POST PARTUM OR POSTABORTAL SEPTIC SHOCK

Learning Objective

Review the definition and incidence of septic shock

Evaluate the significance or postpartum/postabortal septic shock

List the etiological bacteria

Recognise the clinical features

Apply theprinciples of effective treatment

In a patient with a suspected diagnosis of septic abortion, what will be the physical findings,

what will the differential show

In a pateient with a septic abortion, the hypotension may be out of proportion to the observed

blood loss. True or false.

Definition

Any patient with a fever 38.5C 48 hours following an abortion, vaginal or operative

delivery with an uterin infection that appears toxic, with hemodynamic and acid based

equilibrium changes.

Incidence an Scope

In some coutries, septic shock is a complication of abortions and obstetrics patiens

with chorioamnioti puerperal endomyometritis and pyelonephritis. In countries with modern

obstetric practice and easy access medically induced abortions, the incidence bas fallen

markedly in the past 10-15 years.

Etiological Agents

In the majority of cases, gram-negative bacteria are responsible, especially

Escherichia Coli and species Klebsiella, Enterobacter, Proteus, Pseudomonas and

Bacteroides. Gram-positive bacteria are incriminated often, but stphylococci, anaerobic

streptococci and the clostridia can cause a similar picture.

Pathophysiology

The exact mechanisms involved in the pathophysiology of septic shock are not fully

understood. It was thought to be a direct action of the endotoxin released from the cell wall of

the gram-negative bacteria. It is nof felt that the endotoxin exerts its effect indirectly by

initiating a series of complex events involving the complement, edagulatic and fibrinolytic

systems.

Through these systems and released chemical mediators such as prostaglandin,

catecholamine, histamin, glucocrticoids, beta endorphin and lysosomal enzymes, profound

cardiovascular changes occur.

Vasoconstriction, hypotension and reduced tissue perfusion (cold phase) leading to

hypoxia, metabolic acidosis, and cardiovascular collapse follow initial vasodilation and

increased capillary permeability (warm phase). The reduced tissue perfusion is manifested by

oliguria, adult respiratory distress synfrome (shock lung), intractable hypotension, coma, and

eventual death.

Clinical Features

The signs and symptoms of the assosiated cause: e.g septic abortion, puerperal

endomyometritis, pyelonephritis, etc, will be present.

In tehe initial stages of vasodilatation, the patient may be alert, tachycardiac,and

hypotensive, but with warm perpheries-the-so-called “warm shock” phase. Later, as

vasoconstriction supervenes, the patient become less alert, remains tachycardiac and

hypotensive, but the peripheries are pale and calammy-the-so-called “cold shock” phase.

If in a patient with a septic abortion, hypotension develops that seems out of

proportion to the blood loss, septic shock should be suspected. A rapid intravenous infusion

of 500-1000 ml normal saline or ringers should correct the hypotension if the shock is due to

hypovolemia, but not if it is due to sepsis.

The temperature is usually elevated (38-41C) initially, but as the reduced tissue

perfusion upsets the hypothalamic temperature regulating fuction, the patient can become

hypothermic or hyperthermic.

The white cell count may be normal or elevated, with the differential showing

increased immature granulocytes.

The end organ sequelae of reduced tissue perfusion, with increasing hypoxia and

acidosis, are oliguria, adult respiratory distress syndrome, cardiac failure, peripheral

circulatory collapse, and coma.

Management

Just as the exact pathophysiology is uncertain so the treatment of septic shock is

controversial and still evolving. If at all possible, the assistance of appropriate expertise

should be enlisted.

The broad principles of treatment can be described as follows:

1. Cirulation tissue perfusiln

2. 2. Intravenous antibiotics: the initial antibiotic combination must cover all likely

causative organisms and sensitivities. This, and the availability of antibiotics, will

vary in different locations. A suitable routine involves three antibiotics:

Penicillin G 5 million units 4 hourly or ampicillin 1 g 4 hourly.

An aminoglycoside: gentamicin or tobramycin 1,0-1,5 mg/kg 8 hourly. Care must

be taken due to the potential ototoxicity of the aminoglycosides. In oliguric

patient, dose adjustment based on drug serum levels is advisable.

Metronidazole 500 mg 8 hourly.

The combination of penicillin and the an inologycoside will cover most of the

probable pathogens except Bacteriodes fragilis and some species of

Pseudomonas. The metronidazole will cover the bacteriodes. Alternatives to

metronidazole are clindamycin, cefoxitin. If pseudomonas species are isolated,

carbenicillin or ticarcillin may be neccessary.

3. Removal of the septic focus: this is the most important aspect of treatment and may

invove

Manual vacuum aspirin. MVA is the preferred method of evacuation (see

Appendix1). Evacuation be sharp curettage should only be done if manual

vacuum aspiration is not available.

Evacuation of the uterus by D and C or oxytocin

Exploratory laparotomy if the patient’s condition does not improve

Hysterectomy may have to be considered in patients not responding to treatment

following curettage suggesting that the process has progressed to myometrial

microabscess formation. It may also be required in patients with severe clostridial

infection and extensive myometrial gas formation not responding to other

measures.

4. Laboratory investigations and X-rays: depending on the severity of the patient’s

condition, the following investigations may be needed:

Culture and gram stain of the urine, blood and septic site

Hemoglobin, hematocrit, platelets, white cell count and differential

Coagulation profile

Serum electrolytes, creatinine and blood urea

Arterial blood gases

Urinalysis

Chest X-rays

Abdominal and pelvic X-ray looking for air under the diaphragm or a foreign

body, either of which may indicate uterine perforation. In cases of suspected

clostridial sepsis, there may be myometrial gas pattern.

5. Maintain circulation and tissue perfusion: this is best monitored by a combination of

central venous pressures (CVP) meausrement, urinary output, and the patient’s mental

state. The CVP will allow guided transfusion of appropriate blood, colloid or

crystalloid solutions. In the critically ill patient, insertion of a Swan-Ganz catheter

may be necessary.

The use of vasoactive drugs is controversial and must be guided by experts. The beta-

adrenergic properties of isoproterenol and dopamine mayh enhance peripheral tissue

perfusion. Naloxone has been used to counterac: beta-endorphin-inducd hypotension.

If congestive hearts failure develops, the patient is digitalized. Corticosteroids are

advocated by most authorities, but their use is still controversial. They are usually

given in doses of 2 g of hydrocortisone intravenously every four hours (or equivalent

dose of another corticosteroid).

Metabolic acidosis is corrected with intravenous sodium bicarbonate.

6. Respiratory support may be required with oxygen and mechanical ventilation

monitored by arterial blood gases.

7. Disseminated intravascular coagulation may require specific treatment.

Those instruments that are considered to be semicritical items require high-

level disinfection as aminimum requirement. This procedure is effective for all

microbial forms but may not be able to kill large numbers of bacterial spores. Two

types of procedures may be used.

a. Boiling: boiling offers a cheap and readily accessible form of high-level

disinfection. It can be axxomplished by using a “hot water disinfector” who

lowers a trivet or instruments into boiling water. Plain tap water can be used: if

scale develops, a descaling agent can be added. It is essential that the contact time

be at least 20 minutes after boiling has started.

Important points include:

Change water at least daily

Keep water level full during the day

Ensure all parts of the instruments are in contact with boiling water (i.e

open boiling water (i.e. open scissors, forceps)

Wash and dry the boiling vessel at the end of each day.

b. Chemicals: high-level disinfection with chemicals has beenreffered to as “cold

sterilization”. High-level chemical disinfectants have a demonstrated level of

activity against bacterial spores and all other forms of microorganisms. The

capability of killing a bacterial spore is an assurance of the relative power and

activity spectrum of the gennicide. Thus if the contact time is long enough as long

as 24 hours, it can be used as a sterilant.

Some examples of high-level disinfetants are

Glutaraldehyde preparations

Hydrogen peroxide

Sodium hypochlorite

Sodium Hypochlorite (1:50 dilution): Chlorine compounds such as

sodium hypochlorite (household bleach) require a contact time of 20 or more

minutes. The compounds are very corrosive to stainless stee. A 1:50 dilution of

household bleach, 1 teaspoon in 1 cup of water (5ml of bleach in 240 ml of

water), provides 1000 ppm of available chlorine, and is a high level disinfectant.

After didinfection, instruments must be thoroughly rinsed with sterile water and

then air-dried or dried using a sterile cloth. Sodium hypochlorite solutions

should be prepared weekly and stored at room temperature in an opaque

container to ensure the concentration is maintained.

4.1.3 Antiseptica

An antiseptic is a chemical agent intended for use on skin or tissue. It

reduces the less resistant, non-spore forming micro-organisms on the skin and

mucous membranes.

What are antiseptics for?

Patient skin preparation

Skin wound cleanser

Hand washing agent and surgical scrub

Remember that for the antiseptic to be effective, it must be applied for at

least 30 seconds and allowed to dry. Some preparations are used as both

antiseptics and disinfectant, e.g. alcohol, but they are produced in different

formulations, and are therefor not interchangeable for these two tasks.

The following agents are commercially available as antiseptics agents:

Isopropyl alcohol (70-90%)

Chlorhexidine gluconate (4%,2% detergent base, 0,5% tincture)

Iodine/iodophor (10%, 7,5%,2%,0,5%)

DO NOT USE ANTISEPTICS AS CLEANING AGENTS FOR

SUFACES OR INSTRUMENTS-THEY ARE NOT DISINFECTANTS.

4.1.4 Rountines For Disinfection of Work Areas

General housekeeping routines involve cleaning and disinfecting surfaces and

objects with a low-level disinfect. Cleaning of body fluid spills requires special

consideration.

Cleaning materials and practices

The following detergent disinfectants are suggested for use in the daily

cleaning and disinfection of all surfaces:

Phenolic

Iodophor

Quaternary ammonium compounds

Soudium hypochlorite (1:100 dilution prepared weekly) is a disinfectant

which can be used for environmental cleaning as outlined below.

Always have a bottle of appropriately diluted disinfectant available. Sodium

hypchlorite solutions should prepared weekly and strored at room

temperature in an opaque container to ensure the concentration maintained.

Can the detergent be used on everything?

Yes, it can be used on:

Baby scales

Table tops

Floors

Sinks

Toillets

Examinations tables: Uncovered examination tables should be cleaned

between patients. Table covers, linen, plastic, etc. Should be changed between

patient. If there is a body fluid spill clean and disinfect the table removing the

cover, otherwise clean the table daily.

Spot cleaning of body fluid spills

If possible, wear gloves while cleaning.

Wipe up as much of the visible material as possible with cloth and dispose

in a garbage container.

Clean the spill area with the prepared disinfectant detergant. Rinse and dry

with a clean cloth.

After the spills are wiped up and cleaned, disinfect the surface with the

1:100 dilution of bleach by putting a small amount of the solution on the area

and wiping it with a clean towel.