Life Threatening Maternal and Perinatal Infections

1. Life Threatening Maternal and Perinatal Infections Medical Legal Issues in Obstetrics Practice November 19-20, 2009 Ronald S. Gibbs, MD Professor, Department of Obstetrics and Gynecology Associate Dean, Continuing Medical Education

2. Learning Objectives At the completion of this presentation, in the learner’s practice, she/he will • Know how to recognize sepsis early in the course. • Know how to institute effective therapy promptly. • Know when surgical intervention is needed. • Know how and when to screen for Group B Streptococci (GBS) among pregnant women. • Know which antibiotics to use for GBS prophylaxis among women who can not receive penicillin.

3. The Obstetrician Gynecologist and Sepsis • Most OBGYNs see sepsis infrequently or rarely. • Patient survival depends upon early critical decision making. • Sepsis/infections are important causes of death among OBGYN patients.

4. Causes of Pregnancy-Related Death: Livebirth in U.S. For Livebirth, N = 797, 1987-1990, Berg et al (CDC), O&G 1996;88:1-7

5. Pelvic Microbiology

6. Recent Definitions Describing Sepsis and Related Conditions From Sweet RL & Gibbs RS "Infectious Diseases of the Female Genital Tract," 5th ed 2009.

7. Epidemiology of Sepsis, 1979 to 2000, United States Martin GS et al. NEJM 2003; 348:1546-54

8. Clinical Manifestation of Sepsis Temperature instability Altered sensorium: Combativeness, confusion, disorientation, impaired judgment. Flushing, peripheral vasodilation Pulmonary: ARDS (in 25-50% with septic shock):tachypnea, dyspnea, stridor, cyanosis, pulmonary edema Cardiac: Tachycardiaarrhythmiaischemia, even MI

9. Clinical Manifestation of Sepsis Hematologic: DIC, thrombocytopenia, spontaneous bleeding. Abdominal/pelvic: Intestinal obstruction, evisceration, jaundiceperitonitis and abscess Wound: Cellulitis, abscess, necrotizing fasciitis, Meleney’s gangrene, myonecrosis. Renal: Oliguria, anuria, pyuria

10. ***Hypovolemia ***Hypovolemia ***Hypovolemia *Pulmonary Embolism *Amniotic Fluid Embolism *Diabetic Ketoacidosis *Cardic Tamponade *Aortic Dissection *C. difficile Colitis *Hemorrhagic Pancreatitis *Infected Vascular Catheter *Cardiogenic Shock Differential Diagnosis of Sepsis

11. Management of Sepsis • Admission to ICU (unless to OR first) • Support the organ systems • Eradicate the infection • Most common avoidable errors leading to death: • Failure to use appropriate antibiotic • Failure to institute appropriate drainage

12. Evidence-Based Management of Severe Sepsis and Septic Shock • Dellinger RP, Levy MM, Carlet JM. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock. Crit Care Med 2008;36:296-327.

13. Evidence-Based Management of Severe Sepsis and Septic Shock

14. Evidence-Based Management of Severe Sepsis and Septic Shock

15. Evidence-Based Management of Severe Sepsis and Septic Shock

16. Evidence-Based Management of Severe Sepsis and Septic Shock

17. Evidence-Based Management of Severe Sepsis and Septic Shock

18. Evidence-Based Management of Severe Sepsis and Septic Shock

19. Evidence-Based Management of Severe Sepsis and Septic Shock

20. Evidence-Based Management of Severe Sepsis and Septic Shock

21. Evidence-Based Management of Severe Sepsis and Septic Shock

22. Evidence-Based Management of Severe Sepsis and Septic Shock

23. Management of Sepsis: Surgical Eradication of Infection This is the critical decision of the obstetrician gynecologist: • When to operate and • What procedure to do.

30. 2002 GBS Prevention Guidelines • Recommend screen based approach only. • Change alternative antibiotics for penicillin allergic patients. • More specific recommendations for clinical scenarios.

31. 2002 GBS Screen Based Approach • All pregnant women should be screened at 35-37 weeks’ gestation for vaginorectal GBS colonization. At time of labor or ROM, intrapartum chemoprophylaxis (IPC) should be given to pregnant women identified as GBS carriers. (A-II)

32. 2002 GBS Screen Based Approach • If result of GBS culture not known at time of labor, give IPC if: • < 37 weeks’ gestation or • ROM  18 hours or • T  100.4F ( 38.0C) (A-II)

33. 2002 GBS Screen Based Guidelines • Specimen Collection • Distal vagina and anorectum • Collected by patient or provider (B-II) • No speculum • Transport medium acceptable • Label “GBS culture”

35. 2002 GBS Screen Based Approach • Laboratory Processing • Inoculate into selective broth medium. (eg LIM or Trans-Vag) (A-II) • Methods provided for susceptibility to clinda/erythro for GBS from penicillin allergic women. • Labs “should report results to site of delivery and provider.”

36. 2002 GBS Screen Based Approach • Inform patients of results and recommended intervention. • In absence of GBS bacteriuria, do not treat GBS genital colonization before intrapartum period. (D-I)

37. 2002 GBS Screen Based Guidelines • Penicillin G: Drug of choice. • Ampicillin: Alternative. • For penicillin allergy: • Clindamycin/erythromycin no longer drugs of choice.

38. 2002 GBS Screen Based Guidelines • Patients with PCN allergy, not at high risk for anaphylaxis: • Cefazolin, 2gm IV then 1gm every 8 hours until delivery. (B-III)

39. 2002 GBS Screen Based Guidelines • Patients with PCN allergy at high risk for anaphylaxis: • GBS susceptible: Clinda, 900 mg IV q 8h OR Erythro, 500 mg IV q 6h • GBS resistant to Clinda or Erythro or unknown susceptibility: Vancomycin, 1 gm IV q 12h (C-III)

40. 2002 GBS Guidelines- CDC Summary:If GBS isolate is resistant to EITHER erythromycin OR clindamycin and patient has high risk allergy to penicillin, then use vancomycin.

41. MMWR February 2009

42. CDC Guidelines on GBSPossible Changes in 2010 • Recommendations of antibiotic selection in patients who cannot take penicillin. • Dose of penicillin. • Management of premature rupture of membranes. • Others.

43. References • Sweet RL & Gibbs RS “Infectious Diseases of the Female Genital Tract,” 5th ed 2009. • Martin GS et al, The epidemiology of sepsis in the United States from 1979 through 2000.NEJM 2003; 348:1546-54 • Dellinger RP, Carlet JM, et al. Surviving Sepsis Campaign International Guidelines for Management of Severe Sepsis and Septic Shock 2008. Crit Care Med 2008;36:296-327. • CDC. Prevention of Perinatal Group B Streptococcal Disease, Revised Guidelines from CDC, MMWR 2002; 51 (No. RR-11): 1-24.