Genital Tract Sepsis

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Genital Tract Sepsis
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The Case..

• Maria is a 21 year old primigravida at term, who
  presents at the labour ward in the morning with
  prelabour rupture of membranes (PROM)
• On examination she appears well nourished,
  without evident anaemia
• BP 110/60mmHg, Pulse 84bpm, Temperature
  (axillary) 36.5C
• On abdominal palpation she has a gravid,
  non-tender uterus, SF height of 37cm
• The foetus has a cephalic presentation with 1/5
  palpable over the symphysis pubis
• The foetal heart rate is 144 bpm. The woman has
  no contractions

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Is a vaginal examination an essential part of the
initial assessment?

• No, however a sterile speculum examination may be
  useful to confirm PROM and take a swab if there
  is doubt regarding ruptured membranes
• Cord prolapse is not likely as the head is
  engaged (cephalic 1/5 palpable) and FH rate
  normal
• Digital vaginal examination should be avoided to
  minimise risk of introducing ascending infection

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How should this woman be further managed?

• Mobilise, regular assessment of fetal
  movements/foetal heart rate/maternal temperature
• If Preterm Prelabour Rupture of Membranes (PPROM)
  give antibiotics (ampicillin IV 2 gr. stat then 1
  gr each 6 hours)
• Induction of labour after 18 24 hours.

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Other than body temperature, what other tests
could be used to monitor for the first signs of
ascending genital tract infection?

• Other vital signs
• Maternal pulse, BP, respiratory rate
• Fetal heart rate assessment
• FBC
• Vaginal swabs

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• Maria establishes regular contractions after 4
  hours of observation
• On vaginal examination the cervix is 4cm dilated
  and fully effaced
• After a further 4 hours of unremarkable labouring
  VE shows her cervix to be 5-6cm dilated
• The labour is augmented with oxytocin. After a
  further 5 hours she gives birth to a daughter
  by vacuum extraction due to maternal exhaustion
  and persistent OP position

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• An episiotomy is performed during the extraction
• The delivery is complicated by an atonic uterine
  bleed with an estimated loss of 800mls
• The bleeding is eventually controlled by
  ergometrine IM and cytotec tablets administered
  rectally
• Mother and child are transferred to the postnatal
  area a short time later in a stable condition

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What aspects of her labour might predispose Maria
to puerperal infections?

• PROM
• Ventouse extraction
• Episiotomy
• PPH/Anaemia

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• On day 2 postpartum, Maria complains of headache,
  nausea and generalised abdominal discomfort.
• What examinations would you perform?
• BP 110/50mmHg, Pulse 110bpm, Temp 38.2C
• The abdomen is diffusely tender, non-distended
  and there is no rebound tenderness
• The uterus is well contracted
• The lochia appears normal

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What information relating to this patients
antenatal care may be of relevance in this
initial evaluation?

• Tetanus vaccine
• Hb, is she anaemic?
• Malaria prophylaxis
• HIV status
• Maria is managed with Fanzidar, 3 tabs STAT with
  malaria as a working diagnosis. A blood smear is
  sent. She is kept on the post-natal ward for
  further examination.

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What other clinical signs may support the
diagnosis of malaria?

• Anaemia
• Jaundice
• Splenomegaly

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What are life threatening complications of P.
falciparum?

• Profound hypoglycaemia
• Cerebral malaria
• Severe malaria

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• Treatment of severe or cerebral malaria
• QUININE 10 mg/kg in 5 dextrose IV over 4
  hours/8 hrs
• As soon as patient can take orally infusion is
  replaced by tablets (same dose and intervals)
• Treatment length 7 days.
• Monitor vital signs, blood sugar, urine output
  and consciousness level

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• On day 3 the patients condition is worsening.
  She is weak, she has no appetite, her abdominal
  pain is worsening which she now relates to her
  lower abdomen. She has no urinary symptoms but
  has passed some loose motions
• On examination, BP 90/50mmHg, Pulse 120bpm, Temp
  39.2C. The patient seems restless with an
  increased respiratory rate. The chest is clear on
  auscultation
• There is slight abdominal distention along with
  rebound tenderness in the lower abdomen

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What is the term used to describe the patients
clinical state?

• Septic shock

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• The diagnosis of septic shock is based on
  clinical signs relating to disturbed physiology
• BP ?
• Pulse ?
• Resp. rate ?
• Temp ?? or ??
• Glasgow coma scale ?
• Oliguria

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Septic shock-How should this patient be managed?

• Ask for help!
• A airway position so airway not occluded / at
  risk of aspiration
• B breathing can be supplemented with oxygen
• C circulation must be supported with IV fluids
  (and perhaps eventually blood). Aim for 2L in the
  first hour. A venous cut down may be necessary.
  Wide-bore IV cannulae are essential.
• D Drugs Antibiotics, consider corticosteriods

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• IV antibiotics as per WHO guidance
• AMPICILLIN 2g/6 hrs (streptococcal infections)
• GENTAMYCIN 5mg/kg/24hrs (gram negatives)
• FLAGYL 500mg/8 hrs (clostridium and
  anaerobes)
• If in a malaria risk area treat with
• QUININE 10 mg/kg in 5 dextrose IV over 4
  hours/8 hrs
• Ideally cultures and malaria-slide should be
  obtained prior to the commencement of treatment
• Consider
• DEXAMETAZONE 4 mg/kg IV/6 hrs
• Move patient to an area where repeated assessment
  can be performed (ideally ITU) and catheterise
  bladder to accurately measure diuresis

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What differential diagnoses might one consider in
this scenario?

• Womb endometritis
• Wound perineum, vagina, cesarean section
• Weaning mastitis or mamma absces
• Water Urine Tract Infection
• Wind pneumonia
• Walk Venous Tromboembolism
• Malaria
• Meningitis

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What would you suspect if...

• Maria had a tender uterus and foul smelling
  lochia?
• Endometritis (puerperal sepsis)
• Treatment?
• Three course IV antibiotics
• Ergometrine 0.5 mg IM bd

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Endometritis (puerperal sepsis)

• If no improvement after 24-48 hours?
• Suspect retained products of pregnancy perform
  evacuation under antibiotic coverage.
• If still no improvement after 24 hours?
• Perform laparotomy for wound revision, maybe
  hysterectomy.

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What would you do if...

• Maria had a wound infection?
• Surgical revision (usually) and antibiotics
• consider to add cloxacillin for staphylococcus
  aureus.
• Prevention?
• Hygiene
• Prevent anaemia
• Safe obstetric and surgical techniques
• AVOID CESAREAN SECTIONS AT STILBIRTHS IF POSSIBLE

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What would you suspect if...

• Maria had breast pain, tenderness and
  inflammation?
• Mastitis
• Treat with...
• Warm compresses
• Frequent emptying of the breast, preferably by
  the baby, but may pump if feeding is too
  uncomfortable
• Analgesics, rest, fluids, observation
• Lactation consultation to ensure good latch and
  adequate emptying of breast
• Antibiotics Cloxacilline 500 mg/6 hrs for 10
  days or
• Erythromycin 250 mg/6 hrs for 10 days

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Any Questions?