1. Max Brinsmead MB BS PhD May 2015
Maternal Sepsis
Max Brinsmead MB BS PhD
May 2015

2. 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

4. 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

5. 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

6. Organisms Involved Anaerobic Organisms Gram Negatives Gram Positives
Bacteroides
Streptococci
Peptostreptococci
These are all commensal in the bowel (and vagina) but seriously pathogenic in the higher genital tract and Blood
Gram Negatives
E Coli
Klebsiella
Salmonella
Proteus
Pseudomonas
Gram Positives
Streptococci Gp B
Streptococci Gp A
Staphylococci
Clostridia

7. The Septic Cascade

8. Clinical Features Then Pre terminal 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

9. 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

10. 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

11. 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

12. 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 to 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

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