Maternal sepsis and septic shock — structured SAQ (15 marks)

(a) Definition and why Sepsis-3 and qSOFA fail in pregnancy (3 marks)

One mark for the definition of septic shock; two marks for the limitations (one for any two reasons, one for the specific sensitivity finding). ^[2][10]

• Definition: maternal septic shock is sepsis with persisting hypotension requiring vasopressors to maintain a mean arterial pressure of 65 mmHg or above, and a raised serum lactate (over 2 mmol/L), despite adequate fluid resuscitation.^[2]
• Reasons Sepsis-3 and qSOFA fail in pregnancy: (i) Sepsis-3 was built for the non-pregnant adult and its SOFA thresholds do not account for the normal physiological changes of pregnancy (baseline tachycardia, raised cardiac output, low systemic vascular resistance, mild tachypnoea, mild leukocytosis).^[2] (ii) qSOFA is a mortality-prediction tool rather than a screening tool, and in the Bauer multicentre case-control study its sensitivity for sepsis in pregnancy was only 0.50 — it missed roughly half of cases — whereas SIRS scored 0.93 and maternal early warning criteria 0.82.^[10] (iii) A single observation set is unreliable because the patient deteriorates between readings; the trend matters.^[2]

(b) First hour of management, antibiotics and source control (6 marks)

One mark each for oxygen and access, one for bloods and cultures without delay, two for the antibiotic regimen with doses, one for fluids, one for the source-control decision. ^[1][15]

• Oxygen and access: high-flow oxygen to saturations of 94 to 98 percent (she desaturates fast in pregnancy because functional residual capacity is reduced and oxygen consumption is raised); two large-bore cannulae.^[1]
• Bloods and cultures: full blood count, C-reactive protein, lactate, renal and liver function, coagulation; two sets of blood cultures before antibiotics only if it does not delay them; wound swab and urine culture.^[1][5]
• Empiric antibiotics within one hour (SOMANZ, severe or hospital-acquired pattern): piperacillin 4 g plus tazobactam 0.5 g intravenously 8-hourly; consider adding gentamicin 4 to 7 mg/kg first dose intravenously. An alternative community-acquired regimen is amoxicillin or ampicillin 2 g intravenously 6-hourly plus gentamicin 4 to 7 mg/kg first dose intravenously plus metronidazole 500 mg intravenously 12-hourly.^[15]
• Fluids: 30 mL/kg of balanced crystalloid over the first three hours in aliquots, reassessing after each bolus; watch for pulmonary oedema.^[1]
• Source control: the wound with dehiscence and the post-caesarean uterus are the likely source — surgical review for debridement of a necrotic or infected wound, and evaluation for retained products or pelvic collection. Source control is the definitive treatment and must proceed in parallel with resuscitation.^[5][15]

(c) Vasopressor, target and intensive care criteria (3 marks)

One mark for the vasopressor and target, two for the intensive-care criteria. ^[1]

• Vasopressor: norepinephrine is first-line, titrated to a mean arterial pressure of 65 mmHg or above; she remains hypotensive despite adequate fluid, so she meets the criterion to start it now rather than giving more fluid and risking pulmonary oedema.^[1]
• Indications for intensive care: refractory hypotension requiring vasopressors, respiratory failure or a rising lactate with organ dysfunction, reduced conscious level, or the need for mechanical ventilation or renal replacement therapy. A septic woman on a norepinephrine infusion belongs in intensive care.^[1][5]

(d) Group A strep regimen change and follow-up (3 marks)

One mark for adding clindamycin for toxin suppression, one for considering immunoglobulin, one for the follow-up. ^[15][9]

• Antibiotic change: add clindamycin 600 mg intravenously 8-hourly for toxin suppression, and consider intravenous immunoglobulin 1 to 2 g/kg for up to two doses in the first 72 hours, because group A strep produces superantigen toxins that drive refractory shock and clindamycin suppresses toxin synthesis more effectively than cell-wall-active agents alone.^[15]
• Follow-up: physical rehabilitation, lactation support, a named psychological debrief for a near-miss event, contraception counselling, serology for her household contacts where indicated, and explicit counselling on the increased recurrence risk in any subsequent pregnancy with a documented plan.^[9][17]