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Ростовский Государственный Медицинский Университет

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Systemic:

Feverorrigors Vomitingordiarrhoea Rash Lethargy Reducedappetite

Gynaecological:

Antenatalandpostnatal:

Abdominalorpelvicpainortenderness Offensive vaginal discharge (smelly suggests anaerobes, serosanguinous suggests streptococcal)

Antenatal:

Ruptureofmembranesorcontractions(maysuggestchorioamnionitis)

Postnatal:

Uterinetenderness Offensiveorexcessivelyheavylochia(vaginaldischargeafterbirth) Symptomsofinfectionincaesareansectionwound,e.g.painaroundsite,dischargefrom wound Breastengorgementorredness

Non-gynaecological:

Urinarysymptoms Productivecough.

Examination

Considerpossiblesourcesofinfection(Table66.2).ExamineusinganABCDEapproach (Table66.3).

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Table66.3Findingswhichmaybesuggestiveofsepsisduringpregnancyorpostnatally

B Tachypnoea>20breaths/min

Hypoxia

C Tachycardia>100bpm

Systolicbloodpressure<90mmHg,ordecreaseinsystolicbloodpressurefrombaseline>40mmHg,ormean arterialpressure<70mmHg Oliguria(urineoutput<0.5mL/kg/hourfor≥2hoursdespitefluidresuscitation)

D Impairedlevelofconsciousness

Temperature>38°Cor<36°C

E Head-to-toeexaminationincluding:

Antenatal:

Palpatinguterus fortendernes s

Postnatal:

Breastexamination Caesareansectionwounds,vulvaandvaginaforevidenceofinfection Palpateuterusforevidenceoflackofinvolution

Cardiac, respiratory,abdominal, ENT, and skin examinationsas appropriateto considernon-gynaecological sourcesofinfection

Investigations

Bedside

Recordbasicobservationsonanappropriatematernitychart(‘MEOWS’) UrinalysisandMC&S Swabs andcultures asappropriate,e.g.throat,high vaginal,wound,placental,sputum,epidural, episiotomy,caesareansectionwound,expressedbreastmilk Antenatally, a CTG should be performed as the fetus may show signs of distress if chorioamnionitisisthesourceofsepsis.

Bloods

FBC U&E CRP Lactate Bloodcultures,ideallytakenbeforeantibiotics,aslongastreatmentisnotdelayed ABG.

Imaging

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ChestX-ray Anyotherimagingwhichmaybeappropriatetoconfirmasourceofinfection,e.g.pelvicUSS CTifpelvicabscessissuspected.

Management

Acutemanagement

General

Thereisasignificantoverlapbetweensepsisduringpregnancyandthepostpartumperiod and sepsis in the general adult population. Therefore, much of the management is the same(seeChapter122)butthereareafewextraconsiderations:

IV immunoglobulin is recommended for severe invasive streptococcal or staphylococcal infections,ifothertherapieshavefailed Isolatethepatientinasideroomifpossibleandwearappropriatepersonalprotectiveequipment.

Antibiotics

Give broad-spectrum empirical antibiotics within 1 hour as per trust guidelines, e.g. Tazocin

(4.5gIVTDS)plusclindamycin(0.6–4.8gIVin2–4divideddoses) Analternativemaybecarbapenemplusclindamycin IfMRSApositive,addvancomycinorteicoplanin Take care ifthepatientis breastfeeding as some antibiotics will be unsuitable—consultwith a microbiologistifthereisanydoubt.

Antenatally

Delivery of the baby may be beneficial to the mother, the baby, or both. In the event of chorioamnionitis, urgent delivery is usually the only treatment option. However, in other circumstances,e.g.anuncomplicatedpneumonia,thebabywouldnotbedeliveredunlessitwould improvematernaloutcomes Thedecisionregardingtimingandmodeofdeliveryshouldbemadebyaseniorobstetrician If pretermdeliveryislikely, steroids should beconsideredduetofetal lungimmaturity,but they shouldbeusedcautiouslyastheycanworsenmaternalsepsis Continuous CTG is recommended. Significant changes in CTG should prompt clinical reassessmentofthesepticmotherforpossibleurgentdelivery Epiduralandspinal anaesthesia shouldbe avoidedinsepticpatients.A general anaestheticwill usuallyberequiredforacaesareansection.

Postnatally

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Seekadvicefromapaediatricianforalldeliveriesinvolvingmaternalsepsis.

GroupAstreptococcalinfections

If the mother hashadaninvasive groupA streptococcal infection,thebabyshould also receive antibiotics Discusswithamicrobiologistwhether householdcontactsrequireprophylaxis ifthemother has hadagroupAstreptococcalinfection.

Treatmentafterstabilization

Treatmentafterstabilizationisaspersepsisinthegeneraladultpopulation(seeChapter122).

Furtherreading

1. MBRRACE-UK (2020). Saving Lives, Improving Mother’s Care: Lessons Learned to Inform Maternity Care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18. Oxford: National PerinatalEpidemiology Unit,UniversityofOxford.Available

at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-

2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10_ONLINE_VERSION_1404.pdf

1 Available at: https://www.npeu.ox.ac.uk/assets/downloads/mbrrace-uk/reports/maternal-report-

2020/MBRRACE-UK_Maternal_Report_Dec_2020_v10_ONLINE_VERSION_1404.pdf

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Chapter67

Thrombosis and embolism during pregnancy and the postnatal period

Guideline:RCOGGTG37b(Thromboembolicdiseasein pregnancyand the

puerperium: acute management): https://www.rcog.org.uk/en/guidelines-

research-services/guidelines/gtg37b/

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Venous thromboembolism (VTE) includes deep vein thrombosis (DVT)and pulmonary embolism (PE) and is a major cause of maternal morbidity and mortality. The risk of thromboemboliceventsis ↑inpregnancyasitisa hypercoagulablestate.In addition to this,subjectiveclinicalassessmentofVTEcan bedifficultin pregnancysothereshould be a high index of suspicion of VTE in those with symptoms and a low threshold for objectivetesting.TheinvestigationandmanagementofVTEinthenon-pregnantgeneral populationiscoveredinChapter99.

Diagnosis

VTEinpregnancypresentsinthesamewayasinnon-pregnantpatients.SeeChapter99 fortypicalhistoryfindingsandotherriskfactors.

Investigations

Bedside

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ECG:

Possiblefindings:

Sinustachycardia Rightaxisdeviationandrightbundlebranchblock Rightheartstrain(TwaveinversioninV1–4andsometimesII,III,andavF) DeepSinleadI,qwaveandinvertedtwaveinleadIII(S1Q3T3)

ABGifsaturations<94%(seeChapter79):

Type1respiratoryfailureissuggestiveofaventilation/perfusion(V/Q)mismatch.

ThereiscurrentlynoevidencefortheuseofWell’sscoreinpregnancy.

Bloods

FBC U&E LFT Coagulationprofile.

D-dimershouldnotbeusedinpregnancy,aspregnancyitselfwillcauseittoberaised.

Imaging

DVT:

Compressionduplexultrasound:ifpositiveandPEisalsosuspected,nofurtherinvestigations arerequired

PE:

EchocardiogramifevidenceofrightheartstrainonECG Chest X-ray to assess for changes resulting from a PE and also to rule out alternative pathologies(theradiationriskisnegligible) V/Qscanningorcomputedtomographypulmonaryangiogram(CTPA)(Box67.1).ACTPAis preferredifthechestX-rayisabnormal.

Box67.1V/QscanningorCTPAinpregnancy

Seek senior advice as both CTPA and V/Q scanning expose the fetus to radiation. Patientsshouldbecounselledontherisksandbenefitsofbothoptionsandbeallowed tomakeaninformeddecision.

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V/Qscanningmaycarryaslightly↑riskofchildhoodcancers.Oneextracaseoffatalchildhood cancerwillbecausedforevery34,000V/Qscansthatareperformed CTscanningisassociatedwithalower radiationdosetothefetus(approximately20% ofthe radiationdoseusedinV/Qscanning),butaslightlyhigherriskofmaternalbreastcancer CTscanning increases themother’sbackgroundriskofbreastcancer byapproximately 13%, e.g.if the patient’sbackground riskofdeveloping cancer over 10 years is 0.1%(1 in1000), theirnewriskwillbe0.013%extra,i.e.0.113%intotal(1.13in1000) CTscanningalsohastheadvantagethatotherpathologiesmaybediagnosed,e.g.pneumonia Theabsoluteriskofharmisverylowforbothscanningmethods;however,theriskofnothaving eitherscanneedstobeweighedagainsttheriskofhavinganundiagnosedPE,orinappropriately treatingapatientwhodoesnothaveaPE Thenegativepredictivevaluesarecomparable.

Management

Acutemanagement

Allvenousthromboembolism

Givetreatment-doseLMWH,asperlocalguidelines,untilthrombosiscanbeexcluded

UsebookingweighttocalculatethedoseforLMWH.

Deepveinthrombosis

Ifultrasoundisnegative+lowlevelofclinicalsuspicion→discontinuetreatment Ifultrasoundisnegative+highlevelofclinicalsuspicion→discontinuetreatmentandrepeatthe scanonday3andday7 Elevatetheleg Compressionstockingsmayhelptoreducepainandswelling.

Pulmonaryembolism

Giveoxygentotargetsaturations≥94% GainIVaccess Giveanalgesiaasrequired Ifthepatientishaemodynamicallyunstable(i.e.possibilityofmassivePE),give100%oxygenand carryout urgentechocardiogram or CTPA within1 hour.Patients mayrequire IV unfractionated heparin(UFH),thrombolytictherapy,thoracotomy,orsurgicalembolectomy.

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Treatmentafterstabilization

Therapeuticanticoagulationshouldbecontinuedforthedurationofthepregnancyandforatleast6 weekspostnatally.Aminimumof3monthsoftreatmentshouldbegivenintotal Womenshouldbetaughttoself-injectwithLMWH Beforestoppingtreatment,theongoingriskofthrombosisshouldbereassessed WomenshouldbeofferedachoiceofLMWHorwarfarinpostnatally,afterdiscussingtheneedfor regularcoagulationmonitoringwithwarfarin

WarfarinMUSTNOTbeusedantenatallyunlessspecificallybeingprescribedandmonitored by an obstetric consultant, as it can cause birth defects, and placental, fetal and neonatal haemorrhage

Postpartumwarfarinshouldbeavoideduntilatleastthefifthday,andlongerforwomenwithan↑ riskofPPH Bothheparin/LMWHandwarfarincanbeusedinbreastfeeding Thepatientshouldbereviewedpostnatallyinajointobstetricandhaematology/medicineclinic Thrombophiliascreeningshouldbeconsideredonceanticoagulationhasbeenstopped, onlyifit wouldaffectthewoman’sfuturemanagement.

Specialconsiderations

Labouranddelivery

WomenshouldstopLMWHwhentheythinktheyareinlabour Ifdeliveryisplanned,holdtreatmentdosesofLMWHfor24hourspriortotheplanneddelivery (whetherinductionoroperative) LMWH should not be used for 4 hours after the removal of epidural catheters, or after spinal anaesthesia.Epiduralcathetersshouldnotberemovedwithin12hoursofaninjection Itmaybenecessarytousewounddrainsduringcaesareansectionifpatientsareanticoagulatedto avoidtheformationofhaematomas.

Womenathighriskofhaemorrhage

If womenareathighriskofhaemorrhagebutstillrequireanticoagulation,itis preferable touse UFHratherthanLMWH.

Furtherreading

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1.WanT,SkeithL,KarovitchA,etal.(2017).Guidanceforthediagnosisofpulmonaryembolismduring pregnancy:consensusandcontroversies.ThrombRes.157:23–8.

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Chapter68

Urinaryincontinenceinwomen

Guideline:NICENG123(Urinaryincontinenceandpelvicorganprolapsein

women:management):https://www.nice.org.uk/guidance/ng123

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Urinaryincontinenceistheinvoluntaryleakageofurine.Sometimes,itcanbesecondary topelvicorganprolapse;theexternalprotrusionofthevagina,uterus,bladder,orrectum (seeChapter64).Theseconditionsarecommonandcanhaveamajorpsychologicaland socialimpactonthepatient,leadingtoaseverelyreducedqualityoflife.

Diagnosis

Categoriesofurinaryincontinence

Stressincontinence:leakageofurineonphysicaleffortorexertion,e.g.coughing.Usuallyoccurs

duetosphincterweakness Urgeincontinence/overactivebladder:leakageofurineaccompaniedorprecededbyasudden strongdesiretopassurine Mixed incontinence: leakage of urine associated with symptoms of both stress and urge incontinence. Usually one of these is predominant and treatment should be directed at the predominantsymptom Overflow incontinence: occurs when the bladder becomes large and flaccid with little or no detrusortone/function.Thisusuallyoccursduetoinjury,e.g.postoperativelyorpostpartum.Itis diagnosedwhentheresidualvolumeis>50%ofbladdercapacity.

https://t.me/med1917

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