Puerperal sepsis and endometritis — structured SAQ (15 marks)

(a) Definition (2 marks)

• Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or the postpartum period.^[1]
• Fever-based definitions (puerperal pyrexia — 38 degrees on two occasions at least 24 hours apart) under-detect and over-detect because sepsis is infection plus organ dysfunction: fever is neither necessary nor sufficient. This patient meets neither a high fever threshold alone nor, more importantly, the organ-dysfunction test — her tachycardia, tachypnoea and hypotension are the organ-dysfunction signals.^[1]

(b) Immediate management within the first hour (5 marks)

One mark per bundle element named, maximum five. ^[2]

• Call for help — senior obstetrician, anaesthetist, midwifery coordinator; escalate to intensive care early.^[2]
• Oxygen to target saturations.^[2]
• Blood cultures (before antibiotics only if it does not delay the dose).^[2]
• Intravenous broad-spectrum antibiotics within the hour — each hour of delay to antibiotics carries an odds ratio of about 1.04 for in-hospital mortality; never receiving antibiotics carried an adjusted odds ratio of 22.7 for death in the UK case-control analysis.^[3][4]
• Intravenous fluids, serum lactate, and urine output measurement; vasopressors early if fluid alone does not restore perfusion.^[2]

(c) Antibiotic regimen and the antitoxin agent (4 marks)

Regimen (2), principle (1), antitoxin agent (1). ^[5]

• The Cochrane benchmark for postpartum endometritis is clindamycin plus gentamicin, with once-daily gentamicin at least as effective as thrice-daily; a broad alternative is ampicillin plus gentamicin with metronidazole, and clindamycin plus gentamicin covers the penicillin-allergic woman.^[5]
• The principle is broad cover of aerobes, anaerobes and streptococci, then narrow on culture; oral continuation after successful intravenous therapy adds nothing.^[5]
• In suspected invasive group A streptococcal disease or toxic shock, add clindamycin to the beta-lactam for its antitoxin effect — it suppresses exotoxin production by inhibiting protein synthesis, independent of whether the organism is sensitive to the beta-lactam.^[6]

(d) Source control (4 marks)

One mark for the principle; one each for three named sources. ^[2]

• Principle: no antibiotic drains an abscess. Identify and control the source; imaging refines source control and never precedes the first antibiotic.^[2]
• Retained products: resuscitate and give antibiotics first, then evacuate by a senior operator once she is stabilised — reversing that order is a classic viva failure.^[5]
• Wound or pelvic collection: image-guided drainage by interventional radiology, or surgery when unavailable or when drainage fails.
• Necrotising soft-tissue infection: immediate surgical referral for radical debridement — a surgical disease with an antibiotic adjunct, not the reverse. Also notify public health and assess the household and the baby when group A Streptococcus is confirmed.^[6]