a) Outline briefly the difficulties associated with the diagnosis of sepsis during late pregnancy and labour.
b) List the leading causes of sepsis in pregnant patients.
c) What are the common pathogens encountered in pregnancy-related sepsis?
d) List two antibiotics contra-indicated during pregnancy.
a) Applying SIRS criteria to pregnancy may be problematic as there is:
1. Leukocytosis
2. Body temperature is raised during pregnancy and labour
3. Tachycardia and tachypnoea are seen during normal labour
b)
1. Pyelonephritis
2. Chorioamnionits
3. Septic abortion
4. Episiotomy infections
5. Necrotising fasciitis
6. Septic thrombophlebitis
7. Aspiration pneumonia
c)
1. Gram negative more common than Gram positive agents
2. E.Coli
3. Group B Streptococcus
4. Can also be polymicrobial – E.coli, Klebsiella
d)
1. Tetracyclines
2. Chloramphenicol
3. Aminoglycosides
4. Metronidazole
5. Sulphonamides
6. Trimethoprim
7. Fluoroquinolones
8. Some macrolides
9. Nitrofurantoin
10. Isoniazid
Note: Some antibiotics in the above list are relatively rather than absolutely contra-indicated. The list is not exclusive and candidates giving other valid choices were given credit.
a) Outline briefly the difficulties associated with the diagnosis of sepsis during late pregnancy and labour.
Problems of the obsolete definition of sepsis and SIRS:
Other problems (stolen from the LITFL entry on this topic)
b) List the leading causes of sepsis in pregnant patients.
also...
|
|
c) What are the common pathogens encountered in pregnancy-related sepsis?
Oh's Manual quotes the following bugs:
To this, the Sanford Guide adds a few:
(these are specific to chorioamnionitis and septic abortion)
d) List two antibiotics contra-indicated during pregnancy.
The full list:
Contraindicated antibiotics | Why |
Aminoglycosides in high doses | Increased uptake by neonatal kidney leads to increased nephrotoxicity (but apparently gentamicin is still relativey safe) |
Streptomycin | 8th cranial nerve damage |
Sulfonamides | Kernicterus in the newborn due to displacement of bilirubin off albumin, particularly if used shortly before birth. The specific culprit is sulfamethoxazole. Trimpethoprim appears to be relatively safer. |
Tetracyclines | Tetracyclines have nightmarish dental and bony effects. In fact, these drugs are contraindicated from 16th week of gestation all the way until the 7th year of extrauterine life. |
Quinolones | Quinolones cause birth defects (though it seems fluoroquinolones are safe, and it was really mainly nalidixic acid that was the culprit). |
Rifampicin | Seems to be somewhat teratogenic, mainly in animal studies (spina bifida and impaired osteogenesis seem to be the major consequences)- but in humans one may overlook this if rifampicin is strongly indicated (eg. treatment of lifethreatening tuberculosis) |
Fusidic acid | Like sulfonamides, causes displacement of bilirubin by competing with it for albumin binding |
Chloramphenicol | This "Grey baby syndrome" is the consequence of disrupted mitochondrial function, when chloramphenicol metabolites interfere with the electron transport chain. Foetal failure to properly metabolise chloraphenicol by glucourinidation seems to be to blame. |
Azole antifungals | Teratigenic and embryotoxic. The specific dangerous ones are ketoconazole fluconazole and voriconazole, earning a D classification. |
Echinocandins | Hard to discuss humans in the absence of real data, but in animals using normal treatment doses caspofungin and anidulafungin cause skeletal abnormalities, reduction of litter size, ossification and rib malformations. |
Flucytosine | Embryotoxic and in fact abortificant in the first trimester, which is hardly surprising given that its main metabolite is 5-fluorouracil |
Albendazole | Teratogenic and embryotoxic. If the pregnant lady has some sort of hideous helminthic parasitosis which cannot wait until after delivery, ivermectin is probably a safer alternative |
Foscarnet | Seems to be teratogenic in animals, but if your CV infection is so severe and resistant that you've failed primary therapy, the chances are that your foetus is already significantly damaged by congenital CMV. |
The college answer for Question 3.1 from the first paper of 2014 also lists nitrofurantoin, isoniazid and macrolides as drugs which are relatively contraindicated. This in fact, is not true:
Chapter 64 (pp. 684) General obstetric emergencies by Winnie TP Wan and Tony Gin
Chapter 65 (pp. 692) Severe pre-existing disease in pregnancy by Jeremy P Campbell and Steve M Yentis
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