Sepsis is a very dangerous casein obstetrics

1. Dr. Madhuri Patel

2. Prevention And Management Of
Sepsis In Obstetrics And
Gynaecology

3. Sepsis In Obstetrics
▪ Bacterial infections during labour and the puerperium are among
the leading causes of maternal mortality worldwide, accounting for
about 1/10 of the global burden of maternal deaths.
▪ Leading cause of maternal deaths in the UK between 2006-2008.
▪ Long term disabilities e.g. chronic pelvic pain, fallopian tube
blockage, secondary infertility.
▪ New-born mortality – estimated 1 million new-born deaths are
associated with such infections annually.

4. Definition
▪ SEPSIS: Life threatening organ dysfunction due to a dysregulated host
response to infection.
▪ SEPTIC SHOCK: Persistent hypo-perfusion despite adequate fluid
replacement therapy.
▪ MATERNAL PERIPARTUM INFECTION (WHO
recommendations for prevention and treatment of maternal peripartum
infections, 2015)
Infection of the genital tract occurring at any time between the onset of
rupture of membranes or labour and the 42nd day postpartum in which
two or more of the following are present: pelvic pain, fever, abnormal
vaginal discharge, abnormal smell/foul odour discharge or delay in
uterine involution.
▪ Common terms : maternal sepsis, puerperal sepsis, genital tract sepsis

5. Diagnostic Criteria In Suspected/Confirmed
Infection
General
▪ Core temperature >38.3oC or <36oC
▪ HR >90bpm
▪ Tachypnea
▪ Altered mental status
▪ Significant oedema or positive fluid balance ( >20ml/kg over
24hrs)
▪ Hyperglycaemia ( plasma glucose >110mg/dl or 7.7mmol/l )

6. Diagnostic Criteria In Suspected/Confirmed
Infection
Inflammatory
▪ TLC >12,000/uL or <4,000/uL
▪ Normal white cell count with
>10% immature forms
▪ Plasma CRP >2SD above normal
value
▪ Plasma procalcitonin >2SD
above normal value
Hemodynamic
▪ SBP <90mmHg
▪ MAP <70mmHg
▪ SBP decrease >40mmHg in
adults or <2SD below normal for
age
▪ Cardiac index >3.5l/min/m2

7. Diagnostic Criteria In Suspected/Confirmed
Infection
Organ dysfunction
▪ PaCO2/FiO2 <300
▪ Urine output <0.5ml/kg/h
▪ Creatinine increase >0.5mg/dl
▪ INR >1.5 or APTT >60s
▪ Platelet count <100,000/uL
▪ Plasma total bilirubin >4mg/dL or
>70mmol/L Tissue perfusion
Lactate >3mmol/L Decrease
capillary refill or mottling
Tissue perfusion
▪ Lactate >3mmol/L
▪ Decrease capillary refill or mottling
Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G,
SCCM/ESICM/ACCP/ATS/SIS 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.
Critical Care Med. 2003;31(4):1250–1256. Review.

8. Spectrum Of Sepsis

9. Etiology Of Obstetric Sepsis
▪ Septic abortion
▪ PROM / PPROM
▪ Chorioamnionitis
▪ Postpartum endometritis
▪ Wound sepsis
▪ Respiratory infection / Pneumonia
▪ Pyelonephritis / Urinary Tract Infection
▪ Necrotising fasciitis
▪ Acute appendicitis/ pancreatitis/ cholecystitis

10. Risk Factors
▪ Obesity
▪ GDM/DM
▪ Anaemia
▪ Vaginal Discharge
▪ H/O Pelvic Infection
▪ H/O GBS Infection
▪ Amniocentesis And Other
Invasive Procedures
▪ Cervical Cerclage
▪ Prolonged Ruptured Of
Membranes
▪ Close Contact With People With
Gas Infection
▪ Impaired Immune Systems
Because Of Illness Or Drugs,
Chemotherapy, Long Term
Steroid Therapy
▪ Post Splenectomy
▪ Sickle Cell Disease

11. Pathophysiology: Common Organisms
▪ E. Coli
▪ Klebsiella
▪ Group A β haemolytic
streptococcus
▪ Group B Streptococcus (GBS)
▪ Staphylococcus
▪ Bacteroids
▪ N. Gonorrhoea
▪ C. Trichomonas
 Cl. Welchii
 Mycoplasma hominis
 H. influenzae

12. Pathophysiology: Inflammatory Mediators
▪ TNF - α
▪ IL – 1 β and I L – 6
▪ Arachidonic acid metabolites (Leukotrienes, PG, Tx)
▪ Complement system
▪ Coagulation cascade
▪ Fibrinolytic system
▪ Prekallikrein
▪ Bradykinin
▪ Histamine
▪ β- endorphin / Encephalin
▪ Myocardial depressant factors.

13. Mechanism:
Inflammatory mediators cause:
▪ Endothelial dysfunction
▪ Increased vascular permeability
▪ Myocardial suppression
▪ Activation of coagulation cascade leading to DIC.

14. Evolution Of Sepsis
In Early Stage Of Sepsis
Released Vasoactive Mediators
causes:
▪ Vasodilation
▪ Platelet aggregation
▪ Capillary plugging
▪ Endothelial damage
▪ Resulting in cellular hypoxia
▪ Lactic acidosis
▪ Worsening of tissue perfusion
In Late Stage 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.

15. Investigations
▪ CBC
▪ ESR
▪ Blood Grouping And Rh Typing
▪ Urine – Routine And Microscopy, Culture and Sensitivity
▪ Blood Culture And Sensitivity
▪ Blood Gas Analysis
▪ Blood Glucose
▪ Serum electrolytes, BUN, creatinine
▪ Coagulation Profile
▪ Liver function test

16. Special Investigations
▪ Endocervical and high vaginal swab culture must be taken prior to
internal examination.
▪ The material is sent for Gram staining
▪ Culture and sensitivity both in aerobic and anaerobic medium.
▪ Ultrasonography
▪ Supine and upright x-ray of abdomen – Air, Foreign body
▪ CT, MRI – special cases to see for myometrial necrosis.

18. Summary List Of WHO Recommendations For
Prevention And Treatment Of Maternal Peripartum
Infections Context Recommendation
▪ Routine perineal/pubic shaving prior to giving vaginal birth is not
recommended.
▪ Digital vaginal examination at intervals of four hours is
recommended for routine assessment of active first stage of
labour in low-risk women.
▪ Routine vaginal cleansing with chlorhexidine during labour for the
purpose of preventing infectious morbidities is not recommended.
▪ Routine vaginal cleansing with chlorhexidine during labour in
women with group B Streptococcus (GBS) colonization is not
recommended for prevention of early neonatal GBS infection.
▪ Vaginal cleansing with povidone-iodine immediately before
caesarean section is recommended.

19. Routine Antibiotic Prophylaxis:
Not recommended:
▪ During the second or third trimester for all
women with the aim of reducing infectious
morbidity.
▪ For women in preterm labour with intact
amniotic membranes.
▪ For women with prelabour rupture of
membranes at (or near) term.
▪ for women with meconium-stained amniotic
fluid.
▪ for women undergoing operative vaginal
birth.
▪ not recommended for women with
episiotomy.
▪ for women with uncomplicated vaginal birth.
Recommended
▪ Women with group B Streptococcus (GBS)
colonization for prevention of early
neonatal GBS infection.
▪ For women with preterm prelabour
rupture of membranes.
▪ For women undergoing manual removal of
the placenta
▪ For women with a third- or fourth-degree
perineal tear.
▪ for women undergoing elective or
emergency caesarean section, should be
given prior to skin incision, a single dose
of first-generation cephalosporin or
penicillin should be used in preference to
other classes of antibiotics.

20. Other Recommendations:
▪ The choice of an antiseptic agent and its method of application for
skin preparation prior to caesarean section should be based
primarily on the clinician’s experience with that particular
antiseptic agent and method of application, its cost and local
availability.
▪ A simple regimen such as ampicillin and once-daily gentamicin is
recommended as first-line antibiotics for the treatment of
chorioamnionitis.
▪ A combination of clindamycin and gentamicin is recommended as
first-line antibiotics for the treatment of postpartum endometritis.

28. Management: MEDICAL EMERGENCY !!!
Sepsis induced hypo-perfusion:
▪ IV crystalloid > 30ml/kg to be given within the first 3hr.
▪ Additional fluid to be guided by frequent reassessment of hemodynamic
status
▪ Target MAP – 65mmHg
▪ To normalize lactate in patients with elevated lactate levels as a marker of
tissue hypo-perfusion.

29. Management: MEDICAL EMERGENCY !!!
Diagnosis:
Microbiologic culture, including blood, to be taken before antimicrobial therapy.
Antimicrobial therapy:
• IV antimicrobial, ASAP, within 1 hr of recognition of sepsis and septic shock
▪ Broad-spectrum, one or more antimicrobial, to cover all likely pathogen.

30. Management: MEDICAL EMERGENCY !!!
▪ To narrow down once pathogen is identified and/or adequate clinical
improvement is noted
▪ How to choose? Consider anatomic site, prevalence within community &
hospital; resistant patterns; specific immune defects; age & co-mordities.
▪ De-escalation with discontinuation of combination therapy within the first few
days in response to clinical improvement and/or evidence of infection
resolution.
▪ Duration – 7 to 10 days.
▪ Longer course for those who have slower clinical response, undrainable foci of
infection, S. aureus, some fungal & viral infections, immunologic deficiencies.
▪ Shorter course with rapid clinical resolution, following effective source control

31. Management: MEDICAL EMERGENCY !!!
▪ Source control: percutaneous drainage or surgical intervention
▪ Fluid therapy:
Crystalloid
Albumin, if require substantial amount of crystalloids
▪ Vasoactive medications:
Norepinephrine
Add vasopressin or epinephrine to increase MAP
Dopamine as alternative only in selected patients (i.e. low risk of tachyarrhythmia,
absolute or relative bradycardia)
Dobutamine – persistent hypo perfusion despite adequate fluid loading and
vasopressor agents

32. Management: MEDICAL EMERGENCY !!!
▪ Corticosteroids – not recommended
▪ Blood & blood products transfusion
Hb <7.0g/dL
Platelet if:
<10x109/L in the absence of bleeding
<20x109/L if significant bleeding risk
<50x109/L for active bleeding, surgery or invasive procedures.
▪ Immunoglobulins – not recommended, weak recommendation with low quality of
evidence. Require further evaluation.
GTG RCOG – IVIG is recommended for severe invasive streptococcal or staphylococcal
infection if other therapies have failed.
 Glucose control: Insulin when 2 consecutive blood glucose levels >180mg/L

33. Management: MEDICAL EMERGENCY !!!
▪ VTE prophylaxis:
LMWH or UFH
Combination of mechanical and pharmacologic whenever possible.
Mechanical, when pharmacologic is contraindicated.
 Stress ulcer prophylaxis:
Proton pump inhibitor
Histamine-2 receptor antagonist

34. Management: MEDICAL EMERGENCY !!!
 Renal replacement therapy
 Sedation, analgesia
 Mechanical ventilation
 Nutrition (enteral feeding preferred over parenteral nutrition)
 Bicarbonate therapy

35. Indications For Transfer To ICU
SYSTEM INDICATION
▪ CVS - Hypotension/raised serum lactate despite fluid resuscitation,
suggesting the need for inotrope support
▪ Respiratory - Pulmonary oedema,
Mechanical ventilation,
Airway protection.
▪ Renal - Renal dialysis
▪ Neurological - Significantly decreased conscious level
▪ Miscellaneous - Multi organ failure,
Uncorrected acidosis,
Hypothermia.

36. Antimicrobials
Antimicrobials Limitations
Co-amoxiclav Does not act on MRSA, Pseudomonas. Increase
risk of NEC in neonates exposed in utero
Metronidazole Acts on anaerobes
Clindamycin Most streptococci and staphylococci, including
MRSA
Piperacilin-tazobactam and Carbapenems Not nephrotoxic Covers all except MRSA Renal
sparing
Gentamicin No problem in normal renal function, but if
given regularly, serum levels must be
monitored.

37. Fetus
▪ Increased perinatal morbidity and mortality
▪ Risk of neonatal infection, encephalopathy and Cerebral palsy
▪ Consider delivery: Decision on timing and mode of delivery should
be made by senior obstetrician.
▪ Antenatal steroid if preterm delivery.
▪ Continuous electronic fetal monitoring intrapartum.
▪ Avoid epidural/spinal anaesthesia

38. Infection control
▪ Local infection control guideline
▪ Hand hygiene
▪ Isolation
▪ Inform neonatologist
▪ Educate family members and healthcare workers to seek medical
attention should any symptoms develop.
▪ Antibiotic prophylaxis for healthcare workers who have been
exposed.

39. Guidelines & recommendations:
▪ Managing sepsis in pregnancy: Prerna Mehrotra, Joel Swindin, Steve
Cantellow Published : December 17, 2020
DOI :https://doi.org/10.1016/j.ogrm.2020.11.003
▪ Surviving Sepsis Campaign : International Guidelines for management of
Sepsis and Septic Shock : 2016
▪ Sepsis : recognition, diagnosis and early management. NICE guideline
(NG51), July 2016.
▪ WHO recommendations for prevention and treatment of maternal
peripartum infections. 2015.
▪ The UK Sepsis Trust 2016.
▪ Bacterial Sepsis in Pregnancy, Green-top Guideline No. 64a, April 2012.

40. The fact that there is no such thing
as a perfect anti-sepsis, does not
mean that one might as well do
brain surgery in a sewer.
- Robert Solow

41. THANK YOU