
Diabetes
Anaemia
Immunospression
Urinary tract infection
Vaginal discharge/History of pelvic infection
Amniocentesis & cervical cerclage
Prolonged rupture of membranes
History of GBS infection
Family with Gp A Streptococcal infection
Organisms Involved
Gram Negatives
•
•
•
•
•
E Coli
Klebsiella
Salmonella
Proteus
Pseudomonas
Gram Positives
•
•
•
•
Streptococci Gp B
Streptococci Gp A
Staphylococci
Clostridia
Anaerobic Organisms
• Bacteroides
• Streptococci
• Peptostreptococci
These are all commensal
in the bowel (and vagina) but
seriously pathogenic in the
higher genital tract and
Blood
The Septic Cascade
Clinical Features
Initially
• Tachypnoea & Tachycardia
• Fever, warm extremities and flushing
Then
• Hypotension
• Hypothermia
• Poorly perfused extremities
Pre terminal
•
•
•
•
Jaundice = Liver failure
Pulmonary oedema = Heart failure
Oliguria = Renal failure
Loss of consciousness = Brain failure
Diagnosis
Requires high index of suspicion
• Especially in high risk individual
• Beware of unusual pain/tenderness any site
• Widespread macular rash occurs with toxic shock syndrome
Be aware that progress can be very rapid
Diagnosis can be enhanced by use of a MEOWS
• This is the Modified Early Obstetric Warning Chart
Measures of serum lactate useful
• Lactate >4 mmol/L are diagnostic
• +/- Arterial oxygen saturation
Management
Infusion of large volumes of fluid - URGENTLY
• At least 20 ml/Kg
Broad Spectrum Antibiotics
•
•
•
•
•
After taking blood for cultures
Penicillin or Cephalosporin for Gram positives
Gentamicin or equivalent for Gram negatives
Metronidazole or Clindamycin for Anaerobes
Must be IV and must be in large doses and URGENTLY
Transfuse for anaemia
• Less than 7.0 G/dl
Give oxygen
Monitor BP, JVP and Urine Output
A Word about Antibiotics
Requirements may vary depending upon the
possible primary site of infection
And clinical circumstances...
– MRSA = methicillin resistant Staph aureus
– ESBL = extended-spectrum beta lactamase (producing)
Consult with local Microbiologist or Guidelines
Management 2
Surgery Required
•
•
•
•
To empty the uterus
To debride necrotic tissue
To drain abscesses
Sometimes to “clear the pelvis”
IV gamma globulins for Gram +ve exotoxins
The use of vasoactive agents e.g. Dopamine or Nor Adrenaline t
raise BP is a measure of desperation
• When the mortality will exceed 50%
Treat Renal, Lung and Heart Failure as required
Early involvement of multidisciplinary care is desirable
Isolation and/or treatment of contacts may be required
Any Questions or Comments?
Please leave a note on the Welcome Page to this website