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MRCOG PART 2 SBAs and EMQs

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Essay 340

Essay 340 Posted by PAUL A.
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]. (b) She is subsequently delivered and discharged. How can maternal mortality from infections be prevented? [6 marks]
sdggus Posted by sdggus D.
a) i will enquire a few things in history. i will ask that she was vaccinated for swine flu or not. i will enquire about history of cough, expectoration and shortness of breath. i will also ask about any special exotic food intake in the last couple of days, which could explain diarrhoea.i will go through her ante- natal notes to learn about her steroid injections and to go through her blood tests ( white cell count, c reactive protein )and any organisms grown in vaginal swab or not.i will also ask about any history of unhealthy dischargep/v or any smelly or pyogenic discharge p/v. i would also like to enquire about baby.
on examination, i will recheck her vitals including respiratory rate and saturation of oxygen. i will look for abdominal examination to look for abdominal tenderness, any contraction, presentation of baby. i will do a ctg to check fetal well being and ultra sonography to confirm presentation, AFI.
among investigations, i will send bloods for white cell count, c reactive protein, liver function tests, urea and electrolytes, blood film, blood culture and stool culture.i would like to admit this patient in an isolated room and will follow local trust guidelines for infection control protocols. i will explain her that most likely diagnosis is chorioamnionitis, meaning infection of womb. i will also tell her that delivery of the baby is the ultimate management of this condition. knowing the guarded prognosis of neonate at this gestation, i will arrange for a neonatal consultation. i will discuss with the microbiologist on duty regarding choice of antibiotics and start accordingly iv. i will begin paracetamol to reduce temperature, properly hydrate her. monitor urine output. after controlling the acute situation, i will assess her cervical fingings to plan her delivery.

b) to prevent maternal mortality from infection, it is necessary to diagnose the infection proeprly.multidisciplinary input, including physician, microbilogist should be sought for a proper plan of diagnosis and management pending the diagnosis, patient should be covered by a broad spectrum antibiotic, with regular monitoring of vital signs, keeping an eye on early warning scores. interventions should be made quickly with worsening early warning scores, including shifiting mum to HDU, treating her in isolation where appropriate to prevent spread.
Where are our old posted essays? Posted by miss T.
We had posted essay but cant see it now, what happened to many posts that were here...
TSH Posted by PAUL A.

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 Do not repeat the question with superimposed infection
most probably chorio amnionitis that led to septic shock Will this cause sore throat? .Other differential
diagnosis should include swine flu,or gastroenteritis . Management will require
admission as an emergency, correction of shock and infection, and delivery will you deliver if she has flu of gastroenteritis?.
Communication,resuscitation,monitoring and investigations are done simultaneously.
Local guidelines and protocols are followed.    Guidelines and protocols for what? Communication involve call for
help,inform consultant obstetrician, reception desk why reception desk? to call anesthetist,chief
midwife, neonatologist,porters why??. 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 (1) , IV broad spectrum antibiotics, and antipyretics (1) . Will ask the anesthetist to
put a central venous pressure catheter to avoid fluid overload
  not necessary 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(1) . Automated monitoring of pulse BP and temperature.
And monitoring Respiratory rate and level of consciousness using Glasgo coma
scale. (There is no logic to your answer - Hx, examination, investigations, treatment. You have given antibiotics before any investigations) 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 which test? as early treatment with
oseltamivir or zanamovir would be more effective if given within 1st 48hr of
symptoms . Urine dipstix for nitries,glucose why?? 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 (So what will you do if you have a pathological CTG and the woman is still unstable?) .
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 (1) 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
This is meaningless. Use of prophylactic antibiotics in emergency cesarean section after clamping
the cord what about elective CS?. Use of prophylactic antibiotics in elective cesarean section in certain
situations eg morbidly obese patient, diabetid patients or those with HIV Should be given for all CS.
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 Do you know how many mothers die from MRSA? What about group A strep from recent CEMACE alert?

 

I suggest you re-answer the question and include your answer plan. There should be a recognisable structure to your answer..

sdggus Posted by PAUL A.

a) i will enquire a few things in history. i will ask that she was vaccinated for swine flu or not. i will enquire about history of cough, expectoration and shortness of breath. i will also ask about any special exotic food intake in the last couple of days, which could explain diarrhoea.i will go through her ante- natal notes to learn about her steroid injections and to go through her blood tests ( white cell count, c reactive protein ) How useful are normal blood tests from the day before?? and any organisms grown in vaginal swab or not.i will also ask about any history of unhealthy dischargep/v or any smelly or pyogenic discharge p/v (1). i would also like to enquire about baby (what about the baby?).
on examination, i will recheck her vitals including respiratory rate and saturation of oxygen (You are yet to recognise that this is a severely ill woman. Will you take any infection control measures?). i will look for abdominal examination to look for abdominal tenderness(1), any contraction, presentation of baby. i will do a ctg to check fetal well being and ultra sonography to confirm presentation, AFI (? value in the presence of PPROM).
among investigations, i will send bloods for white cell count, c reactive protein, liver function tests, urea and electrolytes, blood film (WHY??), blood culture and stool culture (1).i would like to admit this patient in an isolated room and will follow local trust guidelines for infection control protocols. i will explain her that most likely diagnosis is chorioamnionitis (SO WHY ISOLATE HER?), meaning infection of womb. i will also tell her that delivery of the baby (1)is the ultimate management of this condition. knowing the guarded prognosis of neonate at this gestation, i will arrange for a neonatal consultation. i will discuss with the microbiologist on duty regarding choice of antibiotics and start accordingly iv How should the microbiologist know? You are the obstetrician. i will begin paracetamol to reduce temperature(1), properly hydrate her. monitor urine output. after controlling the acute situation, i will assess her cervical fingings to plan her delivery.

b) to prevent maternal mortality from infection, it is necessary to diagnose the infection proeprly.multidisciplinary input, including physician, microbilogist should be sought for a proper plan of diagnosis and management pending the diagnosis, patient should be covered by a broad spectrum antibiotic (? what about viral infections?), with regular monitoring of vital signs, keeping an eye on early warning scores. interventions should be made quickly with worsening early warning scores, including shifiting mum to HDU, treating her in isolation where appropriate to prevent spread.

How do you stop someone dying from any disease?

1) Prevent disease - education, vaccination, prophylaxis

2) Diagnose early - education of patients / clinicians

3) Treat promptly and appropriately

miss T Posted by PAUL A.

This lady is in septic shock, the likely cause being chorioamnionitis. She is at risk of further deterioration with multiple organ failure and potential maternal and fetal mortality so prime need is immediate resuscitation.
I will look immediately to the ABC (1), need of airway, breathing by giving high flow oxygen thru face mask and circulation by maintaining 2 IV lines with large bore cannula and initiating fast crystalloid fluids IV. Input/Output monitoring is essential and indwelling catheter will be inserted. Multidisciplinary approach (1) include senior obstetrician, anesthetist, intensivist, midwife and neonatologist.
(will you take a Hx?) Investigations include full blood count for Hb, WBC, CRP, Coagulation screen, urea and electrolytes plus renal (what are U&Es?) and liver function tests. Septic screening including blood culture, throat swab, urine analysis and culture, high vaginal swab(1)., stool analysis. CTG trace for fetal viability and well being(1).
A brief (why only a brief Hx in a seriously ill woman?) look into history with onset and duration of symptoms, did she get antibiotics and dexamethasone before (what difference will this make?). Quick (why quick? Severely ill women need detailed assessment) examination including PA for fundal level (? Value in presence of PPROM), contractions and is the uterus relax between contraction(?? UTERINE TENDERNESS – that is the one clinical sign you need). Pelvic examination is needed after initial hemodynamic stabilization to see if she is in spontaneous preterm labour.
Drug management include triple antibiotics coverage(which antibiotics?). Steroids for fetal lung maturity, if not given earlier(will you wait for them to be effective?). IV antipyretics (? NSAIDs??) and cold sponges.
After initial stabilisation, she need to be delivered (if she has flu?) balancing her condition, with fetal status and neonatal bed and physician availability. If she is already in labour with cephalic presentation, augmentation is needed (why augment normal labour? What are the fetal consequences of augmenting normal labour?) but if cervix is not favourable a cesarean delivery will be a good option as likely success of induction at this gestational age is low(not true – IOL likely to be successful but issue is whether fetal condition would permit this). CS should be done by the senior obstetrician (lower segment not formed, difficult delivery in absence of amniotic fluid). Fetus is at risk of infection, pulmonary hypoplasia (is it?? when do the terminal alveoli develop?) and contracture formation. Senior neonatologist need to attend the delivery and baby will be admitted to NICU.
The family need to be informed continuously of her condition and plans. Delivery decision and route will be made jointly by women and obstetrician. Risk management form need to be filled up (what is the trigger?) and all events should be documented.
(b) Maternal mortality can be prevented by counselling (how??), screen and treat commonest infections, and early treatment (1) in case of symptomatic infection.
General health advise (like what?) will be given at initial contacts with GP.
Pregnant women should be screened for asymptomatic bacteriruia and positive results should be treated. Ladies with recurrent urinary tract infection are given prophylactic antibiotics for the duration of pregnancy, adequate fluid intake plus report early should symptom arise.
Women are screened at the time of intra-uterine procedures like IUCD insertion (maternal mortality??) and evacuation and curettage based on risk factor or are treated empirically if time does not permit the results to be available.
Bacterial endocarditis antibiotic prophylaxis is recommended for women with heart disease to cover labour (wrong – see new guidelines for preventing bacterial endocarditis).
Early treatment of acute PID (how do you define maternal mortality?) is recommended before the results are available based on symptoms direction to prevent the consequences of delay (chronic pelvic pain, infertility).

Bahawana Posted by PAUL A.

My immediate management would be to stabilise the patient and making sure that her airway is clear and give her oxygen to maintain her saturation.  Next, I would put two wide bore cannula and do bloods including full blood count (Raised white blood cell count indicative of infection), CRP (marker for infection and useful for monitoring), Renal and liver function test (multi system failure or DIC) and blood culture (causative organism), Fibrinogen degradation products and fibrin (DIC).This will be  acase of multidisciplinary involvement  involving anaesthesist, paediatrician, midwife, microbiogist and I will involve my consultant early in her care. You have assessed ABC and obtained IV access but not resuscitated the woman. You have taken blood tests before taking a Hx or examining the woman.

I will take detailed history about onset,duration,nature of pain( D/d placental abruption  is the presentation consistent with abruption??, any surgical cause),information about change in colour, smell of liquor (1) , any vaginal bleeding,any abdominal contractions(likely to go into labour). Any recent of viral infection, swine flu will help make diagnosis. This is most probably case of chorioamnionitis leading to sceptic shock. I will do abdominal examination (looking for what?) will help in diagnosis and per speculum examination to take high vaginal and endocervical swabs.

I will immediately liaise with anaesthetist (anyone else?) as she will need intense monitoring in HDU/ITU.  A central venous/arterial line would be needed to do continuous monitoring of BP and Pulse. I would catheterise the patient and do strict input/output measurement and send urine for culture/sensitivity at the same time.

I will liaise with microbiologist to start broad spectrum antibiotics (like?) and also give her paracetamol to bring her temperature down(1). I will also inform neonatologist (1). I would request continuous fetal monitoring (immediate management)and liquor volume (? Relevance in presence of PPROM), end diastolic flow (WHY???) and growth if possible to ensure foetal well-being(SO WHAT WILL YOU DO DIFFERENTLY IF FETAL GROWTH IS ON THE 1ST CENTILE OR THE 90TH CENTILE?)..I will ensure that she had steroids (will you delay delivery to give steroids?). Once stable I will discuss with patient regarding delivery of the baby even though premature as severe infection can result in increased perinatal morbidity and mortality. Also mother takes precedence over foetus here. If already not in established labour, Caesarean section would be best option (? evidence). I will also consider thromboprophylaxis and debrief patients about all the events.  

b) In recent CEMACE, infection has come out as the leading cause of maternal death. Prevention starts at pre-pregnancy stage or even earlier. Immunisation (eg rubella, DPT (how many maternal deaths in the UK are caused by rubella or DPT?)) can prevent some diseases. The patient should be advised about importance of hygiene, washing vegetables, salads thoroughly, wearing gloves while gardening, cat litter (toxoplasmosis (how many deaths?)), avoiding cheese (listeria), washing hands before having food.

Also optimising previous health conditions (good control of diabetes) will reduce risk of infection.If prone for urinary tract infections or prolonged rupture of membranes , prophylactic use of antibiotics will minimise infection.

Patient should be made aware of early signs of infection (1) and seek timely help to prevent dissemination of  infections.

You have written a description of what you will do rather than answer an exam question. Management = Hx, examination, investigations, treatment. The fact that you take FBC at one point and obtain CSU when you pass a catheter does not mean you answer the question in that way.

Essay 340 answer Posted by N G.

 

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. 

Posted by Neelima  D.

 

 

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

 

Deccan Posted by deccan C.
This clinical picture suggests chorioamniotis and septic shock with high suspicion of group A streptococcal infection. This is a medical emergency characterized by rapid and fatal course with risk  of multiorgan failure if treatment  is delayed. This diagnosis carries significant risk of maternal and perinatal mortality of up to 30%. Rapid and aggressive management is required which consists of fluid resuscitation, control of infection and immediate delivery of the fetus. Management should be undertaken by multidisciplinary team which should include obstetrician, neonatologist, microbiologist and physician with input from the anaesthetist. History is taken regarding fever with chills, rash, vaginal discharge, productive cough and urinary symptoms suggestive of infection. Examination is undertaken to identify wide spread rash, or red eyes, mouth and vagina which suggest toxic shock syndrome. Abdomen palpated to assess the size of the uterus and uterine tenderness. Monitoring is essential by close observation of maternal pulse, blood pressure, temperature, respiratory rate, urine out put and oxygen saturation.  Modified early Obstetric warning score should be used to identify severity of infection and need for early referral to ICU. Blood, swabs from throat, vagina, MSU are collected for culture and sensitivity to isolate the organism. Other investigations include FBC , CRP as raised WBC count and CRP are indicators of infection  and act as base line values for monitoring control of infection. U & E, serum creatinine are useful to identify renal impairment. Liver function tests and coagulation screen are done to exclude liver failure and coagulopathy. Raised serum lactate indicates reduced tissue perfusion. Haemodynamic stabilization is undertaken by infusing intravenous crystalloids  to maintain blood pressure and tissue perfusion. Vasopressor such as dopamine is also required. Fluid management should be monitored by CVP monitoring. Intravenous broad spectrum antibiotics should be administered within one hour of recognition of sepsis without waiting for microbiology reports. Commonly used regimens include penicillin /ampicillin plus gentamycin and metronidazole. Intravenous immunoglobulin has got immunomodulatory effect may be useful adjunct to the antibiotic therapy in the treatment of Gr. A streptococcal infection.  Symptomatic treatment is required for the control of fever, pain and diarrhea. Fetal well being is undertaken by CTG. Ultrasound scan is done to identify the presenting part as it is difficult to ascertain clinically. Blood investigations( WBC count, CRP, Blood glucose, serum creatinine, LFT, Clotting profile and serum lactate) should be repeated every day to monitor the severity of infection and for to detect organ failure. Woman and her family should be fully informed about the diagnosis, risks and implications of severe sepsis for the mother and the fetus. Neonatologist’s help is sought to explain the gestational age specific neonatal survival chances based on the data from the local neonatal unit. Administration of corticosteroids is considered for fetal lung maturity as it may theoretically suppress immunity in the presence of systemic illness. Senior Obstetrician’s opinion is taken. Delivery should not be delayed vaginal delivery is allowed in case of dead fetus or if she is in active labour with good cervical dilatation and presenting part down even if presenting by breech. Caesarean section is indicated in case of unsatisfactory CTG recording and in the absence of labour pains. Woman’s views are taken regarding delivery if possible. SCBU is informed about the possible admission of very premature baby. B) All the health professionals  must be aware of the symptoms and signs of maternal sepsis and critical illness and of rapid and potentially lethal course of severe sepsis and septic shock. Genital tract sepsis prompts urgent medical review. All maternity units should have guidelines for the investigations and management of genital tract sepsis. If sepsis is suspected , regular frequent observations should be made and use of Modified Early Obstetric Warning Score in all maternity in patients helps to identify seriously ill pregnant women to be refered to critical care.High dose broad spectrum intravenous antibiotic treatment should be started immediately and delivery is indicated if pelvic sepsis is suspected. All women   who are undergoing  surgical evacuation of pregnancy should be screened for genital tract infection and antibiotic prophylaxis is recommended. Care should be taken to ensure that the uterus is empty following a surgical evacuation of the uterus.  Follow up should be arranged  with community carers( GP, midwife and health visitors) who should be vigilant about the symptoms of sepsis  should visit regulary. Early referral to hospital may be life saving.
was sent on 1/1/11 by e mail Posted by H H.

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.
 
 

EssaY 340 Posted by j  .

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.

ss Posted by shmaila S.

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.

Septic Shock (sofia) Posted by sofia  S.
Septic shock. Ans a:Patient is in septic shock most probable cause for which is chorioamnionitis but pylonephritis,gastroenteritis,pneumonia meningitis and dvt should be ruled out. I will call for help and inform consultant, anesthetist , intensive care specialist and senior midwife and confirm availability of bed in scbu.i will resuscitate and assess simultaneously.follow the unit protocol.check airway and breathing,o2 saturation and give intransal oxygen. Establish iv line with 2 wide bore cannula and start iv crystalloid/colloid resucsitation. Monitor her by early obstetric warning chart. Review her antenatal records to confirm gestational age,previous investigations like FBC and vaginal swab culture, betamethasone injection and antibiotic intake . Ask her about change in color and odour of discharge which will suggest chorioamnionitis. Any vaginal bleeding would suggest abruption placenta. Vomiting along with diarrohea, presence of blood mucus in stool and history of partially cooked food may indicate gastroenteritis or food poisoning.cough with sputum and shortness of breath to rule out pneumonia. Contact with person with H1N1 or other illness. Neurological symptoms and headach would suggest meningitis. Examination include checking hydration,throat exam with swab for culture. Chest examination for breath sound . abdominal examination for fundal height ,uterine tenderness, presence of contraction and fetal heart rate. Any loin tenderness.legs for erythema and tenderness. Per speculum examination for discharge, high vaginal swab. Per vaginal exam for cervical status in presence of contractions. Investigation will include FBC, CRP to asses severity of infection. Electrolyte , coagulation profile as she is at high risk of DIC. Baseline renal and liver function teat. Blood sugar.throat swab and sputum for culture.urine stool ,high vaginal swab and blood culture to identify source of sepsis.CTG for fetal wellbeing and usg for confirmation of presentation. Management should be multideciplinary involving obstretic consultant, anesthetist,neonatologist, intensive care specialist and microbiologist. Start her on broad spectrum antibiotic likeiv cephalosporin and metronidazole+/- gentamycin. Antipyretics for fever, maintain hydration and asses her for thromboprophylaxis.icu care will be needed if features of ARDS or BP not responsive to fluid therapy and inotropic support is needed. Response to treatment by improvement in vital parameters. Change in antibiotic if no response in 24-48 hrs or according to culture report in consultation with microbiologist. Plan delivery once patient stable. Mode of delivery will depend on fetal condition, cervical status.and most likely by cesarean. Maternal wishes should be taken into account. Ans b:Maternal mortality can be prevented by clear communication between hospital and community care provider(GP, midwife and healthvisitor) to arrange proper follow up .monitoring P,BP,temp and lochia for several days after discharge to detect earliest symptoms of sepsis and early referral.all healthcare worker should be aware signs of genital tract sepsis.guidelines should be present for managment of genital tact sepsis.if sepsis suspected then use of MEOWS is recommended. Use of broad spectrum iv antibiotic immediately while awaiting culture result. Identification and education of high risk cases for sepsis like prolonged prom, manual removal of placenta, obesity,diabetes, immunocompromised, cervical encircalage or GBS carrier. Optimize management by coordination between members of multideciplinary team and expert advice from consultant microbiologist at earlier stage. Audit of all cases of severe morbidity or mortality from genital tract sepsis.
Essay 340 by N Posted by Sherif N.

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.

 

Posted by amr G.

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

essay 340 by OB Posted by Ana B.

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 2nd 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.  

NG Posted by PAUL A.

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 (1) 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 (1 multi-disciplinary care ).Abdominal and  sterile speculum examination are required  to give further clues to the diagnosis (how will this give you a clue?) and to confirm the position of the baby (what difference does it make if it is OP or OA?).Urgent investigations (Where is Hx / examination?) 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 (? Blood cultures, swabs…).IV Fluids and broad spectrum antibiotics should be started after sending blood cultures (1)  and an arterial blood gas should be considered .Quick (severely ill woman – why does it have to be quick? ) review of notes will provide information regarding corticosteroids and any other risk factors(like what?).

Only after maternal stabilization CTG (1) 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 (? Acute management). There is no logical approach: Hx, examination, invest, treatment.

 

b)Infection can cause severe maternal and fetal morbidity and mortality (that is why you were asked the question).The first step tp prevent this is to educate (1) 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. (value of vaccination, prophylactic antibiotics.

You prevent mortality from any disease by preventing the disease, early diagnosis and prompt appropriate treatment)

Neelima Posted by PAUL A.

A)

The initial treatment is Oxygen by face mask and aggressive fluid resuscitation (1) 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 (1) 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(1). A cardiotocograph (1) 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(? Any other investigations? If you had written an answer plan with Hx, exam, invest, you would have remembered to write about investigations).Broad spectrum IV antibiotics (1) should be started such as cefuroxime and metronidazole and IV/PR paracetamol (1) given to bring down the temperature.If she fulfils the local protocol for swine flu (why if? Does she or does she not meet the criteria?), 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(1).The management should also involve intensive care specialists, physicians, microbiologists, virologists,anaesthetist  and the neonatologist(1 multi-disciplinary care).Corticosteroids (are you going to wait for them to be effective?) should be given to mature the baby's lungs if not given previously.

The initial blood investigation (after you have started antibiotics??) 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 (?? Given that there may be an indication for delivery??) 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 (what will make you decide that these are indicated?).Delivery should not be delayed if sepsis (including say flu infection? Is this an indication for delivery?) is suspected and and an induction of labour (1) 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 (1) 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 (1) 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. (Prevention [peophylaxis, vaccination], early diagnosis, prompt treatment)

Neelima

Deccan Posted by PAUL A.

This clinical picture suggests chorioamniotis and septic shock with high suspicion of group A streptococcal infection. This is a medical emergency characterized by rapid and fatal course with risk  of multiorgan failure if treatment  is delayed. This diagnosis carries significant risk of maternal and perinatal mortality of up to 30%. Rapid and aggressive management is required which consists of fluid resuscitation, control of infection and immediate delivery of the fetus (You have reached significant conclusions without even setting eyes on the woman. You should reserve judgement and base your treatment on your Hx, examination and investigation findings). Management should be undertaken by multidisciplinary team (1) which should include obstetrician, neonatologist, microbiologist and physician with input from the anaesthetist. History is taken regarding fever with chills (what difference does this make given the information provided inn the question?), rash, vaginal discharge (what about the discharge? She has PPROM), productive cough and urinary symptoms suggestive of infection(given your opening statements, are you still going to deliver if she has UTI?). Examination is undertaken to identify wide spread rash, or red eyes, mouth and vagina which suggest toxic shock syndrome(what is ‘toxic shock syndrome’ typically associated with?). Abdomen palpated to assess the size of the uterus and uterine tenderness(1). Monitoring is essential by close observation of maternal pulse, blood pressure, temperature, respiratory rate, urine out put and oxygen saturation.  Modified early Obstetric warning score should be used (1) to identify severity of infection and need for early referral to ICU. Blood, swabs from throat, vagina, MSU are collected for culture and sensitivity to isolate the organism(1). Other investigations include FBC , CRP as raised WBC count and CRP are indicators of infection  and act as base line values for monitoring control of infection. U & E, serum creatinine are useful to identify renal impairment. Liver function tests and coagulation screen are done to exclude liver failure and coagulopathy(1). Raised serum lactate indicates reduced tissue perfusion. Haemodynamic stabilization is undertaken by infusing intravenous crystalloids  to maintain blood pressure and tissue perfusion. Vasopressor such as dopamine is also required (when is the last time you used this drug?). Fluid management should be monitored by CVP monitoring. Intravenous broad spectrum antibiotics should be administered within one hour (where did you get 1 hour from? Why wait up to 1 hour?) of recognition of sepsis without waiting for microbiology reports. Commonly used regimens include penicillin /ampicillin plus gentamycin and metronidazole(1). Intravenous immunoglobulin (have you ever used this or seen it being used?) has got immunomodulatory effect may be useful adjunct to the antibiotic therapy in the treatment of Gr. A streptococcal infection.  Symptomatic treatment what is this?) is required for the control of fever, pain and diarrhea. Fetal well being is undertaken by CTG(1). Ultrasound scan is done to identify the presenting part as it is difficult to ascertain clinically. Blood investigations( WBC count, CRP, Blood glucose, serum creatinine, LFT, Clotting profile and serum lactate) should be repeated every day (ACUTE MANAGEMENT) to monitor the severity of infection and for to detect organ failure. Woman and her family should be fully informed about the diagnosis, risks and implications of severe sepsis for the mother and the fetus. Neonatologist’s help is sought to explain the gestational age specific neonatal survival chances based on the data from the local neonatal unit. Administration of corticosteroids is considered for fetal lung maturity as it may theoretically suppress immunity in the presence of systemic illness (Not contraindication to steroids). Senior Obstetrician’s opinion is taken. Delivery should not be delayed vaginal delivery is allowed in case of dead fetus or if she is in active labour with good cervical dilatation and presenting part down even if presenting by breech. Caesarean section is indicated in case of unsatisfactory CTG recording and in the absence of labour pains. Woman’s views are taken regarding delivery if possible. SCBU is informed about the possible admission of very premature baby. B) All the health professionals  must be aware (1) of the symptoms and signs of maternal sepsis and critical illness and of rapid and potentially lethal course of severe sepsis and septic shock. Genital tract sepsis prompts urgent medical review. All maternity units should have guidelines (1) for the investigations and management of genital tract sepsis. If sepsis is suspected , regular frequent observations should be made and use of Modified Early Obstetric Warning Score in all maternity in patients helps to identify seriously ill pregnant women to be refered to critical care.High dose broad spectrum intravenous antibiotic treatment should be started immediately and delivery is indicated if pelvic sepsis is suspected. All women   who are undergoing  surgical evacuation of pregnancy should be screened for genital tract infection and antibiotic prophylaxis is recommended. Care should be taken to ensure that the uterus is empty following a surgical evacuation of the uterus.  Follow up should be arranged  with community carers( GP, midwife and health visitors) who should be vigilant about the symptoms of sepsis  should visit regulary. Early referral to hospital may be life saving.

J Posted by PAUL A.

A..The probable differential diagnosis are chorioamnionitis,flu like infections[swine flu], severe gastro enteritis. I will admit the patient after systematic assessment (You have not presented a systematic assessment: ABC and resuscitation, Hx, examination, investigations IN THAT ORDER).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 (You have venous access before taking a Hx or examining the woman and you have taken blood then proceeded to examine the woman. If you were so concerned, you should have started fluid resuscitation).Throat/nasal swabs incase of suspected respiratory infection.MSU to be sent to rule out UTI (1). Abdominal examination to assess the SFH and uterne tenderness (1) 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 (1) may indicate tachycardia in the presence of maternal infection. Patient will be admitted in HDU of labour ward and consultant obs/anaesthesit/neonatology team (1 multi-disciplinary care) to be informed of admission. IV antipyretics (which one?) and antibiotics (like what?) started according to hospital protocol. Zanamavir (1) 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 (how many pregnant women die from hep B, or HIV every year?).Patients who are non immune to rubella (how many maternal deaths??) and syphilis should avoid contact ith infected people and report immediately of any symptoms.Early diagnosis and treatment (1 how?) is important in preventing mortality.Raising awareness of symtoms of impending infection in PPROM and flu vaccination (1) is important.Adherence and development of national and local guidelines (1) of infection in pregnancy shoul be stressed and auditing the current practise  ill ensure things are done correctly.

Answer for essay 340 Posted by Yingjian C.

(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.   

ss Posted by shmaila S.

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 340 Posted by suad H.



 

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.


 
 

Shmalia Posted by PAUL A.

(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 (1) . i will send bloods for FBC, G&S, U&E,LFT's, CRP,clotting profile, blood cultures(1).I will commence her observation on MEWS chart (1).i will transfer her to high dependency unit (before taking a Hx or examining her?) in isolation away from other pregnant women and use barrier nursing (1) with patient protective equipment. i will examine (will Hx not help you?) 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(1)..i will transfer her to high dependency unit in isolation away from other pregnant women and use barrier nursing with patient protective equipment (you have already written this). i will commence her on broad spectrum antibiotics like Augmentin, metronidazole and gentamycin(1). if allergic pennicillin then clindamycin. i will also commence her on antivirals for H1N1 ( osteltamivir,tamiflu)(1).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 (1 multi-disciplinary care).she may need arterial line. once patient is stabilised i will commence CTG for fetal monitoring(1)  and make a decision about timing and mode of delivery with steroid cover for fetal lung maturation(will you delay delivery for steroids to be effective?).i will commence her on thromboprophylaxis once clotting results are available(even if you are going to deliver?)

Although you have earned a pass mark, your answer does not follow a logical sequence and does not reflect an appropriate answer plan.

(b)    Maternal mortality can be prevented by making women aware (1) 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 (1) and  close monitoring in a high dependency unit with multidiciplinary team approach (1).early commencement of broad spectrum antibiotics. infection can be prevented following infection control guidelines and maintaining hand hygeine and using patient protecting equipment.

Sofia Posted by PAUL A.

Septic shock. Ans a:Patient is in septic shock most probable cause for which is chorioamnionitis but pylonephritis,gastroenteritis,pneumonia meningitis and dvt (is this presentation consistent with DVT?)  should be ruled out. I will call for help and inform consultant, anesthetist , intensive care specialist and senior midwife and confirm availability of bed in scbu(1).i will resuscitate and assess simultaneously.follow the unit protocol.check airway and breathing,o2 saturation and give intransal oxygen. Establish iv line with 2 wide bore cannula and start iv crystalloid/colloid resucsitation(1). Monitor her by early obstetric warning chart(1). Review her antenatal records to confirm gestational age (waste of time – accept what the question states),previous investigations like FBC and vaginal swab culture (what difference will these make?), betamethasone injection and antibiotic intake . Ask her about change in color and odour of discharge which will suggest chorioamnionitis(1). Any vaginal bleeding would suggest abruption placenta(is the Hx given in the question consistent with abruption?). Vomiting along with diarrohea, presence of blood mucus in stool and history of partially cooked food may indicate gastroenteritis or food poisoning.cough with sputum and shortness of breath to rule out pneumonia. Contact with person with H1N1 or other illness. Neurological symptoms and headach would suggest meningitis (There are 2 -3 marks for Hx and you waste your time and space covering every possible diagnosis). Examination include checking hydration,throat exam with swab for culture. Chest examination for breath sound . abdominal examination for fundal height ,uterine tenderness(1), presence of contraction and fetal heart rate. Any loin tenderness.legs for erythema and tenderness. Per speculum examination for discharge, high vaginal swab. Per vaginal exam for cervical status in presence of contractions. Investigation will include FBC, CRP to asses severity of infection. Electrolyte , coagulation profile as she is at high risk of DIC. Baseline renal and liver function teat(1). Blood sugar(why??).throat swab and sputum for culture.urine stool ,high vaginal swab and blood culture to identify source of sepsis(1).CTG for fetal wellbeing (1) and usg for confirmation of presentation. Management should be multideciplinary involving obstretic consultant, anesthetist,neonatologist, intensive care specialist and microbiologist (you already informed them). Start her on broad spectrum antibiotic likeiv cephalosporin and metronidazole+/- gentamycin(1). Antipyretics (which one?) for fever, maintain hydration and asses her for thromboprophylaxis.icu care will be needed if features of ARDS or BP not responsive to fluid therapy and inotropic support is needed. Response to treatment by improvement in vital parameters. Change in antibiotic if no response in 24-48 hrs (ACUTE MANAGEMENT) or according to culture report in consultation with microbiologist. Plan delivery once patient stable. Mode of delivery will depend on fetal condition, cervical status.and most likely by cesarean. Maternal wishes should be taken into account. Ans b:Maternal mortality can be prevented by clear communication between hospital and community care provider(GP, midwife and healthvisitor) to arrange proper follow up .monitoring P,BP,temp and lochia for several days (how many days? By who?) after discharge to detect earliest symptoms of sepsis and early referral.all healthcare worker should be aware signs of genital tract sepsis(1 what about sepsis from other sources?).guidelines should be present for managment of genital tact sepsis(1).if sepsis suspected then use of MEOWS is recommended. Use of broad spectrum iv antibiotic immediately while awaiting culture result. Identification and education of high risk cases for sepsis like prolonged prom, manual removal of placenta, obesity,diabetes, immunocompromised, cervical encircalage or GBS carrier. Optimize management (1) by coordination between members of multideciplinary team and expert advice from consultant microbiologist at earlier stage. Audit of all cases of severe morbidity or mortality from genital tract sepsis.

N Posted by PAUL A.

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(1), antipyretics (is this resuscitation?), and broad spectrum IV antibiotics covering Gram +ve, Gram -ve bacteria and anaerobes (if this woman came to your unit, will you give her antibiotics before you have even taken a Hx or examined her?). corticosteroids to be given, even if decision of delivery will be taken before the time needed for corticosteroids to act(? meaning).

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, dysentery (is this appropriate Hx in a woman with suspected chorioamnionitis?). examination of the chest for wheezes, abdomen for uterine tenderness(1), PV for offensive discharge. ultrasound needed to detect fetal viability, amount of liquor(? relevance), do BPP(??? why), CTG (1) 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(you should have thought of that when you wrote your answer plan)), cross match and save bllod in case. FBC, U&E, liver functions,(1)

multidisciplinary team (1) 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 (1) whether by induction of labour, if cervix is favourable and maternal and fetal conditions permit, or CS(1).

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

b) proper instruction should be given to the patient (1) 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 (what about antenatal infection?) couldn't be prevented and already occured, so prompt and immediat management (1) is needed to prevent deterioration of the patient's conmdition and prevent maternal mortality.

Amr Posted by PAUL A.

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.(will you take a Hx?) Respiratory rate and oxygen saturation should be checked (Will you examine her chest?).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(1).If suspicion of swine flu is strong multidisclinary team (1) 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(1).The patient is properly managed in ITU or high dependancy unite taking proper precaution for isolation and infection control(1).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 (how will this be useful?).If the patient is proved to be in chorioamnionitis , delivery (1) should be affected.Induction of labour , or C.S according to the cervical favourability and fetal well being(1).

No logical approach – Resuscitate, Hx, exam, invest, treatment

 

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 (1) 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 (1) about the early symptoms of infection is essential.the health care professionals should have high index of suspicion (1) to diagnose and start treatment for infectious morbidities

OB Posted by PAUL A.

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  why take blood before taking a Hx or examining the patient? Will clinical assessment not influence your investigations? as patient in shock. Starting IV fluids resuscitation is important(1)

Taking history will help diagnosis and differential diagnosis: enquiry about the members of family affected (1)  (viral infection), severity of their condition and similar signs; change in diet or eating out (gastroenteritis); symptoms like cough (chest infection); abnormal smelly discharge(1), 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(is this presentation consistent with VTE??). Aslo I would enquire about current and recent medications, allergies, current medical conditions and problems during the pregnancy (waste of time & space). 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 (when you have to write this you should recognise your approach is wrong) 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 (1) 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 (1).

As objective examination (do you do investigations BEFORE examination?) should  performed starting from  vital signs,  auscultation of the chest ,  palpation of the  abdomen, uterus for uterine tenderness(1), assessing presentation and lie  by ultrasound (is this examination?); and speculum examination  if necessary to assess approximate vaginal dilatation (do you assess dilatation on speculum examination?); and if in advanced labour – vaginal examination may be necessary.

As the patient is unstable ; continues monitoring, with obstetrics early warning chart (1) (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(1). Multidisciplinary approach should be used with discussions and informing of anaesthetist, senior midwife, neonatologist and senior obstetrician, microbiologist (1) at the later stage within 24-48 hours when culture is available. IV resuscitation, broad spectrum intravenous antibiotics such cephalosporin’s of 2nd generation (is this sufficient for chorioamnionitis?), IV paracetamol (1) 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(1), 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 (1) 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 (1) 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.

Yingjan Posted by PAUL A.

(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(1). 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 (1) why take blood before taking Hx or examining the woman? Will these not influence your investigations?). At the same time, I would contact the obstetric consultant, intensive care physician, anesthetist and neonatologist (1) what will you tell them? You know very little about the woman). An empirical broad spectrum intravenous antibiotics such as the ampicillin (is this a broad spectrum antibiotic?) should be commenced as soon as possible, after cultures are done.

I would then take a brief history (surely you need a full and thorough Hx in a seriously ill woman) from her, focusing on her history of pre-term rupture of membranes, if she had been monitoring her temperature at home regularly(what difference will this make?), the colour of the liquor(1), if there is any bleeding per vaginum and contraction pains. I would like to know the duration which she has been feeling unwell (1 day or 7 days – how will your management differ?) and find out more about the diarrhea- its duration (1 day or 7 days – what difference?), 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(looking for what? Fetal presentation??). 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(for what?).

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 (what is the indication for CS?)

b) Maternal mortality from infections can be prevented by several measures (Waste of time & space). 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 (1) 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 (1) and to return promptly to hospital if she feels unwell.

Posted by Dr Dyslexia V.

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.

X Posted by PAUL A.

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 How do you know? You have not taken a Hx or examined the woman 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 Are the symptoms presented an indication for delivery on their own? You should follow a simple process – take a Hx and examine the patient before making a diagnosis. Quick history You need a detailed Hx in a seriously ill woman in regards to other source of infection should be taken such as presence of cough, coma how do you take a Hx of 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 (1) , 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(1), 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 (1) 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 if you are going to write this, it better be correct and make sense. So she weighs 70kg – you will give 1.4L over what? 24 hours??? 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 (1) could be started till culture and sensitivity reports come back. A cardio tocogram is done to assess fetal (1) 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 (you are going to give it then deliver – where is the evidence that this is beneficial?). She should be monitored in ITU with charting such as MEOWS(modified early obstetrics warning chart)(1). 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 READ THE QUESTION – SHE IS DELIVERED AND DISCHARGED!!!!!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.

Read post above about answering essay questions. You got your level 1 plan wrong in (b) and there is no way back.

Marking Scheme Posted by PAUL A.

Answer plan 

(a)

Infection control

ABC & resus

Hx

- sore throat / flu in family (Flu, Gp A strep)

-colour of vaginal loss

-fetal movements

Exam

-chest / abdo

-speculum

Invest

-Bloods

-micro: blood cultures, swabs

-CTG

Treat

-broad spect antibiotics

-antiviral

-paracetamol

Monitor

-MEOWS chart

-HDU care / MDT

Delivery

 

(b)

? bugs

Prevent – vaccine / prophylaxis

Recognise early

Aggressive treatment

Guidelines


Marking Scheme

A good answer should include the following

(a)

  • Take measures to prevent the spread of infection (1 mark)
  • MDT with senior obstetrician / anaesthetist / HDU physician (1 mark)
  • ABC and resuscitate (1 mark)

History

  • Sore throat / flu symptoms in other family members may suggest flu or Group A Strep (1 mark)
  • Vaginal loss, fetal movements (1 mark)

Examination

  • Cardio-respiratory (1 mark)
  • Uterine tenderness & speculum examination (1 mark)

Investigations

  • FBC, CRP, U&E, LFT, G&S. ABG may be indicated (1 mark)
  • Blood cultures, throat and genital tract swabs (1 mark)
  • Fetal monitoring CTG (1 mark)

Treatment

  • Broad spectrum iv antibiotics (1 mark)
  • Anti-viral agent (1 mark)
  • Paracetamol. Oxygen may be needed (1 mark)

Monitoring

  • MEOWS chart (1 mark)

Delivery

  • Should be initiated on clinical suspicion of genital tract sepsis (1 mark)
  • Induce labour with oxytocin, CS for obstetric indications (1 mark)

 

(b)

  • Know recent rise in mortality from community-acquired group A streptococcal infection and flu (1 mark)
  • Know value of flu vaccination and routine use of prophylactic antibiotics in specific circumstances (1 mark)
  • Know importance of prompt recognition of sepsis both in hospital and in community (1 mark)
  • Know features of severe sepsis including tachypnoea, hypothermia and neutropaenia (1 mark)
  • Prompt and aggressive multi-disciplinary management including systemic antibiotics and fluid management and anti-viral therapy until if flu suspected clinically (1 mark)
  • Need for guidelines on the recognition and management of sepsis (1 mark)

 

 

CMACE EMERGENT THEME BRIEFING #1: Genital Tract Sepsis. September 2010

correction Posted by suad H.

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

answer to Q340. sorry for being late Posted by AMMAR A.

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

adadad Posted by PAUL A.

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