Essay 340

a)This patient is in septic shock secondary to severe infection which is most likely chorioamnionitis and needs to be managed as an emergency.Immediate resuscitation in the form of establishing and airway,ensuring that the patient is breathing spontaneously and circulation should be the first step.This will need early involvement of the entire team including senior obstetrician,anesthetist,senior midwife.Abdominal and  sterile speculum examination are required  to give further clues to the diagnosis and to confirm the position of the baby.Urgent investigations like full blood count ,C reactive protein, urea and electrolytes  along with group and save should be sent urgently while putting in 2 wide bore cannulae.IV Fluids and broad spectrum antibiotics should be started after sending blood cultures and an arterial blood gas should be considered .Quick review of notes will provide information regarding corticosteroids and any other risk factors.

Only after maternal stabilization CTG should be done.Ultrasound scan may need to done to establish fetal viability.At this point Neonatologist should be informed and involved while planning to deliver in order to inform parents about the possible outcomes for the baby due to prematurity ,sepsis or even ex utero transfer to a tertiary center.Focus of infection should be investigated with thorough infection screen i,e vaginal,rectal,oral swabs, urine culture  and chest x ray keeping in mind that swine flu/other viral infection in mind as differential diagnosis.Microbiologist may need to be involved if the patients response to antibiotics is poor.

b)Infection can cause severe maternal and fetal morbidity and mortality.The first step tp prevent this is to educate and inform the patient about the infection,its early symptoms and signs to watch for and  numbers to call in case of concern.She should be made aware that infection can lead to sepsis and premature labour  which may result in sepsis,breathing difficulties and neurological sequel in the baby especially if premature. PID,Group B/Group A streptococcus,asymptomatic bactiuria  should be treated appropriately to prevent morbidity and mortality.

As an inpatient early warning scoring system is a useful tool in trained hands to highlight a potential life threatening infection and should be widely used. 

A)

The initial treatment is Oxygen by face mask and aggressive fluid resuscitation by crystalloid and colloids.I would like to assess the level of consciousness and would like to ask for associated factors such as nausea, vomiting, cough, chest pain, breathlessness, headache and flu-like symptoms,nature and colour of liquor and urinary symptoms of dysuria and frequency.I would examine the chest to look for infection and an abdominal examination for fundal height and tenderness. A cardiotocograph for fetal well being should be done.I would do a per speculum ex to check dilatation, colour of liquor and to take triple swabs.Broad spectrum IV antibiotics should be started such as cefuroxime and metronidazole and IV/PR paracetamol given to bring down the temperature.If she fulfils the local protocol for swine flu, should be swabbed and started on oseltamivir 75mg bd and barrier nursed till swab results are back.She should be monitored in HDU and a modified obstetrics early warning sign chart used.The management should also involve intensive care specialists, physicians, microbiologists, virologists,anaesthetist  and the neonatologist.Corticosteroids should be given to mature the baby's lungs if not given previously.

The initial blood investigation would include. FBC and CRP to check Hb and inflammatory markers and urea and electrolytes to check for dehydration and electrolyte imbalance. Liver function test and clotting as 

they can be deranged in sepsis.Blood culture to look for septicaemia and sensitivity to antibiotics.LMWH and TED stockings should be prescribed for the duration of stay in the hospital.Further investigations such as chest X-ray, abdominal USS, fetal dopplers should be performed if clinically indicated.Delivery should not be delayed if sepsis is suspected and and an induction of labour performed(if cephalic) after discussion with the patient.

B)

To prevent maternal mortality from sepsis, all health professionals must be aware of the sign and symptoms of maternal sepsis and critical illness. Maternal tachycardia, abdominal pain and tenderness are important early features that should prompt urgent medical review.All maternity unit should have guidelines for investigations and management of sepsis. Regular frequent observation should be made and use of MEOWS chart promoted.High dose broad spectrum antibiotics should be started immediatlywithout waiting for the microbiology results.

Neelima

Thanks - it will be marked and posted online.

PAUL

>
> A healthy 35 year old woman with 3 previous vaginal deliveries is being
> managed as an out-patient following pre-term rupture of the membranes at
> 26 weeks gestation. She presents at 28 weeks gestation feeling very unwell
> and complaining of sore throat, diarrhoea and constant abdominal pain. She
> has a pulse of 120/min, BP = 80/40 mmHg and Temp = 39C. (a) Discuss your
> initial acute management [14 marks].
> This patient has pre term premature rupture of membranes with superimposed
> infection most probably chorio amnionitis that led to septic shock.Other
> differential diagnosis should include swine flu,or gastroenteritis .
> Management will require admission as an emergency, correction of shock and
> infection, and delivery.
> Communication,resuscitation,monitoring and investigations are done
> simultaneously. Local guidelines and protocols are followed. Communication
> involve call for help,inform consultant obstetrician, reception desk to
> call anesthetist,chief midwife, neonatologist,porters. Patient and her
> partner are kept informed of her condition and neonatologist inform them
> regarding care of of neonate who would be pre term. A person should be in
> charge of documenting findings. Resuscitation involve securing airway,
> observe breathing and give oxygen, and secure circulation by application
> of two wide bore IV canulas for fluid administration to correct shock, IV
> broad spectrum antibiotics, and antipyretics. Will ask the anesthetist to
> put a central venous pressure catheter to avoid fluid overload that can
> precipitate pulmonary edema, which can likely occur in this patient. A
> urinary catheter should be put for volume outflow check. Patient should be
> managed in high dependency unit.
> Early warning sign chart is done. Automated monitoring of pulse BP and
> temperature. And monitoring Respiratory rate and level of consciousness
> using Glasgo coma scale. Investigations include, FBC,blood group and
> save,infection markers,WBC and CRP, blood culture, renal function tested
> as it can be affected ( urea and electrolytes ) liver function tests and
> test for swine flu as early treatment with oseltamivir or zanamovir would
> be more effective if given within 1st 48hr of symptoms . Urine dipstix for
> nitries,glucose proteins. Vaginal and rectal swabs taken. As a decision is
> taken to deliver her after correction of maternal condition , continuous
> electronic fetal monitoring is done.
> When patient is stable ,mode and place of delivery is considered in liason
> with the neonatologist ( presence of SCBU. In utero transfer or ex utero
> if not available), and patient wishes .
> b) She is subsequently delivered and discharged. How can maternal
> mortality from infections be prevented? [6 marks]
> During the antenatal care,prompt and early treatment of infections should
> be done,eg asymptomatic bacteruria or chest infections. Screening for
> asymptomatic bacteruria will detect cases needing treatment to prevent
> pyelonephritis that can lead to septic shock. Earl diagnosis and treatment
> of swine flu will reduce mortality. Proper management of conditions that
> lower maternal susceptibility to infection eg diabetes. Use of antiseptic
> precautions in labour ward and operating theatres through protocols that
> are reguraly drilled and audited to conform with patient safety. Use of
> prophylactic antibiotics in emergency cesarean section after clamping the
> cord. Use of prophylactic antibiotics in elective cesarean section in
> certain situations eg morbidly obese patient, diabetid patients or those
> with HIV.
> There should be organisationl arrangements that will allow proper
> circulation in the wards,proper aeriation, isolation of patients with
> infection to avoid cross infection. Measure for infection control should
> be in place and regular screening foe MERSA.
 
 

J REPLY

A..The probable differential diagnosis are chorioamnionitis,flu like infections[swine flu], severe gastro enteritis. I will admit the patient after systematic assessment.Airway will be assessed and nasal oxygen will be supplemented if any sign and symtom of respiratory distress. Two iv bore cannula inserted and bloods will be obtained for FBC, CRP, blood culture and sensitivity and baseline renal function. ABG is indicated in case of respiratory distress.Throat/nasal swabs incase of suspected respiratory infection.MSU to be sent to rule out UTI. Abdominal examination to assess the SFH and uterne tenderness may indiacte chorioamnionitis. Speculum examination to look for any foul smelling liquor and vaginal swabs will be done to rule out infection. Fetal monitoring by CTG may indicate tachycardia in the presence of maternal infection. Patient will be admitted in HDU of labour ward and consultant obs/anaesthesit/neonatology team to be informed of admission. IV antipyretics and antibiotics started according to hospital protocol. Zanamavir and barrier nursing advocated in case of suspected swine flu.Continuous observations an 2 hourly tempertaure should be recorded.

b.Routine antenatal screening for aymptomatic bacteriuria ,hepatitis B,HIV, Syphilis will help in early diagnosis.Patients who are non immune to rubella and syphilis should avoid contact ith infected people and report immediately of any symptoms.Early diagnosis and treatment is important in preventing mortality.Raising awareness of symtoms of impending infection in PPROM and flu vaccination is important.Adherence and development of national and local guidelines of infection in pregnancy shoul be stressed and auditing the current practise  ill ensure things are done correctly.

iam posting this answer again , please kindly mark it.

(a)           This patient has septic shock .it is an obstetric emergency. i will check for airway ,respiratory rate and oxygen saturation on air.give oxygen by rebreathable face mask. maintain intravenous access and commence iv fliuds with colloids first about 500mls stat. i will send bloods for FBC, G&S, U&E,LFT's, CRP,clotting profile, blood cultures.I will commence her observation on MEWS chart.i will transfer her to high dependency unit in isolation away from other pregnant women and use barrier nursing with patient protective equipment. i will examine her for source of infection, take throat swab  for suspected group A strep and HINI viral swab. send urine and vaginal swab and stool for C&S..i will transfer her to high dependency unit in isolation away from other pregnant women and use barrier nursing with patient protective equipment. i will commence her on broad spectrum antibiotics like Augmentin, metronidazole and gentamycin. if allergic pennicillin then clindamycin. i will also commence her on antivirals for H1N1 ( osteltamivir,tamiflu).i will catheterise her and maintain 1hrly input/output chart. i will inform on call anesthetist, obstetric consultant on call,medical team on call, microbiologist on call and peadiatrition on call.she may need arterial line. once patient is stabilised i will commence CTG for fetal monitoring and make a decision about timing and mode of delivery with steroid cover for fetal lung maturation.i will commence her on thromboprophylaxis once clotting results are available.

(b)    Maternal mortality can be prevented by making women aware of signs of sepsis like fever, foul smelling lochis, abdominal pain or feeling generally unwell, and encouraging them to report early.post natal follow up by midwife and be vigilant about signs of sepsis.  early recognition of signs of septic shock by medical staff and  close monitoring in a high dependency unit with multidiciplinary team approach.early commencement of broad spectrum antibiotics. infection can be prevented following infection control guidelines and maintaining hand hygeine and using patient protecting equipment.

differential diagnosis could be: chorioamnionitis (she has history of ROM 2 weeks back), or may be flu (fshe is having sore throat), gastorenteritis (she has diarrhea).

anyway initial rescussitation of the patient should be done immediatly by maintaing ABC, patent airway, breathing and 2 wide bore cannula for circulation and runninf IV fluids, antipyretics, and broad spectrum IV antibiotics covering Gram +ve, Gram -ve bacteria and anaerobes. corticosteroids to be given, even if decision of delivery will be taken before the time needed for corticosteroids to act.

history should be then taken from patient or her relatives about previous flu, contact with infected persons, cough, expectoration. or intake of food from outside, nausea with the vomiting and diarrhea, dysentry. examination of the chest for wheezes, abdomen for uterine tenderness, PV for offensive discharge. ultrasound needed to detect fetal viability, amount of liquor, do BPP, CTG to detect fetal weel being and presence of any uterine contractions.

swabs from throat, vagina, urine analysis with culture and sensitivity. blood culture during the pyrexia (to be sent before starting antibiotics), cross match and save bllod in case. FBC, U&E, liver functions,

multidisciplinary team is needed, consisting of neonatologist (and inform NICU about possibility of having a newborn soon), anasthetist, intensivist, internist, senior midwife.

once the condition of the patient is stabilised, further management will be taken according to the cause, if chorioamnionitis, delivery should be prompt whether by induction of labour, if cervix is favourable and maternal and fetal conditions permit, or CS.

if flu or gastorenteritis, then patient could be discharged after stabilising her general condition.

b) proper instruction should be given to the patient about the warning symptoms and signs of infection, from persistent fever, feeling unwell, discomfort of difficulty in breathing, offensive vaginal discharge, abdominal pain and ternderness, large uterus or non contracting....she should immediatly seek the nearest hospital for help, also contacts of the hospital should be available with the patient to call for help if she can't reach the hospital

continue on antibiotics after discharge till the condition is completly resolved

if postpartum infection couldn't be prevented and already occured, so prompt and immediat management is needed to prevent deterioration of the patient's conmdition and prevent maternal mortality.

From the patient clinical picture , the patient is most probably having influenza infection which may be caused by H1N1 virus(swine flu)  However , exclusion of choriamninoitis as a complication of\ preterm premature rupture of membranes is a must.Respiratory rate and oxygen saturation should be checked.Swin flu swbas should be obtained as soon as possible..Other investigations are required to exclude chorioamnionitis like full blood count, CRP , high vaginal swab.If suspicion of swine flu is strong multidisclinary team car should be initiiated, including obstetrician, aenethesits, ITU specialist.Starting treatmenbt with antiviral drugs should be initioated, the first choice is Zanamivir taken by inhalation.The patient is properly managed in ITU or high dependancy unite taking proper precaution for isolation and infection control.Follow up of respiratory rate , pulse , temprature , blood pressure and oxygen saturation is a must.Presence of offensive vaginal discharge, uterine tenderness , are suggestive of chorioamnionitis, and treatment with broad spectrum antibiotics should be started.Obstetric ultrasound scan will be useful  to check liquer volume.If the patient is proved to be in chorioamnionitis , delivery should be affected.Induction of labour , or C.S according to the cervical favourability and fetal well being.

Maternal mortality from infection can be prevented by giving proper instruction to the women regarding the prevelant infections, mode of transmission and how to avoid these infection.Immunization agianst common infections e.g swine flue should be encouraged .Adopting proper anti-infection measures in health care facilities , especially during operative and other invasive procedure is mandatory.Proper detection and treatment of obsteric complications that can lead to infection like premature rupture of membranes , retained placenta, post C.S infection should be checked. Instructing women about the early symptoms of infection is essential.the health care professionals should have high index of suspicion to diagnose and start treatment for infectious morbidities

The initial management would be A, B, C approach as patient is unstable. IV access, taking blood cultures and bloods for FBC, Urea and Electrolytes, CRP, Liver function tests as for inflammatory markers and involvement of renal and liver function as patient in shock. Starting IV fluids resuscitation is important. 

Taking history will help diagnosis and differential diagnosis: enquiry about the members of family affected (viral infection), severity of their condition and similar signs; change in diet or eating out (gastroenteritis); symptoms like cough (chest infection); abnormal smelly discharge, bleeding pv (chorioamnionitis) ; history of disuria, urinary frequency (pyelonephritis); frequency of diarrhea and character of the stool ( severity of diarrhea and dehydration). Shortness of breath, chest pain and calves tenderness are important indications of PE or DVT. Aslo I would enquire about current and recent medications, allergies, current medical conditions and problems during the pregnancy. Recent fetal movements and character of abdominal pain, such as an onset, duration, regularity, severity and whether it is getting worse.

Additional investigations apart from mentioned above would be infection screening such as : vaginal swab for culture and sensitivity,  the sputum if any cough; the stool culture. MSSU should be sent for culture and sensitivity if any clinical signs or it is indicated by urinalysis. Nasopharyngeal swab for Swine Flu Virus / H1N1 Virus if no history of having  seasonal flu jab may be indicated if history suggest more likely viral illness.

 CTG performed as part of investigation for fetal wellbeing .

As objective examination should  performed starting from  vital signs,  auscultation of the chest ,  palpation of the  abdomen, uterus for uterine tenderness, assessing presentation and lie  by ultrasound ; and speculum examination  if necessary to assess approximate vaginal dilatation; and if in advanced labour – vaginal examination may be necessary.

As the patient is unstable ; continues monitoring, with obstetrics early warning chart (monitoring of vital signs, urinary input/output) after transferring to HDU bed are indicated. Isolation and preventive measures may be necessary if swine flu is suspected. Multidisciplinary approach should be used with discussions and informing of anaesthetist, senior midwife, neonatologist and senior obstetrician, microbiologist at the later stage within 24-48 hours when culture is available. IV resuscitation, broad spectrum intravenous antibiotics such cephalosporin’s of 2^nd generation, IV paracetamol to reduce the fever should be initiated.

The discussion with a patient and relatives  with regards of current situation and started management, possible outcomes and a trigger for the delivery, and possible transfer if no cots available. Maternal wishes, for example:  the mode of delivery; should be taken into account.  The family and woman should be constantly updated and involved in decision making. Neonatologist could discuss prematurity and further management of the baby before if the delivery is anticipated in the near future.  In case chorioamnionitis the mode of delivery woman if in labour -allow delivery,    liaising with SCBU;  IOL if favourable cervix  providing the condition of fetus is  not compromised, caesarean section the another option and should be performed by Senior Obstetrician.

2) Maternal mortality can be prevented by making women aware about clinical signs of infection such as offensive discharge, feeling generally unwell, abdominal pain, fever. The written information given would be to the patient advantage. It is important to encourage women to report condition when early signs are present. If sepsis is suspected prompt early treatment with a combination of high-dose of broad-spectrum  intravenous antibiotics, such as cefuroxime and metronidazole, may be life saving. The severity of illness should not be underestimated; early referral to the hospital, treatment, including delivery should not be delayed once septicemia has developed because the deterioration can be extremely rapid. Women should be fully informed of the dangers of conservative management.  

(a) This patient is hemodynamically unstable as evidenced by hypotension and tachycardia. A possible etiology I would entertain is that of septic shock in view of her presentation. My initial acute management would be to resuscitate her. First I would ensure that her airway and breathing are secure; I would like to measure the oxygen saturation and give her supplemetal oxygen. Next I would try to correct the hypotension by setting 2 large bore intravenous lines in her antecubital fossae and running intravenous normal saline. At the same time, I would take blood for full blood count to look at the white blood cell count and its differentials, the platelet counts and the haemoglobin, urea, creatinine, electrolytes, liver panel, clotting times (PT and PTT), C reactive protein, and cultures/ sensitivities. At the same time, I would contact the obstetric consultant, intensive care physician, anesthetist and neonatologist. An empirical broad spectrum intravenous antibiotics such as the ampicillin should be commenced as soon as possible, after cultures are done.

I would then take a brief history from her, focusing on her history of pre-term rupture of membranes, if she had been monitoring her temperature at home regularly, the colour of the liquor, if there is any bleeding per vaginum and contraction pains. I would like to know the duration which she has been feeling unwell and find out more about the diarrhea- its duration, frequency, consistency, abdominal pain- its duration, character, exact location and ask regarding other symptoms such as urinary tract symptoms, cough, breathlessness. I would try to elicit her social circumstance, living conditions, any illicit drug use, smoking, alcohol intake and any recent travel or significant contact history.

Next I would examine her, focusing on her general condition and mental state, cardiorespiratory system, palpate her abdomen, in particular her uterus. I would perform a speculum examination to look for signs of chorioamnionitis characterised by foul smelling discharge. I would perform a high vaginal swab. I would also auscultate the fetal heart to ensure fetal wellbeing. Stool and urine would also be sent for cultures, together with a throat swab.

During the resuscitation process, I would monitor her vital signs continuously. Consideration would be given to setting central venous and arterial lines to aid monitoring. If her blood pressure does not recover after the fluid challenge, inotropes can be considered. She should be nursed in an intensive care unit. Upon stabilisation of her condition, I would prepare her for delivery via a Caesarean section.

b) Maternal mortality from infections can be prevented by several measures. Firstly, there should be a prompt recognition of poor maternal condition, especially in view of her history of PPROM. Staff should be aware that even in a healthy patient, deterioration of health and collapse can take place very swiftly in a setting of sepsis. Charts like the MEOWS can be utilised. Resuscitation should not be delayed. Empirical antibiotics should be started as soon as there is any suspicion of sepsis. Secondly there should be multidisciplinary care and senior staff involved in her case. There should be good communication amongst the team. Thirdly there must be staff training on a regular basis dealing with emergencies as such. Fourthly, patients as such, with a history of PPROM should be monitored closely, even on an outpatient basis. The patient should be educated to look out for signs of infection and to return promptly to hospital if she feels unwell.   

Dear Paul,

2nd question has already appeared and my first one isnt marked yet. i posted on 6th Jan. essays posted on 7th are marked. i hope you have get my answer as i can see it on line now. 

thanks

A

In view of her
clinical history, the most probable cause of her present illness will be
Chorioaminitis and Septic Shock which associated with increased maternal /
fetal mortality and morbidity, but other causes also should be ruled out. Thus
initial management starting, by admitting the patient to the hospital, under multidisciplinary
team care including Obstetrician, physcian, neonatologist, Check her ABC, O2 by
mask,2 wide bore cannula and collect blood for investigation. Careful history
taking regarding the time since fever started and how many times diarrhea/day
and whether there is any associated nausea or vomiting. Also If there are any
respiratory symptoms like cough; or urinary symptoms like dysurea. If there is  any associated vaginal bleeding; or offensive
vaginal discharge. Also enquire about the site, nature, radiation, aggravating
and releasing factor of her abdominal pain. Previous obstetric history and out
come, also social history (alcoholic, drug abuse)

And also check her
handheld card for any previous admission notes (if present) and what treatment
she received when she had PPROM, what type of antibiotic and whether she received
steroid injection, and also any result for her previous and latest
investigations including CBC, CRP, HVS, etc.

Thorough examination
should be done and checking her vital signs and pulse oxymetry (O2 Saturation).
Check her fundal height, presence of tightness, any vaginal loss, and presence
of fetal heart .I will do speculum examination to check the color of the
liqure,smell and any associated discharge or bleeding and perform vaginal
examination to assist cervical dilatation if uterine contraction present. Then blood
should be sent for CBC, RFT, LFT, CRP, Blood c/s. Take vaginal swab for c/s ,
and do ultrasound for fetal wellbeing and baseline CTG.

Initial treatment aim
is to stabilise the patient's condition. Replacement of fluid and electrolyte
by saline infusion, starting IV antibiotic with broad spectrum (3rd gen.
cephalosporin +  flagyl) and antipyretic.

Monitoring by early
warning chart her temperature, vital signs, input/output , and decide the plan
for further management.

If suspected chorioaminitis,
induction of labour after assessing the bishop score should be done using prostaglandins
(PGE2) or syntocenon augmentation (PGE2 may cause fever and loose motion, thus
only given after stabilizing the patient's condition. otherwise syntocenon
augmentation according to unit protocol can be used as first choice).

Before that, assess
SCBU availability and if not, inuterotransfer the patient to another hospital
and inform pediatrician and neonatologist about the patient and the need to council
the parents about the prognosis of the baby if delivered at this age (preterm
delivery SCBU admission increase and prenatal mortality and morbidity). Offer
steroid injection if not given before as studies show it helps to reduce
prenatal mortality and morbidity as well as respiratory distress syndrome. It
also reduces intracranial hemorrhage and the need for SCBU admission (simple
fever not associated with systemic infection is not contraindicated for steroid
injection)

B

Maternal mortality
from infection can be reduced by proper admission to the hospital when needed,
offering antibiotic for prevention and treatment of infection, Immunization against
H1N1, influenza virus or any other recommended immunization when traveling to endemic
areas if needed.

Advise the women to
monitor any sign and symptom of infection, like after PPROM (fever, abdominal
pain, and offensive vaginal discharge) and careful follow-up plan for
monitoring patients with probability of infection, and early medical
advice-seeking if signs and symptoms of infection present. Also offer 24hour
access to the hospital with contact number and health education with leaflet
information given to the patient can help in increasing the awareness of the
presence of infection. Audit and re-audit, as well as follow-up RCOG and NICE
guidelines and setup a unit protocol for managing patients with increased
probability of infection (PPROM) can help in reducing maternal mortality by
infection.

Essay 340

X

a)      She is most likely to be in septic shock. Secondary to chorioamnitis due to her previous history of preterm prelabor rupture of membrane. She requires an admission most likely to the ITU for multidisciplinary involvement of the consultant obstetrician, anaesthetist, incentivist, physician and to inform the neonatologist in view of requiring early delivery of the fetus. Quick history in regards to other source of infection should be taken such as presence of cough, coma, sputum, hemoptysis or dyspnea for presence of respiratory tract infection, loin pain, suprapubic pain, dysuria or cloudy urine for urinary tract infection or any vomiting, diarrhea and abdominal pain for any gastrointestinal tract infection. Examination of the lung for crepitation or rhonchi to assess for lung infection, loin tenderness in pyelonephritis should be done to gather source of infection. A sterile speculum investigation should be done to assess cervical opening in the case of labor, liquor color, and vaginal swab for culture and sensitivity for antibiotic administration. Intravenous access must be established for blood taking of full blood count for presence of neutropenia or neutrophilia in sepsis, CRP for infection, coagulation profile which could be deranged in sepsis, liver enzymes and blood culture for organism identification and antibiotic administration. An arterial blood gas should be done to assess presence of acidosis and hyperlactemia. An initial hydration should be given 20ml/kg an assess for response if still hypotensive she might require vasopressors. A central venous pressure line would be indicated for fluid management in her case. A broad spectrum antibiotics such as cefuroxime and metronidazole could be started till culture and sensitivity reports come back. A cardio tocogram is done to assess fetal status and an ultrasound to assess fetal lie, presentation, fetal weight and placental location for planning immediate delivery in the case of cohorioamnitis. Dexamethasone for lung maturation could be given if not given in previous admission and is not contraindicated in sepsis. She should be monitored in ITU with charting such as MEOWS(modified early obstetrics warning chart). Lactate levels, CRP can be taken to assess her progress for infection status and hydration. VTE prophylaxis should be given such as TED SOCKS, clexane during ITU admission.

b)      She should be managed in ITU post delivery for completion of antibiotics and to fully recover from the sepsis. The antibiotics should be reassessed by culture and sensitivity of the organisms found in her report as this is vital to prevent endometritis. This information should also be audited and information given to the infection control team for future purpose of empirical treatment for the emergence of newer organisms and resistance in infection. She should be managed with guidance of charting such as MEOWS which is friendly to be used for staffs and for proper response for the management in sepsis. We should refrain  from early discharge as sepsis takes a longer course for recovery. Earlier follow up should be arranged upon discharge. The fetal cultures should also be obtained in case of neonatal admission for the organism and this information given to the infection control team. Proper hospital based antibiotics protocol must be made for management of infection locally.

I had posted my answer on 8/1/11 ,but it was not corrected, although an assay posted after mine ,was corrected

the case goes with chorioamninitis, occured as a result of focus of infection in upper respiratory tracts in the presence of PPROM.

i should inform senior, infection control, and neonate expert if delivery is expected. 

i should do full examine for her for upper respiratory tract infection, trying to exclude / confirm the cases tha may develop badly and quickly (swin flu), i ask about similar symptoms in people in contact, vaccination against swin flu. also i should ask about coughing, sputum, dyspnea that may indicate to bronchitis, otitis media or pneumonia, as the bacterial infection may be the focus that cause bacteremia, and chorioamnionitis. i should have the same details about the history of diarrhea, is it enterocolitis, food poisoning. or just secondary to the treatments she may had? in addition, i should ask about the details of her addmission (i may get it from her file), if she had recieved corticosteroids, antibiotics, if she had sexual intercourse lately.

i'll ask about abdominal pain, regidity, how is fetal movement, the nature of discharges or leaking now, the offensive odor. presence of uterine contractions, size of uterus, presentation

to confirm diagnosis, i need CBC, cultures and sensitivity for urine, blood, stool, HVS and the liqour (if could be collected), in addition to blood group and Rh, i shoud request coagulation profile (PT, aPTT and fibrinogen) as septic shock is high risk of thrombosis, blood sugar and renal function test should done.

pelvic exam should be done with sterelised speculum, and with sterlised gloves to assess cervix cahnges, here i pay attention to the smell of discharges and its color, and if color of liqour if visible

i'll do ultrasound to confirm gestational age, presentation, and liqour volume, and to exclude / confirm any congenital anomalies -if this was not documeted during her last addmission-

for treatment, this is critical case, for both woman and her fetus, ot should be addmitted into resuscitation, with IV drip, paracetamol IV, broad spectrum antibiotics should be given, the first line is Klindamycin IV 900 mg / 8 hours with flagyl IV, and if  not available, may be as anal suppesitories.i give corticosteroids as 12 mg betamethason, putting in mind that if there is high index of chorioamninitis suspescion, we will not be abe to wiat 24 hours for the next dose or the most effect. in addition, if i have high index of septic shock, i should give 300 mg hydrocortison IV

if there is a little doubt in chorioamnionitis, and the case was mostly upper respiratory tract infection, antibiotics and paracetamol iv may be the treatment of choice.

if the case was chorioamnionitis, induction of labour is the cornerstone of safety, using prostaglandin vaginally, with vaginal delivery rout of choice. i should continue antibiotics during labour , i should use uterine tonics during the third satge of labour. putting in mind the increased risk of VTE, LMWH (clexan) should be started.

baby should be examined and be under supervesion of neonate specialist.

b- how can maternal mortality from infections be prevented?

firstly, patient and her partner should be informed about the case, and the maternal and fetal risks, avoiding vaginal exam as much as possibg, and when done, it should be with sterlized gloves

during inpatient care: before delivery: antibiotics, vagial delivery, anticoagulant, and supportive treatment like drip and liquids. during labour: continuation of IV antibiotics, paying attention to DIC signs, long-term follow up: continue antibiotics and anticoagulants prophylaxically for 7 days