Sepsis in the pregnant/delivering/delivered patient is a kettle of very different fish, and requires some distinct considerations, blending some of the unique issues from other topics. Question 20 from the second paper of 2023 dealt with postpartum sepsis, otherwise referred to as "puerperal" sepsis, from Latin (where puer is "child" and parus is "bearing", hence para the childbearing woman). Puerperal sepsis is whatever infection you get in your genital tract between the rupture of membranes up until 42 days postpartum, the timeframe being apparently defined largely arbitrarily. The WHO would anyway prefer for you to use the term “maternal peripartum infections” because that shifts the focus off the genitals. Characteristic puerperal organisms and generic sepsis management aside, the examiners referred to "other sepsis-specific management considerations" in the SAQ, attributing 40% of the marks to this matter, which means it deserves some extra attention.
The postpartum patient can be shocked and in multiorgan system failure for a number of possible reasons, not limited to:
If you add "fever" to this, you narrow the range somewhat. Sources of sepsis in the parturient include:
According to Jain et al (2021), about 30% never have a source identified.
The following organisms are listed in the excellent work by Knowles et al (2015):
And often several of these all at once, rather than any sole organism. Polymicrobial sepsis is more common in these people. According to the 2017 SOMANZ guidelines for sepsis in pregnancy, the most important four are:
For chorioamnionitis, the SOMANZ guidelines recommend broad spectrum antibiotics covering a range of organisms. The rationale for this breadth is that there is a number of possible simultaneously important organisms. Thus:
Plus add clindamycin if Grpup 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)
Provided you know what the source is, you should probably make some effort to control it. Indeed CICM examiners made this aspect occupy two of the possible four marks for part (c) of Question 20 from the second paper of 2023. This probably reflects the importance of the source control as a lifesaving activity rather than the knowledge content of the answer, which would have been limited (for example the college marking criteria guide mentions such generic things as "laparotomy and washout", "hysterectomy" and "D&C". These generic source control options in order of increasing morbidity are as follows:
What's so special about the female genitourinary tract and the prevailing host conditions at the end of pregnancy? Well, as mentioned above, the host is vulnerable but young and with solid compensatory mechanisms. Jain et al (2021) have this excellent list of special features, paraphrased below
Predisposition to infection
Pregnancy makes you susceptible to infection immunologically
Delivery makes you susceptible to sepsis mechanically, by opening the barrier between the "internal milieu" and the organisms of the exterior
Delivery also puts you at risk of having invasive procedures, not limited to the vagina (eg. cannulas, IDCs, etc)
The genitorurinary tract during this time is highly vascular which means pathogens have rapid access to the circulation
Factors that increase the severity of sepsis in the parturient
The organism is often one of considerable virulence, eg. Group A strep (i.e. toxic shock syndrome is on the menu)
The infections are most often polymicrobial, so standard surgical prophylaxis may not cover them
Difficulty making the diagnosis:
During delivery, there is always tachycardia and tachypnoea, and inflammatory markers will be already elevated
So, what does this add to the management of sepsis, as asked by the college in the last four marks of Question 20 from the second paper of 2023?