This is an official Northern Trust policy and should not be edited in any way Bacterial Sepsis in Pregnancy and the Puerperium Reference Number: NHSCT/12/616 Target audience: This policy is directed to Obstetricians, Midwives, Anaesthetists, Paediatricians, Neonatologists, Neonatal Nurses, Student Midwives and Medical Students. Sources of advice in relation to this document: Caroline Diamond, Lead Midwife Sinead O’Kane, Head of Midwifery and Gynae Services Replaces (if appropriate): N/A Type of Document: Directorate Specific Approved by: Policy, Standards and Guidelines Committee Date Approved: 14 September 2012 Date Issued by Policy Unit: 13 November 2012 NHSCT Mission Statement To provide for all the quality of services we would expect for our families and ourselves Bacterial Sepsis in Pregnancy and the Puerperium September 2012 Bacterial Sepsis in Pregnancy and the Puerperium 1. Introduction to the Policy In the 2006-2008 Report of the Confidential Enquiries into Maternal Deaths, sepsis rose to be the leading cause of direct maternal deaths in the UK. Substandard care, in particular lack of recognition of signs of sepsis and lack of guidelines on the investigation and management of genital tract sepsis, were identified in many cases with deaths due to Group A Streptococcal (GAS) having risen to 13 women. 2. Aim of policy The purpose of this guideline is to provide guidance on the recognition and management of sepsis in pregnancy and in the puerperium (i.e. sepsis developing after birth until 6 weeks postnatally), in response to the findings of the Centre for Maternal and Child Enquires (CMACE) Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom (CMACE, 2006-2008). 3. Target Audience This policy is directed to Obstetricians, Midwives, Anaesthetists, Paediatricians, Neonatologists, Neonatal Nurses, Student Midwives and Medical Students. 4. Responsibilities Clinical Director The Clinical Director is accountable for ensuring that the policy and guidelines are fit for purpose and their effectiveness evaluated. He will seek assurance from Managers that the policy is implemented and practice is consistent with policy. Managers (or their nominated lead) Managers with responsibility for clinical or care will be accountable for ensuring: • that the policy and guidelines are implemented in all services provided; • that directorate audit plans include audit and audit findings are actioned; 1 • when the need for training is identified, it is resourced; • releasing staff for training when there is an assessed need; and • ensuring dissemination and easy access to policy. Clinical and Care Staff All staff are individually responsible for ensuring that: • their practice is consistent with the law, the NHSCT guidelines and Trust policy; and • patients and clients are given information and, when appropriate, written information on the procedure/intervention they may be consenting to in a format/language, as appropriate. 5. Policy statement Sepsis may be defined as infection plus systemic manifestations of infection. Severe sepsis may be defined as sepsis plus sepsis-induced organ dysfunction or tissue hypoperfusion. Septic shock is defined as the persistence of hypoperfusion despite adequate fluid replacement therapy. Severe sepsis with acute organ dysfunction has a mortality rate of 20-40% which rises to 60% if septic shock develops. The onset of life-threatening sepsis in pregnancy or the puerperium can be insidious, with rapid clinical deterioration. All health professionals need to be aware of the signs and symptoms of maternal sepsis and how rapidly the condition can develop into severe sepsis and septic shock. Risk factors for maternal sepsis in pregnancy as identified by the Confidential Enquiries into Maternal Deaths Obesity Impaired glucose tolerance/ diabetes Impaired immunity/ immunosuppressant medication Anaemia Vaginal trauma, caesarean section, wound haematoma Retained products of conception Vaginal discharge History of pelvic infection History of group B streptococcal infection 2 Amniocentesis and other invasive procedures Cervical cerclage Prolonged spontaneous rupture of membranes GAS infection in close contacts/ family members Black or other ethnic minority groups All healthcare professionals should be aware of the signs and symptoms of maternal sepsis and of the rapid, potentially lethal course of severe sepsis and shock. Suspicion of significant sepsis should trigger an urgent referral to secondary care. Signs and Symptoms and likely causes of sepsis in pregnancy and the puerperium Symptoms Malaise Vomiting +/- diarrhoea Constant severe abdominal or pelvic pain and tenderness Rash, generalised streptococcal maculopapular rash or purpura fulminans Signs Temp < 36 or > 38°C Pulse > 90beats Resp > 20 breaths Hypotension/Pallor / Clamminess Sub-involution of the uterus and/ or offensive lochia Productive cough Fetal tachycardia WCC < 4 or > 12 x 10 and/or raised C - reactive protein Oliguria Impaired consciousness Failure to respond to treatment Hypoxia early or late depending on source of infection Poor peripheral perfusion (prolonged capillary refill) Glucose > 7.7(not diabetic) Investigations when sepsis is suspected Blood cultures are the key investigation and should be obtained prior to antibiotic therapy. Other samples as guided by clinical suspicion of focus of infection e.g. throat swabs, midstream urine, high vaginal swab; cerebrospinal fluid may also be obtained. Other investigations should include FBC, CRP, U&E, LFT, Coagulation screen. Aim to obtain samples within the first hour of the suspicion of sepsis. Tests can be repeated at least 6hours as indicated by the clinical situation. 3 Serum lactate should be measured within 6 hours of the suspicion of severe sepsis in order to guide the need for referral to critical care colleagues. Results may be as follows: Normal level 0.5-1.0mmol/litre. Level > 2.0mmol/l indicate sepsis. But the critical level for concern is level > 5.0mmol/l. This can be obtained from ABG however if difficulty obtaining arterial sample, venous sample can be used. Management of sepsis Monitoring of the woman with suspected/ established sepsis should be multidisciplinary but preferably under the leadership of a single consultant. The expert advice of a consultant microbiologist and/or infection control team should be sought when serious sepsis is involved. As soon as a diagnosis of severe sepsis is suspected the ‘Surviving Sepsis Campaign Resuscitation Bundle’ (Dellinger et al, 2008) should be undertaken within an hour as survival chances are greatly improved. (Appendix 1) Regular observations of all vital signs (including temperature, pulse, blood pressure and respiratory rate) should be recorded on a Modified Early Warning Score (MEOWS) chart. Abnormal scores should not just be recorded but should also trigger an appropriate response (CMACE, 20062008). All staff taking observations should have annual training in the use of the MEOWS chart. Community carers should be aware of the importance of early referral to hospital of recently delivered women who feel unwell and have pyrexia. Women with sepsis in the puerperium are best managed in a hospital where diagnostic services are easy to access and intensive care facilities are readily available. The woman should be isolated in a single room with en suite facilities to reduce the risk of transmission of infection. Healthcare workers should use appropriate personal protective equipment (PPE) when in direct contact with the woman and their immediate surroundings. The presence of shock or other organ dysfunction is an indication for admission to ICU. 4 Treatment in the antenatal period Treatment, including delivery should not be delayed once septicaemia has developed because deterioration can be extremely rapid. Administration of intravenous broad spectrum antibiotics within 1 hour of suspicion of sepsis with or without septic shock. If pelvic sepsis is suspected a combination of high dose broad spectrum antibiotics is recommended. Intravenous immunoglobulin (IVIG) is recommended for severe invasive streptococcal or staphylococcal infection if other therapies have failed. A decision on the timing and mode of birth should be made by a senior obstetrician following a discussion with the patient anaesthetist and neonatal physician. Cautious consideration should be given to the use of corticosteroids for fetal lung maturity in the woman with sepsis. Changes in fetal CTG such as baseline variability or new onset decelerations must prompt reassessment of maternal mean arterial pressure, hypoxia and acidemia. Epidural/Spinal anaesthesia should be avoided in women with sepsis and a general anaesthetic will usually be required. Treatment in the Intrapartum period At term maternal pyrexia may be defined as a temperature of 37·8°C or higher during labour. A temperature of 37·5°C may be of less significance in a woman undergoing a prostaglandin induction or an epidural. Administer Paracetamol 1G IV 4 hourly. Secure aseptically IV access using 16G cannula – document IV bundle details and file within the medical notes. Commence continuous fetal monitoring. Administer antibiotic therapy (after cultures, swabs have been taken. Advise Neonatal paediatrician of sepsis in labour / consult with anaesthetist about need for postpartum Intensive Care. 5 When a mother has been found to have invasive Group A streptococcal infection in the intrapartum period, prophylactic antibiotics should be administered to the baby. Close household contacts should be warned to seek medical attention should symptoms develop and may warrant prophylaxis. MRSA and Group A β-haemolytic Streptococci are easily transmitted via the hands of healthcare workers and via close contacts in households. Invasive group A Streptococcal infections are notifiable and the Infection control team and Consultant for communicable diseases should be informed. Indication for transfer to ICU System Cardiovascular Respiratory Renal Neurological Miscellaneous Indication Hypotension or raised serum lactate persisting despite fluid resuscitation suggesting the need for inotrope Pulmonary oedema Mechanical ventilation Airway protection Tracheal toilet Renal replacement therapy Significantly decreased conscious level Multi-organ failure Uncorrected acidosis Hypothermia Treatment in the puerperium Puerperal sepsis is defined as infection of the genital tract occurring at any time between the onset of rupture of membranes or labour, and the 42nd day postpartum in which two or more of the following are present: Pelvic pain, Fever i.e. oral temperature 38.5°C/101.3°F or higher on any occasion, Abnormal vaginal discharge, e.g. presence of pus, Abnormal smell/foul odour of discharge, Delay in the rate of reduction of the size of the uterus (involution) (<2 cm/day during first 8 days. Puerperal infections are a more general term than puerperal sepsis and include not only infections due to puerperal sepsis, but also all extra-genital infections and incidental infections. Mastitis, urinary tract infection, pneumonia, skin and soft tissue infection, gastroenteritis and pharyngitis. 6 Sepsis should be considered in all recently delivered women who feel unwell and have pyrexia. A history of recent sore throat or (prolonged) contact with family members with known streptococcal infections (pharyngitis, impetigo, cellulitis) has been implicated in cases of GAS sepsis. The common symptoms are fever, diarrhoea, vomiting, abdominal pain, rash (generalised streptococcal or staphylococcal maculopapular rash) offensive vaginal discharge and wound infection. Mastitis must never be over looked. Agonising pain, fever (greater than 38°C) and tachycardia (greater than 100bpm) are indications for intravenous antibiotics and clinical review. 6. Equality, Human Rights and DDA The policy is purely clinical in nature and will have no bearing in terms of its likely impact on equality of opportunity or good relations for people within the equality and good relations categories. 7. Alternative formats This document can be made available on request on disc, larger font, Braille, audio-cassette and in other minority languages to meet the needs of those who are not fluent in English. 8. Sources of Advice in relation to this document The policy author, responsible assistant director or director as detailed on the policy title page should be contacted in relation to any queries on the content of this policy. References Centre for Maternal and Child Enquiries (CMACE). 2006–08 Saving Mothers’ Lives: reviewing maternal deaths to make motherhood safer: The Eighth Report on Confidential Enquiries into Maternal Deaths in the United Kingdom. BJOG 2011;118 Suppl 1:1–203.2. Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke Ret al.(2008). Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med;36:296–327 [published correction appears in Crit CareMed 2008;36:1394-1396]. Royal College of Obstetricians and Gynaecology. 2010 Green Top Guideline No. 64a Bacterial Sepsis in Pregnancy. London: RCOG; 2010. Royal College of Obstetricians and Gynaecology. 2010 Green Top Guideline No. 64b Bacterial Sepsis following Pregnancy. London: RCOG; 7 Appendix 1 Consider sepsis Known/ suspected infection and any 2 of the following (SIRS criteria) Heart rate >100bpm Resp rate >20/min White cell count <4 or >12 x109/l (exception: up to 16 x 109/l is normal in third trimester and in labour) • • • Temperature <36 or >38.3°C Altered mental state (eg drowsy, restless, agitated, unresponsive) Contact obstetric registrar to review woman Inform midwife/ sister in charge on ward and on delivery suite Inform anaesthetic registrar covering delivery suite Within first hour Move to delivery suite special monitoring room 1. High flow oxygen by facemask to keep SpO2 > 95% 2. Fluid challenge if systolic blood pressure <90mmHg or lactate >2. Suggest 500mls Hartmanns solution initially 3. Measure lactate either on arterial blood gas or a venous sample (heparinised sample in ABG machine) 4. Blood cultures and any other cultures as indicated (eg urine, wound swab etc) 5. Give IV antibiotics eg piperacillen-tazobactam 4.5mg IV 8hrly and gentamicin 5mg/kg IV 24hrly. Consult microbiologist in serious penicillin allergy or complex cases Measure hourly urine output and other observations at least every 15 mins Airway compromise or profound hypotension at any time call for immediate assistance from anaesthetics • After first hour, assess response in lactate and other observations • If not returned within normal limits, request anaesthetics review for consideration of ICU admission 8