Genital Tract Sepsis

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) 36.5°C 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

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

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.

Other than body temperature, what other tests could be used to monitor for the first signs of ascending genital tract infection? Other vital signs F Maternal pulse, BP, respiratory rate Fetal heart rate assessment FBC Vaginal swabs

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

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

What aspects of her labour might predispose Maria to puerperal infections? PROM Ventouse extraction Episiotomy PPH/Anaemia

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

What information relating to this patient’s 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.

What other clinical signs may support the diagnosis of malaria? Anaemia Jaundice Splenomegaly

What are life threatening complications of P. falciparum? Profound hypoglycaemia Cerebral malaria Severe malaria

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

On day 3 the patient’s 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 39.2°C. 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

What is the term used to describe the patient’s clinical state? Septic shock

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

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

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

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

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

Endometritis (puerperal sepsis) F If no improvement after hours? F Suspect retained products of pregnancy; perform evacuation under antibiotic coverage. F If still no improvement after 24 hours? F Perform laparotomy for wound revision, maybe hysterectomy.

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

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

Any Questions?