O&G SAQs · Postpartum care — infection and sepsis
Puerperal sepsis and endometritis — structured SAQ (15 marks)
FRANZCOG-format structured SAQ on puerperal sepsis: the WHO organ-dysfunction definition, the first-hour bundle, the empirical antibiotic regimen and the antitoxin role of clindamycin, and source control. Per-sub-part marking rubric included.
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Prompt
You are the registrar on the postnatal ward. A 27-year-old woman delivered three days ago by emergency caesarean in labour after prolonged rupture of membranes. The midwife calls you: she has a temperature of 38.6 degrees Celsius, HR 128 bpm, RR 24, BP 96/58 mmHg, and is complaining of severe abdominal pain 'out of proportion' to her wound. Her lochia is offensive. Her four-year-old at home has a sore throat. (a) Define maternal sepsis using the current WHO consensus definition and state why fever-based definitions are inadequate. (2 marks) (b) Outline your immediate management within the first hour, naming each action. (5 marks) (c) Name the empirical antibiotic regimen, the principle behind it, and the agent you add when invasive group A streptococcal disease is suspected. (4 marks) (d) Explain why source control matters and name what you would drain or evacuate. (4 marks)
How this SAQ is marked
Puerperal sepsis is graded on speed and suspicion. Marks come from specifics: the definition, the bundle elements, the antibiotic regimen by name, the antitoxin rationale, and the source-control sentence. The household sore throat and pain out of proportion are deliberate pointers to group A Streptococcus. [4]
Reveal model answer and mark schemeShowHide
(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]
References6ShowHide
- [1]Bonet M, Nogueira Pileggi V, Rijken MJ, et al. Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation. Reprod Health, 2017.PMID 28558733
- [2]Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med, 2021.PMID 34599691
- [3]Seymour CW, Gesten F, Prescott HC, et al. Time to Treatment and Mortality during Mandated Emergency Care for Sepsis. N Engl J Med, 2017.PMID 28528569
- [4]Mohamed-Ahmed O, Nair M, Acosta C, et al. Progression from severe sepsis in pregnancy to death: a UK population-based case-control analysis. BJOG, 2015.PMID 26213333
- [5]Mackeen AD, Packard RE, Ota E, et al. Antibiotic regimens for postpartum endometritis. Cochrane Database Syst Rev, 2015.PMID 25922861
- [6]Harris K, Proctor LK, Shinar S, et al. Outcomes and management of pregnancy and puerperal group A streptococcal infections: A systematic review. Acta Obstet Gynecol Scand, 2023.PMID 36636775