Question 20

A 37-year-old diabetic female presents with shock and multiorgan failure 7 days after a normal spontaneous vaginal delivery of a healthy baby. She reports a history of worsening abdominal pain, fevers, and a purulent vaginal discharge.
a) List four differential diagnoses for her presentation.    (2 marks)
b) List the most likely causative organisms and justify your initial empiric antibiotic regime.   (4 marks)
c) Assuming resuscitation measures are covered, outline other sepsis-specific management considerations.     (4 marks)

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College Answer

Syllabus topic/section:

2.1.12    Obstetric Intensive care – L2.

Aim:

To allow the candidate to demonstrate assessment and management of obstetric complications to the level of a transitional fellow.

Discussion:
High scoring candidates had a clear structure, listed appropriate bacteria, considered appropriate antibiotics for the scenario including rationale whilst providing specific sepsis management. These candidates also demonstrated familiarity with important terminology, which gives clarity to the answer and examiner and allows candidates to display higher level thinking and structure, e.g., terminology such as Broad-spectrum antibiotics and source control.

Many candidates did not provide good rationale for antibiotic choice when the question asked for a justification of antibiotic regime. Despite asking for specific management considerations related to sepsis - many candidates still answered resuscitation details. As the SAQ stated that resuscitation measures were covered no marks were given for this information. This is where efficient time management in one question may aid in other SAQs downstream. Some candidates wrote more for section c (4 marks) than for section A and B combined (6 marks. Practicing time management strategies would help in the overall success of the candidates’ final marks (i.e. please see comments in SAQ 28).

Below is a breakdown of marks for part C (4 marks):

-    Sepsis specific management (1 mark)

Allow up to one mark for a well-constructed answer encompassing appropriate disease specific sepsis management not included in answers below.

-    Source control: (2 marks)

Including surgical management (if warranted) including the following: (NB not all options required for full marks)
o    Removal of vaginal foreign body, D+C, laparotomy, and washout,
o    EUA re D&C
o    Removal of retained products.
o    Hysterectomy.

-    Other considerations: (1 mark)

o    prophylaxis for close contacts including neonate, reportable disease.
o    IVIG in this patient.

·    Evidence – In Streptococcal TSS meta-analysis, IVIG is associated with 30-day reduction in mortality.
·    Proposed mechanism – boost antibody levels via passive immunity, opsonization of GAS, neutralization of toxins, inhibition of T-cell proliferation and inflammatory cytokines
 

Discussion

a) Causes? The postpartum patient can be shocked and in multiorgan system failure for a number of possible reasons, not limited to:

  • Amniotic fluid embolism
  • PE
  • Sepsis
  • Cardiomyopathy of pregnancy
  • HELLP
  • Haemorrhage

If you add "fever" to this, you narrow the range somewhat. Sources of sepsis in the parturient include:

  • Everything below the belt (most common causes)
    • Endometritis
    • Chorioamnionitis
    • Foreign body/retained products
  • Extragenital infections that either occur as the result of pregnancy, or are exacerbated by it:
    • Cholecystitis
    • Mastitis
  • Complications of delivery and general hospital stay:
    • Bowel injury during caesarian
    • Perineal soft tissue infections
    • Line sepsis from PIVCs
    • Urosepsis from IDCs
  • Incidental sepsis of completely unrelated source, eg. pneumonia
  • Any of the above, but with toxic shock syndrome
  • Nonifectious causes of fever, eg. PE or drug withdrawal

Adding "worsening abdominal pain, fevers, and a purulent vaginal discharge" to the above virtually excludes things like pneumonia, so you are left with:

  • Endometritis
  • Chorioamnionitis
  • Perineal soft tissue infections
  • Foreign body/retained products
  • Toxic shock syndrome as the complication of any of these

b) Pathogens listed by the 2017 SOMANZ guidelines for sepsis in pregnancy

  • Group A streptococci, eg. S.pyogenes (because they are the most common cause of maternal death)
  • E.Coli is the most common cause of peripartum sepsis overall
  • Group B streptococci eg. S.agalactiae (as 25% of Australian women are colonised, and is the next most important cause)
  • S.aureus, as this is the most likely cause of mastitis

Broad spectrum antimicrobials are called for, because these organisms can all co-infect simultaneously, i.e the infection is often polymicrobial.

  • SOMANZ recommend ampicillin + gentamicin + metronidazole
  • eTG recommend ampicillin + gentamicin, and to add metronidazole only if the patient is unable to have ampicillin

Plus add clindamycin if Group B strep is identified or the patient is severely shocked (rationale is that if the patient has toxic shock syndrome, the clindamycin should help block the pathways of toxin synthesis)

c) Specific management here appeared to focus on source control, but if one looks closer at these marking criteria, one will notice that "removal of vaginal foreign body", "D+C", "EUA re D&C" and "removal of retained products" are all basically the exact same thing. Something else would have been required to generate marks here. Thus, the source control options in order of increasing morbidity are as follows:

  • Removal/replacement of any potentially infected IV devices and IDC
  • Delivery. If the child remains in situ.
  • Incision and drainage of any superfical abscess or collection
  • D&C, an examination under anaesthetic, to remove retained products, or debride necrotic tissue
  • Laparoscopic washout of pyoperitoneum
  • Laparotomy and washout, as needed
  • Hysterectomy, reserved for disastrous situations

Als, "prophylaxis for close contacts including neonate, reportable disease" is listed, which would have required trainees to assume that the sepsis is being driven by some pathogen that is communicable and notifiable, which - of the bugs listed by the SOMANZ guidelines as common pathogens -  the only one listed in the federal list of nationally notifiable diseases is S.pyogenes.

References

Yadav, Garima. "Puerperal Sepsis and Septic Shock." Infections and Pregnancy. Singapore: Springer Singapore, 2022. 509-522.

Vaught, Arthur J. "Peripartum Sepsis." Current Obstetrics and Gynecology Reports 12.4 (2023): 209-214.

Jain, Vanita, Aashima Arora, and Kajal Jain. "Sepsis in the Parturient." Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine 25.Suppl 3 (2021): S267.

Knowles, S. J., et al. "Maternal sepsis incidence, aetiology and outcome for mother and fetus: a prospective study.BJOG: An International Journal of Obstetrics & Gynaecology 122.5 (2015): 663-671.

Bowyer, Lucy, et al. "SOMANZ guidelines for the investigation and management sepsis in pregnancy." Australian and New Zealand Journal of Obstetrics and Gynaecology 57.5 (2017): 540-551.