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Obs & gynae clinic - sepsis in pregnancy and the puerperium

Obs and gynae registrar Dr Shireen Hickey and consultant Professor Sian Jones take you through the case of a pregnant woman with suspected viral infection

The case

A woman in mid-pregnancy called an out-of-hours GP as she was feverish, shivery, unwell and had a sore throat. The GP diagnosed a probable viral infection.

A few hours later the GP visited again as she had developed constant abdominal pain associated with vomiting, greenish black diarrhoea, and reduced foetal movements but no vaginal bleeding. The GP suspected placental abruption, and, although she was rapidly transferred to hospital, on admission she was critically ill with marked tachycardia, breathlessness, cyanosis and confusion.

The correct diagnosis of septic shock was quickly established. Fluid resuscitation was started, senior consultants were called, advice was sought from haematology and microbiology consultants and appropriate intravenous antibiotics were commenced immediately. Despite intensive life support she died a few hours after admission to hospital. *

Incidence

According to the latest confidential enquiry into maternal deaths, sepsis was the leading direct killer of pregnant women. Between 2006 and 2008 twenty nine deaths occurred from genital tract sepsis in pregnancy or the puerperium.1 Although these numbers may be small, almost all of these deaths could have been prevented had sepsis been identified and treated earlier.

Puerperal sepsis has been long documented as a cause for maternal morbidity and mortality – in the 18th, 19th and early 20th century it was the leading cause. With the advent of antibiotics numbers started to decline in the 1930s, but recently an upwards trend has re-emerged. The mortality rate from severe sepsis can be as high as 60%.2 The organisms responsible for most of the mortality from puerperal sepsis are group A streptococcus and E.coli.1

Sepsis may occur in early pregnancy, postnatally, following termination of pregnancy or miscarriage. Six of the 29 deaths from sepsis in the 2006-2008 period occurred prior to 24 weeks gestation.1

Features

The onset of bacterial sepsis and deterioration of the pregnant patient can be rapid and catastrophic. Initial minor infective symptoms can develop into life-threatening sepsis over a short number of hours. The signs and symptoms of sepsis in pregnant women may be less distinctive than in the non pregnant population and are not necessarily present in all cases, so a high index of suspicion is necessary.3 Once signs of sepsis are present the infection is already well established and multi-organ failure may start, followed by death.

Clinical features suggestive of sepsis include fever, offensive vaginal discharge, tender uterus, productive cough, dysuria, nausea, vomiting, diarrhoea or a rash. Signs suggestive of sepsis include tachycardia (>100bpm), pyrexia (>38.0oc), or hypothermia (<36.0oc), tachypnoea (>20 breaths per minute), confusion, oedema and hypoglycaemia (in the absence of diabetes).

The following risk factors for sepsis have been identified:

  • anaemia
  • diabetes
  • bmi over 25
  • immunosuppression
  • previous pelvic infection
  • previous Group B Streptococcus infection
  • prolonged rupture of membranes
  • cervical cerclage
  • amniocentesis and other invasive procedures.

Concurrent illness with a sore throat, respiratory tract illness, impetigo, cellulitis and inner ear infection (possibly with Group B streptococcus) in the patient or close relatives should be classed as a red flag symptom and a higher index of suspicion should be implemented in these patients.3

Investigations and  management

Advice regarding general perineal hygiene should be given to all pregnant women, particularly those unwell with a sore throat or respiratory tract infection. The importance of hand washing prior to and after using the toilet or changing pads should be re-iterated.

If a pregnant or postnatal woman presents with a sore throat, a throat swab should be taken to exclude group A streptococcus  .1 Of the 13 women who died from group A streptococcus sepsis the majority had a recent illness themselves or exposure to a child with a sore throat or respiratory illness.1

Antibiotics should be prescribed if a throat swab confirms group A Streptococcus or three of the following are present: history of fever, tonsillar exudate, no cough, tender anterior cervical lymphadenopathy.4

After delivery, observations of pulse, temperature, blood pressure, respiration and lochia should be done regularly while the woman is still in hospital and for several days after discharge by her community carers. This is important in women who leave hospital a few hours after birth, ‘early discharge’, or if a woman complains of feeling feverish or unwell.

Clinicians should have a high index of suspicion for sepsis in all pregnant or recently delivered women who present with pyrexia. Early referral to hospital should occur in these patients.

Women should be referred to the hospital if they have any of the following ‘Red flag’ signs and symptoms.2

  • pyrexia more than 38°C
  • sustained tachycardia more than 90 beats/minute
  • breathlessness (respiratory rate more than 20 breaths/minute)
  • abdominal or chest pain
  • diarrhoea and/or vomiting
  •  uterine or renal angle pain and tenderness
  • woman is generally unwell or seems unduly anxious or distressed.

Early escalation and the input of high dependency care should be sought early in the patient’s illness.

* Case taken from Saving Mothers Lives, reviewing maternal deaths to make motherhood safer.1

Dr Shireen Hickey is a registrar in obstetrics and gynaecology at Bradford Teaching Hospitals NHS Foundation Trust.

Professor Sian Jones is a consultant in obstetrics and gynaecology at Bradford Teaching Hospitals NHS Foundation Trust.

 

References

  1. Centre for Maternal and Child Enquiries (CMACE). (2011) Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer 2006–08. BJOG, 118 (suppl. 1); 1–203
  2. RCOG. (2012) Green top guideline 64b, sepsis following pregnancy
  3. RCOG. (2012) Green top guideline 64a, sepsis in pregnancy
  4. Cooper RJ, Hoffman JR, Bartlett JG, Besser RE, Gonzales R, Hickner JM et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: background. Ann Intern Med 2001;134:509-17.

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