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

2. 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.

3. 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.

4. 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

5. Current Pregnancy
Attended the high-risk clinic for preterm birth at , 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

6. 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

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

8. 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

9. Admit for observation

10. 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.

11. What tests / investigations?

12. 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

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

14. 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

15. 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?

16. 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

17. Septic work-up obtained
Bloods
FBC
WCC 22.3 x 109/L; neutrophils 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

18. 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 x 109/L
Hb 12.4g/dl
Platelets 211 x 109/L
See Maternal EWS

20. What do you do now?

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

22. 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

23. 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++.

24. 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

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

26. 4-7 hours Post-Op to 04.00
Lactate 3.0

27. 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

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

29. 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

30. 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

31. 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