Essay 353

(a) Discuss the criteria for making a diagnosis of severe sepsis [6 marks].

The first criteria is pyrexia but a normal temperature does not exclude sepsis.

Hypothermia is a significant finding that may indicate severe infection and should not be ignored.

Swinging pyrexia and failure to respond to broad-spectrum intravenous antibiotics is suggestive of a persistent focus of infection or abscess.

Severe lower abdominal pain and severe ‘after-pains' that require frequent analgesia or do not respond to the usual analgesia are also common important symptoms of pelvic sepsis.

Diarrhoea is a common and important symptom of pelvic sepsis. Diarrhoea and/or vomiting in a woman with any evidence of sepsis is a very serious sign and an indication for commencing immediate broad-spectrum intravenous antibiotic therapy.

Persistent tachycardia >100 b.p.m. is an important sign which may indicate serious underlying disease.

Tachypnoea is sepsis until proved otherwise—persistently increased respiratory rate >20 breaths/minute is a significant clinical finding that can also indicate other serious pathology, such as pulmonary oedema, pneumonia, thromboembolism or amniotic fluid embolism, and impending cardiac arrest.

Leucopenia <4 · 109 white blood cells/l is a significant finding that may indicate severe infection.

(b) Discuss the interventions that would minimise the risk of mortality or serious morbidity in this woman [14 marks].

The clinical picture of this woman is suggestive of septic shock so prompt interventions include referral to the obstetric services as soon as possible.

The advice of an anaesthetist and the critical care team should be sought at an early stage.

vital signs ( temperature, pulse, blood pressure respiratory rate,and oxygen saturation) should be checked regularly.

Modified Early Obstetric Warning Scoring system (MEOWS) charts should be used to help in the more timely recognition, treatment and referral and to prevent developing, a critical illness.

High-dose broad-spectrum intravenous antibiotics should be commenced immediately, without waiting for microbiology results as immediate antibiotic treatment is life saving.

As she is having septic shock urgent microbiological advice is sought regarding the use of appropriate antibiotic. The choice of antibiotic can be Piperacillin–tazobactam 4.5 g 8-hourly or ciprofloxacin 600 mg 12-hourly plus gentamicin (3–5 mg/kg daily in divided doses every 8 hours by or a carbapenem such as meropenem (500 mg to 1 g 8-hourly by intravenous injection over 5 minutes or by intravenous infusion) plus gentamicin.

Metronidazole 500 mg 8-hourly may be considered to provide anaerobic cover.

If Group A streptococcal infection is suspected, clindamycin (600 mg to 1.2 g by intravenous infusion three or four times daily) is more effective slow intravenous injection).

Investigations include an ultrasound scan to check for retained products of conception and diagnostic evacuation of retained products of conception considered if there is still doubt. Haemoglobin, white cell count and C-reactive protein; blood cultures and swabs (throat, vagina), midstream urine and any other relevant samples (e.g. sputum, breast milk, stool) for microbiology.

Sustained increase in respiratory rate >20 breaths/minute or low oxygen saturation despite high-flow oxygen are significant clinical findings that should prompt urgent examination of the lung fields, lower limbs (for evidence of deep vein thrombosis), arterial blood gas measure-ment, electrocardiogram, and consideration of chest X-ray and ventilation perfusion scan to rule out problems such as pulmonary oedema, embolus or infection.

Persistent or swinging pyrexia and failure to respond to treatment may be the result of a persistent deep-seated focus of infection. Computed tomogra-phy or magnetic resonance imaging be considered to locate focus of postnatal infection. Retained products should be excluded by ultrasound scan and exploration of the uterine cavity considered if there is still doubt.

Hysterectomy should be considered at an early stage, even if the woman is critically ill, because it may be lifesaving. Before surgery, adequate cross-matched blood and blood products should be requested and the maternal condition should be stabilised as far as possible.

Although, aggressive fluid resuscitation is required, this should be under close monitoring to avoid pulmonary edema.

Patient education is essential to minimise the risk. Importance of good per-sonal hygiene should be stressed providing verbal and written information.

All healthcare professionals including GPs and community midwives who are involved in her care should have had training in the early recognition of abnormal vital signs and serious illness.

Guidelines for the detection, investigation and management of suspected sepsis should be available for all maternity units, Emergency Departments, GPs and community midwives. with specific information about Group A streptococcal infection, as the main reason for the rise in maternal mortality from sepsis in this triennium is the increased number of deaths caused by community-acquired b-haemolytic strep-tococcus Lancefield Group A (Streptococcus pyogenes).

1. The history, examination and the relevant investigations will help us to diagnose the severe sepsis.  History includes, unwell feeling and offensive vaginal discharge or lochia, fever with rigor.  On examination, pale look, cold clammy hand, tachycardia (more than 100BPM), irregular cardiac rhythm, cardiac murmurs, cold peripheries and slow capillary filling.  The temperature more than 38degree cent persistently is a sign of severe sepsis.  Patient may develop hypothermia in severe sepsis.  The infection may cause Disseminated Intravascular Coagulation (DIC), so easy bruise or bleeding from the venupuncture sites.  Also causes, de-arranged liver and renal function including raised creatinine level may present.  There may be acidotic breathing and the Arterial blood gas analysis will demonstrate lactic acidosis increased.  From, the investigation FBC, CRP – the WBC level and CRP level would be  very much raised.  Patient may develop altered level of consciousness, may not be oriented to time, place and the neurological assessment with Glasgow coma scale will be low.  If we use the modified obstetric early warning sign chart, all the recordings including pulse BP Temp O2 saturation would be in the red area.
2. Patient needs to be nursed at the intensive care unit, where should have closed monitoring with one to one nursing care.  The team should include, Obstetrician, intensivist, anesthetist, Nurse and Microbiologist.  Patient needs regular (30minutes to hourly), Pulse, BP, O2saturation, temperature monitoring, document in MEOWS chart and also need urometer to do strict Input and output monitoring.  She needs MRSA screen and nurse in isoloation.  She needs barrier nursing, so when we enter the room, we need to wear apron, mask and gloves.  We need to wash the hand before and after seeing the patient.She needs bloods such as FBC, Renal function tests, Liver function tests and correct anaemia with bloods and electrolytes with appropriately.  She also needs blood for culture, urine for Microscopy, culture and sensitivity to check for source of infection and sensitive drugs.  Also, do Chest Xray for pleural effusion, pneumonia, consolidation, and PE to rule out chest infection or thrombosis, so that appropriate antibiotics or treatment can be given.  We need to involve chest physician.  We also need to look for air under diaphragm for any perforation in the abdominal organs and needs review by surgeons if positive findings present.  She also needs CT abdomen and pelvis to rule out pelvic collection or abscess, so that we can treat appropriately.  During examination, we should do pelvic examination and obtain swabs for pelvic inflammatory disease, High vaginal swabs and also would swabs if any of them present.  If she has sore throat, needs swabs from there as well.  She needs intravenous access and iv fulids, would need CVP line for close monitoring.  The broad sprectrum intravenous antibiotic treatment should be started as per microbiologist input and the clinical situation should be reviewed as it progresses.  Once the culture and sensitivity result from various sources as available, changes to drugs can be made based on result and sensitivity.  Identify the source of infection and treat with appropriate intravenous antibiotics which would cover endometritis, pelvic inflammatory disease, urinary / renal tract infection, and episiotomy wound infection.  Patient’s allergies should be known and we should avoid those drugs and give alternative.  Unlikely, but possible, remove source of infection such as remove retained swabs or tampons in vagina or drain pelvic abscess.  If there is history of underlying cardiac disease and patient is showing signs of endocarditis, involve cardiologist in managing her care, in addition to relevant antibiotics.  It could be due to pandemic flu, and if the same is suspected, give the correct drug as well as vaccination.  We need to give bloods if she is severely anemic.  She is high risk of developing thrombosis (DVT and PE), so she needs adequate hydration, TED stockings of appropriate size and Thromboprophylaxis (if no unusal bleed).

a)

The surviving sepsis campaign has done much to highlight the increasing problem of sepsis and to define care bundles to optimise its management. Sepsis is defined as a combination of systemic inflammatory response syndrome (SIRS) and infection – either presumed or confirmed. The criteria necessary for SIRS are two or more of:

·      tachycardia (> 90 bpm)

·      tachypnoea (>20)

·      altered temperature (> 38 or <36)

·      altered white cell count (>12 or <4 x 10⁹ cells/L)

Whilst a pyrexia and leucocytosis are commonly associated with an infectious process, it is important to note that both hypothermia and leucopenia are particularly serious signs of sepsis.

To make the diagnosis of severe sepsis, there additionally needs to be associated organ dysfunction, hypoperfusion or hypotension. However, persistent refractive hypotension would further classify the situation as septic shock.

b)

As demonstrated by the recent confidential enquiry, the mortality associated with severe sepsis is increasing and was the leading cause of direct maternal death in the last report. The potential for rapid deterioration means many women will be severely ill and some die despite optimum care, however, a number of interventions can reduce this risk.

Most important is the early recognition and prompt treatment of sepsis with appropriate high dose broad spectrum antibiotics and supportive care. A history is important, both to identify the presence and severity of symptoms and to identify the potential source of infection – guiding both antibiotic choice and potentially suggesting the need for surgical intervention. The increasing community prevalence of group A haemolytic streptococci mean that a personal and family history of sore throat should always be enquired after. Common symptoms that are out of proportion to what is expected e.g. severe after pains, increasingly heavy lochia should also arouse suspicion of infection, as should unusual levels of anxiety/panic.

Appropriate specimens, depending on history and examination, (e.g. MSU, HVS, blood cultures, throat swab, sputum) should be obtained prior to commencing antibiotics, but treatment should not be delayed whilst awaiting results. Early discussion with a senior microbiologist is advised. Once an organism is identified/sensitivities known, treatment should be narrowed down to reduce the risk of resistance developing.

In some cases treatment may be undertaken in an obstetric unit, but transfer to HDU/ITU will frequently be required. Even if this is not the case, discussion with senior anaesthetist/intensivists is recommended as is review by an outreach team if available. The use of early warning charts (MOWS or MEOWS) will aid identification of those patients who are deteriorating and need more aggressive management. Invasive monitoring may be required, especially with organ failure, and directed investigations needed to guide management, including lactate, renal function, and measures of fluid balance. Hydration can be particularly difficult to manage because of the risks of pulmonary oedema.

In a postnatal patient, the risk of VTE should not be forgotten and TEDS should be used routinely, and LMWH considered as soon as there is felt to be no risk of DIC. If there is no improvement or further deterioration, surgical intervention should be considered either EUA/ERPC or even hysterectomy as this may be lifesaving in a very sick patient.

Finally, it is important to remember the psychological morbidity associated with the separation of a mother and her baby at such an early stage. The partner and other family members may also be significantly affected by the experience and careful counselling and debriefing are required once she has recovered.

Tachycardia and progressively worsening abdominal pain are  important and common  early signs of severe sepsis which require an urgent review .Diarrohea as well as vomiting may be present in pelvic sepsis. Pyrexia is an important indicator,however it may not always be present.Pyrexia >38 c should prompt investigation for infection  taking urine, vaginal,cervical,throat ,wound swabs and blood cultures.On the contrary hypothermia is an ominous sign indicating severe sepsis.Vaginal discharge ,may be present..Tachypnea(resp.rate .20) should not be overlooked .Widespread maculopapular rash (streptococcal infection)can be present.Cold  extremities  present due to reduced peripheral perfusion.Oliguria indicating reduced renal perfusion is present

White cell count may be elevated,instead it can be reduced .Elevated  C-reactiveprotein levels is a useful indicator.Elevated lactate levels because of metabolic acidosis present.Abnormal coagulation tests present in case condition worsens to develop disseminated intra vascular coagulation.Abnormal liver function tests ,abnormal renal function tests due to multiple organ failure.Positive blood cultures will identify the causative organism.

All maternity units should have guidelines for the investigation and management of severe .Regular frequent check up ,of  vital signs ,lochia  by the use of MEOWS (modified  obstetric early warning signs ) chart.Timely and aggressive supportive treatment required. Early involvement of consultant will optimize the outcome.Early administration of  broad spectrum antibiotics  like cefurexime and metronidazole (intravenously) within 3 hours of admission of ED and one hour of non ED ICU admissions.Blood cultures obtained before  antibiotics.Dont wait for microbiological results.If does nt respond in 24-48 hrs and patient is deteriorating antibiotics changed ,alternatives added ,..microbiological advice taken . Blood lactate measured.Blood gases sent  oxygen supplementation given accordingly.Fluid administration 20 ml/kg  crystalloid or colloid and see for the effect immediately.If hypotension unresponsive to fluid   administration then give vasopressors to maintain the mean arterial blood pressure of 65mmhg .Low dose steroids  for septic shock( sepsis with hypotension unresponsive to fluids).Activated protein C (DROTRECOGIN ALFA) can be given according to the standardized protocols of the ICU.It is associated with an increased risk of bleeding.At present balance of risk and benefit is unclear.Graduated compression stockings and thromboprophylaxis  considerd balancing the risks of haemorrrhage with VTE.Multidisciplinary management involving hematologist, anaesthetist,microbiologist and intensive care specialists will optimize the treatment. Staff involved in the care should have ALS certification. .Focus of sepsis should be sought and carefully dealt with when the condition of the patient is stabilized.e.g ultrasound for the retained products of conception,if present evacuation of the uterus .Review the results of appropriate cultures.Critically ill patients should be cared for in high dependency unit with appropriate staff 

Tachycardia and progressively worsening abdominal pain are  important and common  early signs of severe sepsis which require an urgent review .Diarrohea as well as vomiting may be present in pelvic sepsis. Pyrexia is an important indicator,however it may not always be present.Pyrexia >38 c should prompt investigation for infection  taking urine, vaginal,cervical,throat ,wound swabs and blood cultures.On the contrary hypothermia is an ominous sign indicating severe sepsis.Vaginal discharge ,may be present..Tachypnea(resp.rate .20) should not be overlooked .Widespread maculopapular rash (streptococcal infection)can be present.Cold  extremities  present due to reduced peripheral perfusion.Oliguria indicating reduced renal perfusion is present

White cell count may be elevated,instead it can be reduced .Elevated  C-reactiveprotein levels is a useful indicator.Elevated lactate levels because of metabolic acidosis present.Abnormal coagulation tests present in case condition worsens to develop disseminated intra vascular coagulation.Abnormal liver function tests ,abnormal renal function tests due to multiple organ failure.Positive blood cultures will identify the causative organism.

All maternity units should have guidelines for the investigation and management of severe .Regular frequent check up ,of  vital signs ,lochia  by the use of MEOWS (modified  obstetric early warning signs ) chart.Timely and aggressive supportive treatment required. Early involvement of consultant will optimize the outcome.Early administration of  broad spectrum antibiotics  like cefurexime and metronidazole (intravenously) within 3 hours of admission of ED and one hour of non ED ICU admissions.Blood cultures obtained before  antibiotics.Dont wait for microbiological results.If does nt respond in 24-48 hrs and patient is deteriorating antibiotics changed ,alternatives added ,..microbiological advice taken . Blood lactate measured.Blood gases sent  oxygen supplementation given accordingly.Fluid administration 20 ml/kg  crystalloid or colloid and see for the effect immediately.If hypotension unresponsive to fluid   administration then give vasopressors to maintain the mean arterial blood pressure of 65mmhg .Low dose steroids  for septic shock( sepsis with hypotension unresponsive to fluids).Activated protein C (DROTRECOGIN ALFA) can be given according to the standardized protocols of the ICU.It is associated with an increased risk of bleeding.At present balance of risk and benefit is unclear.Graduated compression stockings and thromboprophylaxis  considerd balancing the risks of haemorrrhage with VTE.Multidisciplinary management involving hematologist, anaesthetist,microbiologist and intensive care specialists will optimize the treatment. Staff involved in the care should have ALS certification. .Focus of sepsis should be sought and carefully dealt with when the condition of the patient is stabilized.e.g ultrasound for the retained products of conception,if present evacuation of the uterus .Review the results of appropriate cultures.Critically ill patients should be cared for in high dependency unit with appropriate staff 

Signs and symptoms of sepsis include feeling generally unwell unduly, anxious, distressed and panicky

Pyrexia is common( temperature more than 38 C), but a normal temperature does not exclude sepsis. Paracetamol and other analgesics may mask pyrexia, and this should be taken into account when assessing women who are unwell.

 Hypothermia ( temperature less than 35 C) is a significant finding that may indicate severe infection and should not be ignored.

 Swinging pyrexia and failure to respond to broad-spectrum intravenous antibiotics is suggestive of a persistent focus of infection or abscess.

 Persistent tachycardia >100 b.p.m. is an important sign which may indicate serious underlying disease and should be fully investigated.

Tachypnoea is sepsis until proved otherwise—persistently increased respiratory rate >20 breaths/minute is a significant clinical finding that can

also indicate other serious pathology, such as pulmonary oedema, pneumonia, thromboembolism or amniotic fluid embolism, and impending

cardiac arrest.

 Leucopenia <4 · 109 white blood cells/l is a significant finding that may indicate severe infection.

Diarrhoea is a common and important symptom of pelvic sepsis. Diarrhoea and/or vomiting in a woman with any evidence of sepsis is a very

serious sign and an indication for commencing immediate broad-spectrum intravenous antibiotic therapy.

• Severe lower abdominal pain and severe ‘after-pains’ that require frequent analgesia or do not respond to the usual analgesia are also common important symptoms of pelvic sepsis.

Offensive vaginal discharge accompanied by utrine pain , renal angle tenderness should also be taken into account.

B

The intervension that minimaize the risk of mortality and morbidity include admission to the hospital , in a isolated bed ,preferably in HDU, with one to one care , multidisplinary team approach towards identification of the case  and management by Obstertrician , specialized nurse in infection control, intensivest,measures include primary resestation by ABC measures, stabilization of her general condition Clear, accurate documentation and careful monitoring of fluid balance is essential to avoid fluid overload in women who are unwell, especially when hourly urine output is low or renal function is impaired Using MEOW scoring system. The advice of an anaesthetist and the critical care team should be sought at an early stage. Vitals and clinical improvement should be monitored carfully.

Start investigating the case of sepsis   By FBC, CRP , blood culture , taking swabs from vagina , throat, midstream urine spectrum, breast milk, and stool for microbiology,chest xray , ventilation perfusion scan , ECG , CT chest and abdomen  in suspecting Embolism and even sometimes MRI to indentify  soft tissues case in the pelvis and then treatement  by broad spectrum antibiotics which should not be delayed until culture results , but should be tailored daily according to the response in colleberation with the infection control team to minimize toxcicity and coast .

 Intravenous antibiotic therapy be started as early as possible and within the first hour of recognition of septic shock and severe sepsis without

septic shock, as each hour of delay in achieving administration of effective antibiotics is associated with a measurable increase in mortality.

 Appropriate cultures should be obtained before initiating antibiotic therapy but should not prevent prompt administration of antimicrobial therapy.

Initial empirical anti-infective therapy should include one or more drugs that have activity against all likely pathogens and that penetrate in adequate concentrations into the presumed source of sepsis, as failure to initiate prompt and effective treatment correlates with increased morbidity and mortality; women with severe sepsis or septic shock warrant broad-spectrum therapy until the causative organism and its antibiotic

sensitivities have been defined.

All women should receive a full loading dose of each antimicrobial, but as women with sepsis or septic shock often have impaired renal or hepatic

function, measuring serum levels may be necessary, and advice about further doses should be sought from the critical-care team or a consultant

physician.

when a specific organism is identified, antibiotic therapy can  be modified to the most appropriate regimen.Duration of therapy should be typically 7–10 days; longer courses may be appropriate in women who have a slow clinical response, undrainable focus of infection, or immunological deficiencies, including neutropenia. Blood cultures will be negative in >50% of cases of severe sepsis or septic shock, even though these cases are very likely to be caused by bacteria or fungi, so that decisions to continue, narrow, reduce or stop antimicrobial therapy must be made on the basis of clinical judgement and clinical information.

 Choosing the most appropriate antibiotic regimen may be complex and advice should be sought from a consultant microbiologist as soon as

possible.

co-amoxiclav 1.2 g 8-hourly plus metronidazole 500 mg 8-hourly

or

cefuroxime 1.5 g 8-hourly plus metronidazole 500 mg 8-hourly

or

cefotaxime 1–2 g 6- to 12-hourly plus metronidazole 500 mg 8-hourly

In cases of allergy to penicillin and cephalosporins, clarithromycin (500 mg twice daily or clindamycin (600 mg to 1.2 g by intravenous infusion

three or four times daily) plus gentamicin to give Gram-negative cover are possible alternatives while waiting for microbiological advice.

 In severe sepsis or septic shock (seek urgent microbiological advice):

Piperacillin–tazobactam 4.5 g 8-hourly or ciprofloxacin 600 mg 12-hourly plus gentamicin (3–5 mg/kg daily in divided doses every 8 hours by

slow intravenous injection).

A carbapenem such as meropenem (500 mg to 1 g 8-hourly by intravenous injection over 5 minutes or by intravenous infusion) plus gentamicin

may also be added.

Metronidazole 500 mg 8-hourly may be considered to provide anaerobic cover.

If Group A streptococcal infection is suspected, clindamycin (600 mg to 1.2 g by intravenous infusion three or four times daily) is more effective

than penicillin as it inhibits exotoxin production.12

If there are risk factors for MRSA, add teicoplanin 10 mg/kg 12-hourly for three doses then 10 mg/kg 24-hourly or linezolid 600 mg twice

daily.

Measures to Help control dissimination of infection like isolation , hand hygiene and N95 mask should be used while dealing with patient .

If suspecting endemic flue the aprociate drug plus the vaccine should be given.

TED stoking  with consultion to assess her legibility to LMWH is very important  to garde aganist VTE and PE.

Surgery can be done in cases of documented retained product  by ultrasound not responding to medical treatement hysterectomy can be part of elimination of sever infection in case of sever bleeding. Adequate cross match should be done before

Baby  can be isolated from the mother and nursey team can take care .

a)  Diagnostic criteria for severe sepsis includes  increase in pulse rate and temprature (may be hypothermia) , increase in total leucocyte count with neutropenia & positive CRP . There may be positive cultures.

b)  Admit the patient in ICU/ isolation. Immediately manage by multidisciplinary approach i.e involve critical care team, obstetrician, infection control team, haematologist.

Assess the GCS and maintain ABCs i.e assess respiratory rate and give o2 support if tachypnoic. Maintain I/V line and give fluids (may be ringer lactate/ colloids if needed) and pass CVP line to assess the pressure and maintain intake according to its levels. Pass folys catheter to moniter intake output. Apply cardiac moniter for regular monitoring of pulse, B.P respiratory rate, ECG, O2 saturation .Send ABGs.

Send investigations after maintaining ABCs i.e CBC (Hb, TLC, DLC, Plt),  urine R/E, urine C/S, blood c/s, CRP, RFTs, LFTs, electrolytes, HVS for  C/S , PT/ APTT, S Fibrinogen, FDPs, ECG, CXR, USG pelvis and abdomen specially for  any RPOCs/ free fluid in POD.

Start broad spectrum antibiotics till report of cultures are available

Search for source of infection at other sites. chest, breasts, DVT, Hot tender vagina on examination

Start thromboprophylaxis if she is not in DIC. TED stickings, LMWH.

If in DIC involve haematologist and blood bank team for management accordingly.

Counsell the patient and relatives regarding best possible treatment offering / reassurance

a. Criteria for severe sepsis would be pyrexia of more than 38 C, or less than 35 C ( gram negative sepsis ). Tachycardia of more than 90bpm and tachypnoea of more than 20 breaths per min.  Hypotension with systolic bp less than 90mmHg, in the absence of other cause such as bleeding. Oxygen saturations of below 95%, poor peripheral perfusion with capillary refill time more than 2seconds. Poor urine output or oliguria. There may be a characteristic rash(meningococcal septicaemia). Investigations would show metabolic acidosis, increased lactate level. Full blood count with evidence of raised or low white cell count(>11,000cells/l or <4,000cells/l) and thrombocytopenia. Coagulation abnormalities as dissseminated intravascular coagulation can develop. Liver and renal function abnormalities due to multiorgan involvement. Positive blood cultures and raised C reactive protein.

b. Primarily, early recognition of the condition and prompt management of sepsis can prevent the high morbidity and mortality associated with it(8th CEMD). She would require ITU or HDU care. Multidisciplinary approach with clear clinical leadership by the consultant obstetrician, together with anesthetist, microbiologist and midwife. Prompt intravenous high dose broad spectrum antibiotics should be administered early, without waiting for microbiology results. Combination of Cefuroxime and metronidazole woud be appropriate to cover for gram positive, gram negative microbes and anaerobes . Need to ensure dose is adequate to achieve therapeutic level. Vital signs need to be monitored at 15 -30 min interval. The Modified Early Obstetric Warning Signs chart should be utilized. Oxygen saturations using pulse oximeter and oxygen administration if required (Sao2<95%). Continuous indwelling urinary catheter with hourly urine output chart. Intake and output chart moitoring. Blood investigations such as full blood count and coagulation as there is a risk of disseminated intravascular coagulation.  Urea and electrolytes, creatinine to look for renal impairment or failure. Liver function test for liver failure. Cultures from appropriate sites apart from blood cultures, depending on history. High vaginal swab if foul smelling lochia or episiotomy wound breakdown, mid stream urine culture and sensitivity if having dysuria, frequency, loin pain. Throat swab maybe necessary especially if history of sorethroat or upper respiratory tract infection among family or self due to high prevalence of Group A streptococcus. Chest x ray, arterial blood gases, lactate compliment investigation. Invasive monitoring using central line would aid in fluid management and prevent pulmonary edema, especially as patient will be hypotensive. The microbiology results should be obtained as soon as possible and treatment modified to suit appropriate antibiotics if there is no response and to prevent resistance developing. If condition deteriorates and no response is seen within 24 to 48 hours, antibiotics should be changed and gentamicin or tazocin added, guided by microbiologist. The source of infection has to be removed. Transabdominal ultrasound of pelvis to rule out retained products of conception or free fluid within pelvis. A suction evacuation of retained products of conception by an experienced surgeon as risk of uterine perforation is high. If there is a need to proceed with laparotomy or hysterectomy, a general surgeon involvement would be advisable. As she is postnatal, thromboprophylaxis is crucial. TED stockings, hydration and based on risk assessment, low molecular weight heparin is administered. It is important to keep the patient and family members informed at all times of the progress and update of the condition. A debriefing is needed once patient is well. Accurate documentation of timely interventions and personnel involved is important. An incident reporting form filled.

1) Criteria for diagnosing severe sepsis include hypotension BP <90/60, not responding to fluid resuscitation, pyrexia >38c, Hypothermia temperature <36, tachycardia with Pulse >100/min, tachypnoeia with Respiratory rate >12, White cell count <4 and >12, Lactate > 4mmol on arterial blood gases, hypoxia and hypercapnia.on arterial blood gases. Decreased urine output< 20 ml/hour, altered mental status and confused state are other parameters.

2) Patients needs admission to either High dependency unit or ITU. Multidisciplinary team involvement including Obstetrician, Intensivist, Anaesthesist, Microbiologist is important. Patients should be resuscitated ensuring airways are patent and breathing established. If required patient can be ventilated by anaesthetist. High flow oxygen 15 L/min should be started. Intravenous access be obtained and bloods obtained for Full blood count, urea electrolytes, Liver function test, clotting screen to rule out hepatorenal failure, DIC and other complications of sepsis such as hyperkalemia and acidosis. Blood film can be requested to assess haemolysis if there is any suspicion of patient going into DIC. Arterial line and central venous line might need to be inserted to monitor bloods and avoid fluid overload. Patient should be started on modified early warning score chart and strict intake output balance maintained. Catheterize the patient. Broad spectrum antibiotics should be started within 1 hour of presentation comprising of Mentronidazole 500mg IV and Cefuroxime 1.5g. If there is no response after 24 hours, advice should be obtained from microbiologist. Gentamicin can be added on advice and serum levels monitored to avoid toxicity. Thromboprophylaxis be started in the form of clexane and pneumatic compression stockings as risk of thromosis is very high in septic patient.

Establish the cause for sepsis by reviewing the maternity notes and assessing the paient. Further history can be obtained from patient or partner enquiring about onset of symptoms, site and duration of abdominal pain. Enquire about abnormal vaginal bleeding, foul smelling discharge and history of passage of products. Ask about any chest symptoms to rule out chest infection, urinary symptoms to rule out UTI as possible cause. Abdomen should be examined for any mass, tenderness, guarding and rigidity. Chest should be auscultated and speculum and vagina examination done to take high vaginal and cervical swabs and check episiotomy site. Mid-stream urine and blood culture should be sent for culture and sensitivity ideally before starting antiboitics Further management depends on the cause found and might require uterine curettage if there is evidence of retained product.on pelvic ultrasound, however should be performed after 24 hours of antiboitics. Acute anaemia should be corrected with blood transfusion  

   Patient feeling unwell, impair conciousness, delerium, head ache,neck stiffness in case of meningitis, hot flash, cough, sputum, chest pain in case of chest infection, abdominal pain, offensive yellow or greenish vaginal discharge in case of endometritis or pelvic inflammatory diseases. Perineal pain, swelling and discharge in case of episeotomy or perineal wound infection. Dysuria and frequency and difficulty in passing urine in case of urinary tract infection. Breast pain, swelling and reddness in case of mastitis.

  on examinations cold extremeties, low blood pressure, weak pulse, tachycardia, reduce oxygen saturation, increase tempature or hypothermia in toxic shock, maculopapular rashes, neck stiffness in meningitis, wheeze or ronchi in case of pneumonia or reduce air entry. Breast examination for mastitis and abscess.  Abdominal examinations: guarding tenderness orin case of pelvic inflammatory disease and  rebound tenderness   in case of peritonism. Vaginal examintaion shows wound oedema, break down and discharge. hot vagina, oedematous cervx and excitation positive in case of pelvic inflammatory disease, bulky tender uterus and offensive, yellow or greenish discharge in case of endometritis or pelvic inflammatory disease. Tenderness of bladder in case of urinary tract infection.

b- Immediate intervention, call for help senior obstetrician, anaestetist, SHO, midwife porter, microbiologist, haematologist.

inster intravenous cannula, at same time send blood for FBC, U&E, LFT, CRP, CLOTTING, BLOOD CULTURE, urine culture, tipple vaginal swabs ( high vaginal, endocervical and chlamydial swabs, swabs from wound, urine for MSU, chest Xray, ulrasound of abdomen and pelvis looking for collection.

Start intravenous broad spectrum antibiotics covering gram positive, negative, and an aerobic bacteria, advice from microbiologist continue antibiotics for 24 hours if patient responded, change to oral other wise if no responce advice form microbiologist for change antibiotics.

Fluid replacement by crystaloid up to 3.5liters, colloid or blood transfusion in case of anaemia as toxic shock causing haemolysis, and anaemia reduces tissue perfusion, moniter fluid input and out put by inserting urinary catheter, she may need aterial line to be insterted by anaestetist to moniter blood pressure regularly. Anti emitic in case of vomitting, antipyretics like paracetamol, nonsteroidal anti inflammatory medications for pain reduce inlammation.

Admit patient in separat side room, she may necesisate high dependency or intensive care unit until stabilise. Moniter vital signs hourly until stable, then 4hourly.Thromboembolic deterrant stocking and low molecular weight heparin prophylaxis to avoid thrombosis until she will start mobility.

Documentation, communication with patient and relatives, filling incidence form.

A healthy 23 year old woman attends the assessment unit 4 days after normal vaginal delivery complaining of progressively worsening abdominal pain and feeling unwell. Her pulse = 124 bpm, BP =85/52 mmHg and temperature = 39.2 C. (a) Discuss the criteria for making a diagnosis of severe sepsis [6 marks]. (b) Discuss the interventions that would minimise the risk of mortality or serious morbidity in this woman [14 marks].

a) A 1992 American College of Chest Physicians/Society of Critical Care Medicine consensus panel defined the terms relevant to sepsis. Where sepsis is the response to infection.  Systemic inflammatory response syndrome (SIRS) is a widespread inflammatory response to a variety of severe clinical insults. This syndrome is clinically recognized by the presence of two or more of the following:

• Temperature >38°C or <36°C
• Heart rate >90 beats/min
• Respiratory rate >20 breaths/min or PaCO2 <32 mmHg
• WBC >12,000 cells/mm3, <4000 cells/mm3.

Sepsis is presence of two or more of the above in the presence of infection. It is considered severe sepsis when it is associated with organ dysfunction, hypoperfusion, or hypotension. The manifestations of hypoperfusion may include, but are not limited to, lactic acidosis, oliguria, or an acute alteration in mental status.

The presence of altered mental state, oedema, hyperglycemia signify severity.  It is important to look for organ dysfunction variables which characterize severe sepsis like arterial hypoxemia (FIO₂ <300), acute oliguria (urine output <0.5 mL.kg^-1.hr^-1 ), Creatinine increase >0.5 mg/dL, Coagulation abnormalities (INR >1.5 or aPTT >60 secs), Ileus (absent bowel sounds), Thrombocytopenia (platelet count <100,000 /mm³),   Hyperbilirubinemia (plasma total bilirubin >4 mg/dL or 70 mmol/L). Tissue perfusion variables,  Hyperlactatemia (>1 mmol/L,  Decreased capillary refill or mottling.

b)

Discuss the interventions that would minimise the risk of mortality or serious morbidity in this woman [14 marks].

The latest CEMACE report shows a rise in maternal mortality related to sepsis.  A number of interventions have been proposed by the Surviving sepsis campaign and the care bundles designed when employed correctly are known to reduce mortality considerably.

I would start the management by admitting  her , and taking a detailed history to highlight potential problems like place of delivery a home birth and water birth , ruptured membranes, instrumental delivery , sore throat , history of sore throat in the family members (latest CEMACE report shows increased prevalence of gp A streptococcal infection as a cause of sepsis, is ,mainly community acquired)  presence of offensive vaginal discharge.

On examination in addition to vital signs given above I will look for sore throat, bruising , petichie, jaundice, pallor. Abdominal examination to see tenderness and size of the uterus, and vaginal examination for lochia. All swabs will be taken including throat , HVS , urine will be sent for culture and sensitivity and blood for culture and sensitivity, RFTs, LFTS and clotting profile , grouping and cross matching along with the arrangement for blood or blood products if indicated.

A senior obstetrician will be informed and multidisciplinary team including intensivist, medical specialist, microbiologist, haematologist , ultrasonologist will be involved in the management from the very beginning.

The patient will be admitted to the ICU is requires resuscitation and HDU if stable , one to one nursing care and correction of hypoperfusion , by adminstration of crystalloids and oxygen to increase the mean aterial pressure and oxygen saturation.

I will try to identify the source by arranging a portable ultrasound of the pelvis, and chest Xray, ecg ASAP. Side by side institute antibiotic treatment using broad spectrum antibiotics preferably with in the first hour of her arrival. This would include I/V antibiotics like Cephalosprins, Metronidazole,  or quinolones and metronidazole. This regimen will be reassessd upon response and microbiology reports and tailored accordingly. This will be given for 5-7 days. The source of infection if identified like retained placental pieces, membranes etc will be dealt by surgical evacuation, if there is infection focus like abscess it will be drained.

Fluids therapy , addition of blood if Hb is below 7.0 g/dl and platelets if below 50000 products . In case of myocardial dysfunction ionotropic support with dobutamine will be given. Steroids are known to help in recovery. Recombinant human activated protein c, helps in dealing with severe sepsis and reduce mortality.

In case of ARDS ventilator support will be administered by ICU specialist. Hyperglycemia will be corrected if required and hemodylis considered if indicated. Stress ulcer prevention will be undertaken by administering H2 receptor blockers or proton pump inhibitors. DVT prophylaxis will be instituted by giving LMWH according to weight of the patient ,and compression stockings or intermittent compression device.

All this will follow the protocols laid down by the surviving sepsis guidelines and local hospital policies. 

 a)Maternal sepsis was the leading cause of direct cause of death in the last triennium. The patients’ history may be suggestive of an infection. Details of her delivery ie prolonged ruptured membranes, temperature in labour, manual removal of placenta and vaginal tears are all risk factors for infection. A history of diabetes or immunosupression (eg HIV) also increase her risk. She may complain of fever, malaise, nausea and vomiting and abdominal pain. Signs of shock include hypotension (systolic <90), tachypnoea and tachycardia (pulse >100). A temperature above 38 or less than 36 degrees would indicate that the cause of shock would be more likely to be related to infection. On examination she may have a tender abdomen, a vaginal examination would be necessary to assess an episitomy or tears. Speculum may reveal an open os if there are RPOC, there may also be an offensive vaginal discharge.

Blood tests would show an elevated or low WBC and inflammatory markers eg CRP would be raised. Hb would allow you to differentiate from shock secondary to blood loss however this would be more unlikely 4 days post partum. Lactate >6 is a marker of how compromised the patient is and can guide management. Cultures (urine, HVS, blood) and imaging take longer for results to be available but would help confirm an initial diagnosis.

 b) Early recognition that the patient is unwell and prompt treatment is the cornerstone of management. Training staff to recognise the signs and symptoms of severe sepsis and the use of MEOWS charts would help identify unwell patients such as this lady.Hospital protocols aimed specifically at treating such patients can ensure that appropriate initial treatment is instigated.

This patient would need resuscitation using the ABC approach. Colloid IV fluids such gelofusin can be given initially to help increase her blood pressure. A urinary catheter should be inserted and her urine output monitored on an input/output chart. Anaesthetist’s involvement would be sought and the consultant obstetrican made aware of the patients admission. The patient should be admitted to HDU or ITU so that more intensive monitoring can be carried out eg BP/P/Temp every 5 minutes initially which can be decreased once the patient is more stable.

The source of infection should be investigated, if the patient complains of post partum abdominal pain is it likely to be endometritis however urinary sepsis can also present with supra pubic and loin tenderness. Cultures should be taken but broad spectum IV antibiotics such as cefuroxime, metronidazole and should be given immediately and then subsequently changed if sensitivities indicate more appropriate therapy. Advice should be sought from the microbiologists regarding culture results and antibiotics.

Pelvic ultrasound would be warranted if despite antibiotics there was no clinical important or clinically retained placental tissue was suspected. If chest symptoms were present a cxray would be arranged. A PE can also present with pyrexia, hypotension and tachycardia, if this was suspected a CTPA would be indicated.

If retained placental tissue was noted on imaging, an ERPC under u/s guidance would be warranted. There is a higher risk of perforation so should be carried out by the most senior member of the team.

1. Definitive diagnosis of sever sepsis is based on focused history,meticulous  examination and appropriate investigations ,History of fever,abdominal pain,foul smelling vaginal discharge  , associated with diarrhea  and vomiting  should raise the suspicion of sepsis .

Evidence of hyperpyrexia(>38C)/hypothermia(<35 C),tachycardia(>90 b/min),tachpnea(>20 breath/min),hypotension(systolic  BP<90 mmhg),hypoxemia,oliguria and poor peripheral perfusion (mottled skin)  suggest  sever sepsis.
 Presence of leucocytosis ,elevated lactate level,increased CRP,positive blood culture ,deranged renal and liver functions, metabloci acidosis and abnormal coagulation profile would confirm the diagnosis  of sever sepsis

(B)Various measures  may be undertaken to minimize the mortality and serious morbidity associated with sepsis.Prompt early rcognition is the first  and most important step which should be undertaken.it  depends upon the appropriate assessment(history,examination,investigations)

High index of suspicion should be used in women who are at risk such as post delivery/miscarriage(retained products of conception),prolong rupture of membranes,vaginal trauma,wound haematoma,post caesarean section and following cervical cerclage or amniocentesis.

Atypical presentations may lead to wrong diagnosis and consequently worst outcome.there fore clinicians should be aware of them such as hypothermia,diarrhea,neutropenia, abdominal pain(abruption),reduced or absent fetal heart rate,DIC,sore throat.

Since B hemolytic streptococcus group A has been found the common cause of community acquired  infection,it should be suspected in black ethnic minority,asylum seekers and women with sickle cell disease,presenting with with sore throat or upper respiratory tract infection.these  more commonly present during the months between December and april.

These patients should be urgently shifted to hospital for prompt aggressive  treatment earl

Women who presents with suspicion of sepsis ,should be admitted in hospital for management and close monitoring.Consultant microbiologist  should be involved  at eary stage for expert advice

High dose intravenous antibiotics  such as Cefuroxime and metronidazole should be commenced within therapeutic range.blood samples should be taken before starting antibiotics,however should not wait for results to start treatment.result should be obtained as soon as possible .in case ther is no response,or detriration ,antibiotic  should be changed or Gentamucin or Tazocin  can be added  under guidance of microbiologist.

Source of infection should be find out and eradicated as soon as possible such as wound  infection or retained product of conception .

Patient should be monitored   every 15-30 min for vitals.MEOWS,urine output ,oxygen saturation,blood test (FB,LFT,RFT,coagulationprofile) should be performed daily or more frequently  as indicated.

To reduce the compications  related with sepsis ,aseptic technique,use of sterile equipment .surgical skills  and training and supervision  are  the measures which play an important role.

To reduce the case of infection and related morbidit and mortality .every should have protocols  and guidelines which should be regulated  and followed.Audit and reaudit should be performed   to assess  and modify the current practice  to achieve best outcome.

Education of general population   and clinical staff  at hospital,community  centers ,schools,

and through media  about general hygein  should be convayed  to reduce the infections.

1. To diagnose sepsis, there must be an identifiable pathogen in the presence of at least 2 features of systemic inflammatory response syndrome (SIRS). These features include a body temperature under 35 c or above 38 c; a heart rate consistently above 90; a respiratory rate above 20 and a altered white blood count (below 4 or above 12 – non-pregnant range)

To diagnose severe sepsis, there must be features of SIRS / sepsis and associated evidence of organ dysfunction, hypo-perfusion or hypotension.

This woman clearly fulfils the criteria for severe sepsis as she is tachycardic, hyperperexial and hypotensive.

1. This woman should be admitted to hospital and monitored by appropriately trained staff using modified obstetric early warning scores. She should be managed by an MDT (including midwives, obstetricians, anaesthetists/intensivists and haematologists) using a protocol driven care bundle. ‘Septic care bundles’ applied within 6 hours have been shown to significantly improve survival.

This woman should have basic blood investigations which includes FBC, U&E, LFT clotting and lactate. An FBC will identify anaemia and altered WCC, U&E and LFT will identify organ dysfunction and lactate can help to direct fluid management.

She should have a full septic screen which includes blood cultures (preferably from 2 different sites), sputum cultures, an MSU, and wound and genital swabs as appropriate. If she has respiratory symptoms she should have a chest x-ray.

She should be given appropriate high dose broad-spectrum intravenous antibiotics as soon as possible but definitely within 1 hour. Ideally all cultures should be taken prior to the giving of the abx but these investigations should not delay treatment. These should be modified at a later date after the results of the septic screen are back.

Her saturations should be maintained with high flow oxygen delivered via a well fitting non-re-breath mask and she should be aggressively resuscitated. The surviving sepsis campaign recommends an initial fluid bolus (crystalloid or colloid) of at least 20ml/kg. An indwelling Foleys catheter should be inserted to monitor fluid balance.

If her lactate is above 4 or her hypotension is refractory to fluid replacement, she may need to be transferred to intensive care where more invasive monitoring (central and arterial lines) and vasopresors and/or inotropes can be used.

Within the intensive care environment hydrocortisone has been shown to be effective, as has transfusion of packed red cells if hb is below 7.

Once the septic screen has identified the source of the sepsis it is important to eliminate it surgically. This should be done once the woman is stable but should be considered even if she remains critically unwell as it is may be the only intervention that saves her life.

Finally the woman should be followed up by the treating clinican soon after discharge to address and psychological morbidity, discuss her treatment and how to prevent the same thing happening in future pregnancies.

A healthy 23 year old woman attends the assessment unit 4 days after normal vaginal delivery complaining of progressively worsening abdominal pain and feeling unwell. Her pulse = 124 bpm, BP =85/52 mmHg and temperature = 39.2 C. (a) Discuss the criteria for making a diagnosis of severe sepsis [6 marks]. (b) Discuss the interventions that would minimise the risk of mortality or serious morbidity in this woman [14 marks].

A)     Severe sepsis would be diagnosed when there is sepsis with presence of any major organ dysfunction or hypotension which does not respond to fluid resuscitation. Sepsis is diagnosed when there is SIRS (systemic inflammatory response syndrome) which include presence leukocytosis or neutopenia, with tachycardia, tachypnea, and hyperthermia or hypothermia with the evidence of a infection. There would also be hyperglycemia withoutthe presence of diabetes in this condition as well. And this patient exhibits the clinical feature of severe sepsis with hypotension ( BP 85/52 mm Hg), tachycardia (pr 124), hyperthermia (39.2 celcius) with a possible source of genital tract infection mainly endometritis which suggests severe sepsis.

B)      Early recognition would be the key element in her intervention. A multidisciplinary team approach which include the obstetricians, physiscian, anaesthetist, intensivist, microbiologists, specialist nurses would be important in the management of this patient. The patient would ideally be managed in the ITU for intensive care. Early administration of broad spectrum antibiotic which covers of Group A streptococcal such as Cefuroxime and metronidazole empirically after taking the relevant cultures such as blood culture, high vaginal swab, endocervical swab, urine culture, throat swab. Measurement of lactate would indicate the presence of anerobic activity and resuscitation and arbitrarily taken as level of 4 mmol/l or more. Mean arterial pressure should be minatained more than 65 mm hg. And the use of bolus crystalloids or colloids of 20ml/kg could be used for early fluid resuscitation. Central venous pressure monitoring should be used and the measurement should be maintained above 8 cm H2O or 12 cm H2O if mechanically ventilated. The use of vasopressors such as dobutmine could also be importna to maintain the MAP above 65 mmHg. Strict input output chart would be used to maintain judiscious use of fluids and monitoring urine output. The uses MEOS ( modified early warning chart) would also be important to see and monitor changes in the progress of the patient. Oxygenation shoud be maintained with high flow mask or if required intubation and mechanical ventilation coulb be considered. Hemoglobin level should be maintained and if the Hb level is less than 7 g/dl , then she should be transfused with packed cells. Proper VTE prophylaxis should be given as she falls in the high risk of it and the use of proper hydration, TED socks, intermittent pneumatic device, low molecular weight heparin shoud be given according to local protocol.

Cultures should be reviewed and and the antibiotic shoud be changed to according to the sensitivity. The use of steroids, activated protein factor C could be considered in the management of severe sepsis and it has been shown to improve survival. Need for surgical evacuation of retain product of conceptus in the uterus should also be addressed after ultrasound of the pelvis to remove foci of infection.

a-Diagnosis of severe sepsis can be made by history,examination and investigations.in this woman History of her symptoms together with tachycardia,hypotension and high grade fever is suggestive of severe sepsis.Full blood count looking for high white blood cell count is also suggestive.The rest of examination of breast,abdomen and vaginal examination together with laboratory and radiology investigations can be done to find the cause like septic screen including urine,blood and throat culture.

b-First of all this woman should be admitted to high dependency unit(HDU) so that she can be provided with cardiopulmonary support.

Multideciplinary team including senior obstetrician,consultant of infectious diseases and infection control team should be notified.

Fluids(colloids) should be started to avoid dehydration and to raise her blood pressure but input output chart should be maintained to avoid pulmonary edema.

Antipyratics should be given and broad spectrum antibiotics should be started.These can be started empirically and changed if needed according to sensitivity of cultures taken.

Thromboprophylaxis should be given like good hydration and TED stockings as sepsis increases the risk of thrombosis.

Find the cause of primary focus by history,examination and investigations including laboratory and radiological investigations and treat the cause as soon as possible .Cause can be trated medically or surgically.

coagulation profile should be done to exclude DIC as it can occur as a complication in severe sepsis.

Documentation , incident reporting,audit and efficient communication can help reduce mortality and morbidity.

Debriefing by the treating physician can reduce psychological morbidity.Patient and her relatives should be supported and reassured.

a) Severe sepsis arises when sepsis occurs in combination with one or more vital organ dysfunction. Hypotension [SBP<90 mm Hg] in absence of bleeding and usually refractive to fluid therapy suggests severe sepsis. Hypoperfusion, as evidenced by cold clammy extremities; serum lactate > 4mmol/L and end organ dysfunction is seen in severe sepsis. Persistent low oxygen saturations despite high flow oxygen suggest acute lung injury or ARDS, which may occur when lungs are affected in severe sepsis. Liver dysfunction can cause elevated serum bilirubin, progressive coagulopathy and hypo- or hyper- glycaemia. Oliguria or anuria, electrolyte imbalance occurs if kidneys are affected. If brain is affected, it can lead to acute confusional state, agitation and coma.

b) First intervention in this hypotensive, tachycardic lady should be resuscitation, which must be started immediately while awaiting ICU admission. Early warning charts [MEOWS] should be used to note any improvement or deterioration and act promptly.  Hypotension and/ or elevated lactate [>4mmol/L] should be treated with initial fluid replacement of 20ml/kg.Further fluid replacement is guided by maintaining  central venous pressure of 8-12 mm Hg. If hypotension does not respond to fluid therapy, vasopressors like dopamine or norepinephrine should be considered.  If Mean arterial pressure is < 65 mm Hg, intravenous hydrocortisone should be considered.

Early involvement of multidisciplinary team consisting of consultants in obstetrics, intensive care medicine, anaesthesia, microbiology and haematology is essential for effective resuscitation and treatment of the lady.

Next intervention is to detect the causative organism for sepsis. At least two blood cultures should be obtained before administration of antibiotics. Culture from genital tract is also indicated in this post partum lady.

Administration of IV antibiotics within the first hour of recognition of severe sepsis is recommended. Broad spectrum antibiotics with good penetration into infective foci should be chosen. Patients with impaired hepatic and renal functions may require appropriate dose adjustments after the loading dose. Antimicrobial regimen should be reassessed daily to optimise efficacy, prevent resistance and avoid toxicity. When specific organism is identified, antibiotic therapy can be modified accordingly.

Next intervention would be to identify the specific anatomic site of infection. This should be done within first 6hours of presentation. In this lady, a pelvic ultrasound will be useful in identifying retained products. Exploration of the uterine cavity should be considered if in doubt. Hysterectomy should be considered at an early stage as this may be a life saving procedure.

Blood products should be used in liaison with a consultant haematologist. A Hb of 7.0-9.0 gm/dl is targeted, but higher levels may be required in presence of lactic acidosis, severe hypoxaemia and acute haemorrhage. FFP, platelets and cryoprecipitate should be used to treat DIC.

If there is evidence of acute lung injury/ ARDS, mechanical ventilation with positive end expiratory pressure [PEEP] should be considered. Tidal volume of 6ml/kg and central venous O2 saturation >70% should be maintained.

Urine output should be > 0.5ml/kg/hour to prevent renal dysfunction.

Once stabilised, IV insulin can be used to control hyperglycaemia in severe sepsis.

This post partum lady is in high risk of DVT and PE. Hence thromboprophylaxis with LMWH or unfractioned heparin and mechanical devices like stockings or intermittent compression devices should be used.

Stress ulcer prophylaxis should be provided by H2 blockers or proton pump inhibitors. 

(A)   Severe sepsis is a condition in which immune response of body become overactive and can result in damage to vital body organs, disseminated intravascular coagulation and brain death. The symptoms in the start are often subtle, patient complains of some chills and unwell feeling paired with rapid respiration, gradually as it worsens, the patient develops hypotension, hypothermia and septic shock (diastolic BP <60).Due to hypo perfusion lactic acidosis develops which is diagnosed by lactate level of >4mmol/L.  Further deterioration leads to multiple organ failure. Renal dysfunction is diagnosed by oligurea and raised urea and creatinine levels. Acute lung injury or acute respiratory distress is diagnosed clinically by severe dyspnea, tachypnea, and resistant hypoxemia. The capillary wedge pressure is <18 mmHg and chest X-ray shows bilateral infiltrates. May lead to respiratory failure needing artificial respiration.  Further deterioration may lead to altered consciousness coma and death.

(B)       The patient needs admission in ICU. Airway and breathing should be stabilized. Supplemental oxygen should be provided with continuous pulse oximetry. Chest radiograph and arterial blood gases should be obtained after initial stabilization. Blood lactate should be measured, level >4mmol/L indicates acidosis. White cell count more than 10,000 or less than 4000 indicate severe sepsis.   Blood cultures should be obtained prior to administration of antibiotics. Multidisciplinary care by obstetrician, intensivist, anesthetist and microbiologist is important. Resuscitation should begin with administration of intravenous fluids at the rate of 20 ml/kg of crystalloids or equivalent. If there is no response to initial resuscitation vasopressors should be started.  Mean arterial pressure should be maintained at >65%.In the event of persistent hypotension CVP line is indicated should be maintained at 8mmHg. Central venous oxygen should be maintained at more than 75%.Broad spectrum antibiotics should be started which should cover both aerobes and anaerobes. One regime is co amoxiclauv 1.2 gm into 8 hourly and metronidazole 500 mg into 8 hourly. Low dose steroids should be started in accordance with standard ICU policy. Recombinant activated protein should be started in accordance with ICU policy. In case of respiratory failure assisted ventilation is required. A median inspiratory pressure of <30mmHg should be maintained. Nutritional support is essential in critically ill patients. Hyperglycemia and insulin resistance is common in such patients ,therefore level of glucose should be monitored to maintain between 60mmol and <150mmol.             

a} This patient has pueperal sepsis  as she presents with fever,abdominal pain and malaise  4 days after  delivery.

    Severe sepsis is defined as sepsis   with hypotension intractable to  fluid replacement or sepsis with organ dysfunction.

Clinical features include tachycardia -pulse rate more than 90 bpm,tachypnoea-more than 20,hypo or hyperthermia-temp- leass than 35 or more than 38 c  and hypotension-80/60 mmof Hg.She can have uterine  tenderness.Lab findings include  neutropenia or neutrophilia,low platelet count,abnormal coagulation,raised CRP,ESR .Patients usually detiorate  quickly.

b] Early identification is the key  factor in intervention.Needs multidisciplinary care involving physician,obstetricians,anaesthetist,intensivist and specialist nurse.She has to be  managed in intesive care unit.Following care bundle should be applied.Measure serum lactate-more than 4 mmol\l indicates severe sepsis.Obtain  blood cultures,swabs before starting  antibiotics.Start broad spectrum antibiotics   within 1 hr odf identifying severe sepsis.Start  intravenous  ampicillin+gentamycin +metronidazole-WHO regime {or}  start antibiotics according to local protocol which will cover  Group A streptococcus   in particular and  other polymicrobials.Start IV crystalloids  or colloids  20 ml / kg.Once adequate fluid replacement is done  give epinepherine  or ionotrope  dobutamine to maintain mean arterial pressure to 65 mm of Hg.If hypotension  persits  maintain her central venous pressure to 8 mm of Hg  by aggresive fluid replacement.Maintain oxygen saturation with facial oxygen,give blood transfusion if Hb less than 7 g/dl.Maintain glucose control.Consider streoids.Give thromboprohylaxis .Look for septic foci and remove it.She can be given activated drotrecogin alfa as per ICU protocol.

Criteria to diagnose sever sepsis are symptoms like sever pain and feeling unwell and feverish vaginal bleeding and smelly lochia can be also a presentation of  sepis,signs will include tachycardia more than 10/min as less can only be just physiological of pregnancy.pyrexia either more than 38 or spiking is sign of sever infection  and has to be associated with tachycardia other wise can be only whether or viral.sever infection can have hypothermia as endotoxic shock also associated with low blood pressure .tenderness spcially over uterus can be sign of infection  along with enlarged lymph nodes.

interventions to decrease morbidity and mortality include antibiotics which should be intravenous specially if she is sick along with readmission to hospital . broad spectrum antibiotcs like cphalosporins and metronidazol  can be given according to local protocol and after discussion with microbiologist.although tthis broadspectrum can cover also anerobic infection associated with sever sepsis but gentamycin can be addedd if no response but should be given to dose according to renal functions.blood culture should have been sent prior to start antibiotic to discover septicaemia and direct antibiotics . swabs for high and low vagina as well as endocervical should be sent  specially if smelly discharge or tenderness. infection screen will include MSU and swabs from stool throat and breast

a) In sevre sepsis the patient will complain of headach, fever, sweating, and palpitation. Sometimes patient will feel dizzy and in severe cases loss of conciousness.

On examination typicaly she will have tachycardia, hypotension and fever, and could be associated with lower abdominal tederness or gaurding. By speculum examination, vaginal discharge should be checked ussually offensive with puss, some times retained products of conception can be seen through open cervix. Bimanual examination to assess any adnexal mass, the size of the uterus and any cervical excitation or bulging in posterior fornix that indicates the presence of free fluid in pouch of douglas

investigations include full blood count with WBC and differntiation, which show increase WBC and neutrophilia. CRP and ESR will be ellevated as response to inflammatory procss.blood sampl for culture and sensitvity. vaginal and endocervical swabs should be taken to check for any genital tract infection including Gonorhea and chlamydia.other investigation may be indicated such as MSU and U&E if there is urinary tract symptoms. Renal and liver function test should be taken as baseline invstigation.

Ultrasound could be of great value especialy if there is adnexal mass or abcess, and RPOC can be seen.

B)

Medical or surgical intervention will depend on the cause.

general measures of resusitation in cases of septic shouck, including ABC, secure two Iv lines, start emprical wide spctrum antibiotics covering grame +&-ve and an aerobic bacteria.

maintain good hydration and analgsicand antipyretic such as Paracetamol Iv infusionor rectal should b given.

In cases of RPOC evacuation should be considred after antibiotics started and should be sent to histopathology.

Multidisciplinary input is critical involving anaesthatest senior obstetrcian and ID physician. Admission to HDU is advisable with contious monitoring of vital signs, Po2 and input output charts.

thromboprophylaxis should be given after VTE risk assessment.