Dr S Knowles National Maternity Hospital, Dublin CASE 6 Dr S Knowles National Maternity Hospital, Dublin

Day 1 38 year old Para 2 pregnant woman Gestation 21+6 weeks Presented to a maternity hospital with a history of Abdominal pains/tightenings Vaginal bleeding during afternoon She reported vaginal spotting during the morning.

Obstetric history 1999 Emergency caesarean section for fetal distress at 40+5 weeks gestation liveborn male infant 3.09Kg 2009 Emergency caesarean section at 26+5 weeks gestation following preterm rupture of membranes 5 days previously and maternal pyrexia liveborn male infant 750g neonatal death at 6 days of age.

Current Pregnancy Blood group O Rh+ Rubella immune HIV, hepatitis B and syphilis negative Weight 71.6Kg; BMI 25.7 Attended at 6, 6+5, 8 and 13 weeks gestation with vaginal bleeding Scan confirmed viable pregnancy on each occasion

Current Pregnancy Attended the high-risk clinic for preterm birth at 10, 14, 16, 18, 19, 20 weeks gestation MSU normal Chlamydia trachomatis/Neisseria gonorrhoeae DNA not detected HVS: No bacterial vaginosis Scanty Candida Group B Streptococcus detected – not treated antenatally Cervical length monitored every 2 weeks

Current Pregnancy Cervical length 1 cm (short) at 19+6 weeks gestation. Cervical cerclage inserted 20 weeks gestation. Presented 20+3 weeks gestation passing small vaginal clots Scan confirmed viable pregnancy. Admitted to antenatal ward for observation. Bleeding stopped, no pains. Good fetal movement felt. Discharged

Past Medical History Left oophorectomy (cyst) 2006 Tummy tuck 2011 Cigarettes 2/day No known drug allergies

Examination on Admission Temp 35.5oC; PR 101bpm; BP 146/86; RR 17; O2 sats 97% Pain score 6/10 Urinalysis: ++blood; +leucocytes Transabdominal ultrasound: fetus active; fetal heart 155bpm liquor volume normal placenta posterior upper

Admit for observation

Day 2 Gestation 22 weeks. 06.55 hours Preterm pre-labour rupture of membranes (PPROM) Pains ceased. Maternal EWS normal. Scan: oligohydramnios and fetal heart present.

What tests / investigations?

Day 2: PPROM Cervical suture removed. HVS and suture sent for C+S. FBC: WCC 13.3 x 109/L; 80% neutrophils. Hb 11.5g/dl Platelets 215 x 109/L Not in labour. Fetal heart heard. Maternal EWS normal Rx oral erythromycin as prophylaxis for preterm, prelabour rupture of membranes (PPROM) Monitor EWS every 4 hours

Day 3 Gestation 22+1 weeks Blood stained vaginal loss continues Not in labour Fetal heart heard Maternal EWS normal Continue 4 hourly observations

Day 4 Gestation 22+2 weeks 08.30 Patient reports reduced fetal movements Scan confirmed intrauterine fetal death Induction of labour with vaginal mifepristone Maternal EWS normal

Day 4: Induction of Labour 13.05 Patient feels cold Temperature 38.1oC PR 95 RR 16 BP 120/63 What would you do next?

Facilitator Slide Bloods Septic work-up obtained FBC CRP Septic work-up obtained Blood cultures MSU and HVS Broad spectrum antibiotics IV fluids Oxytocin commenced to speed up delivery

Septic work-up obtained Bloods FBC WCC 22.3 x 109/L; neutrophils 19.71 x 109/L Hb 12.0g/dl Platelets 231 x 109/L CRP: 42.3 mg/L Septic work-up obtained Blood cultures MSU and HVS Broad spectrum antibiotics Benzylpenicillin 3g initially followed by 1.5g every 4 hours + Gentamicin 240mg once daily + Metronidazole 500mg every 8 hours. IV fluids Oxytocin commenced to speed up delivery

Day 4 Continues 20.00 See Maternal EWS Not easy to induce. Not in labour; cervix 2cm. Foul smelling liquor observed. Persistent pyrexia and new onset tachycardia O2 sats 98% CRP = 68.3 mg/L FBC: WCC 23.4 x 109/L; neutrophils 20.62 x 109/L Hb 12.4g/dl Platelets 211 x 109/L See Maternal EWS

What do you do now?

Facilitator Slide Can discuss changing antibiotics – if so, to what? Source control – needs Obstetrician

To theatre for delivery as not in labour Consultant Obstetrician contacted Microbiologist regarding antibiotic therapy which was commenced 7 hours previously Change to: Meropenem 2g 8 hourly Gentamicin (increase dose to 360mg from 240mg; weight 71.6Kg at booking) To theatre for delivery as not in labour Source control

Theatre 20.52 Temperature 40.3oC PR 138 BP 95/40 RR 25 Lactate 1.6 Cervix 2 cm. →Dilatation and evacuation of uterus, pus++.

HDU: 2 hours Post-Op 23.00 Tachypnoea 35 Lactate 3.0 Temp Tachypnoea 35 Lactate 3.0 urine output 660 mls/hr FBC WCC 2.5 x 109/L Hb 11.5g/dl Platelets 136 x 109/L APTT 39.6; ratio 1.5 Total bilirubin 17 PR BP RR

Urine output <0.5mls/hr 4-7 hours Post-Op 01.00 to 04.00 Temp PR BP Urine output <0.5mls/hr RR

4-7 hours Post-Op 01.00 to 04.00 Lactate 3.0

WHAT DO YOU DO NOW? Summary: 7 hours post-op Rx meropenem and gentamicin Blood pressure persistently borderline <90/60mm/Hg Tachypnoea Lactate remains 3.0 Urine output poor <0.5mls/kg per hour x 3 hours

What was done…………. Fluid bolus Discuss with microbiology Add vancomycin and clindamycin

HDU Course Remained in HDU x 48 hours gradually improving Lactate 2.5, 1.6, 1.9, 2.0, 1.6 Good urine output Lochia normal Abdomen soft Alert and orientated Temp PR BP RR

Microbiology and Antibiotics Blood cultures negative Placenta: + E. coli ++ E. faecalis High vaginal swab (x 2): ++E. coli ++ E. faecalis Swab from body of baby: ++E. coli +++ E. faecalis Right ear swab (baby): +E. coli +++ E. faecalis Left ear swab (baby): scanty E. coli +++ E. faecalis E. coli Resistant to co-amoxiclav Susceptible to cefotaxime, gentamicin, ciprofloxacin, meropenem E. faecalis Susceptible to amoxycillin and vancomycin Antibiotic therapy switched to IV cefotaxime + IV amoxycillin Discharged on Day 10 of admission

Key Points Risk factors for maternal sepsis include Preterm delivery (<37 weeks gestation) Prolonged rupture of membranes (>18 hours) Presence of foreign body e.g. cervical cerclage Hypotension is a late finding in a young person with sepsis Polymicrobial infections and negative blood cultures occur with sepsis E. coli is the most common cause of maternal sepsis Delivery (source control) is essential to cure chorioamnionitis