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Sepsis - Maternal medicine Module part2

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A 35-year-old multigravid woman presents 10 days following an uncomplicated vaginal
delivery at term with a painful swelling in the upper, outer quadrant of the right breast. It has
progressed in size over the last two days, despite following advice from her midwife to
breastfeed regularly from the affected breast.
On examination she has a palpable mass in the right axilla which is firm, tender and
erythematous. There is no palpable fluctuance. Her observations are as follows: Pulse 76 BP
110/70, Temperature 37.4, RR 16, Sate 98% on air . She had a benign fibroadenoma excised five
years ago and is concerned about the recurrence of a more sinister pathology.

1) What is the most appropriate initial management in this patient?

2)

What will you do if you fail to get clinical improvement after 24 hours of IV
antibiotics?
Which of the above is recommended to occur within the first hour of recognition
of sepsis in order to reduce mortality?

3) Which of these steps will you do first?

4) A-25-year old lady presented in A&E, 10 hours after normal vaginal delivery with symptoms of high fever, severe abdominal pain and purulent vaginal discharge. She had a temp of 38.9 degrees, tachycardia HR 120/min, RR of 26/min and based on clinical findings, a diagnosis of sepsis was made.

Which one of the following is likely to be causative organism?

5) All are true regarding maternal sepsis management except;

6)

While choosing antibiotics which of these have the broadest range of cover in
treating sepsis?

7) The incidence of recurrent uti in pregnancy is

A woman who is 3 days postpartum presents with systemic sepsis. She had an SVD
following induction of labour at 41 weeks of gestation. Group A Streptococcus is identified in
maternal blood cultures.

8) With regards to her management...

9)

Pyrexia day 1 postdelivery. General anesthesia emergency CS with difficult
intubation, Saturation 92% on air, Known smoker. Bilateral basal crepitations on chest
auscultation

10) The above patient was seen by the registrar who initiated the sepsis hour 1 bundle.

Which one of these measures is not part of the sepsis hour 1 bundle?

11) The incidence of breast abscess in untreated mastitis is approximately

12) Which of the following is NOT a common causative organism of postnatal sepsis?

13) According to WHO, preavalance of puerperal sepsis is ;

A 35-year-old primigravid woman is in spontaneous labour at 38 weeks of gestation and
has a temperature of 38.1°C. Her blood pressure is 146/78 mmHg, her respiratory rate is 24
breaths/min and her pulse is 102 beats/minute. She feels generally unwell but has no specific
symptoms. She has a history of prolonged rupture of membranes (32 hours). You activate the
sepsis resuscitation care bundle.

14) What is a target for this?

15) Which of the following is NOT a risk factor of postnatal sepsis?

16)

What will you do in septic shock if you fail to get satisfactory improvement in
the BP after sufficient fluid resuscitation with crystalloids?

17)

Low grade fever 5 days following uncomplicated vaginal delivery without perineal
trauma with epidural analgesia, Foley catheter reinserted 48 hrs postdelivery due to
voiding dysfunction.

18)

Low grade fever, pleuritic chest discomfort 9 days postdelivery, no productive
cough. Had emergency CS for abruption. Required 4 units transfusion, BMI 36, normal
wound on inspection, No clinical leg pain or swelling, saturation 94% on air. RR24, No
added breath sounds on auscultation.

19)

Pelvic pain, fever and malodorous vaginal discharge that persists 3 days after
delivery. History of membrane rupture of 36 hrs prior to delivery

20)

Low grade pyrexia, localised superficial lower abdominal pain, and erythema
around skin incision day 4 post ceserean delivery, no pelvic pain, vaginal bleeding,
mobilising well.

21)

A 37-year-old woman presents with a secondary postpartum haemorrhage six days
following a spontaneous vaginal delivery. On examination she is acutely tender over the
uterus and has a temperature of 38.2°C.

She is passing large fresh clots per vaginum. You check her delivery records and you note
that the placenta had 'ragged membranes'. All are true in her management options
except

22) A 17-year-old primigravida undergoes surgical termination of pregnancy at 8 weeks gestation. What is the recommended antibiotic regimen to reduce post-operative infection?

23)

A 32 year old para two presents on day 7 post emergency caesarean section, with
erythema, pain and oozing around the wound site. She is alert and well, with BP 124/86, P 95,
Temp 37.5, RR 18 and sats 98% on room air. BMI is 38, she has no other past medical
history. You review the operative notes and discover that it was a challenging caesarean due to
adhesions, it was performed by a consultant and a drain was used, removed on day one postop. The wound was closed with a subcuticular absorbable monofilament suture. What is the
most important risk factor in her history for development of wound infection?

24) Which of the following analgesia should be avoided in cases of sepsis?

25) How many days does it normally take for surgical wound related abscess to develop?

26) The most common site of sepsis in peuperium is;

27)

Q13.A 22-year-old woman is referred by her GP 36 hours following a spontaneous vaginal
delivery. She had an uncomplicated pregnancy apart from a history of prolonged rupture of
membranes for which she was induced. She required epidural analgesia in labour. There were no
concerns in the immediate postpartum period and she was discharged home the following
morning.
On admission her temperature is 38.5°C. She has tachycardia 120 beats/minute and feeling
generally unwell.
What is the most important initial investigation?

A 35-year-old para 1 is 48-hours post emergency caesarean section and has a temperature
of 38.1°C. Her blood pressure is 110/78 mmHg, her respiratory rate is 26 breaths/min and her
pulse is 132 beats/minute. She feels generally unwell. She has a history of prolonged rupture of
membranes prior to delivery (32 hours). You take a venous blood gas, on which the lactate is
1.8. You activate the sepsis resuscitation bundle.

28) What is the most important initial management?

You are asked to review a wound 5 days following caesarean section. The woman has Type
1 diabetes and a BMI of 40kg/m2. The procedure was performed as an emergency for the
management of suspected intrapartum fetal distress and the woman received antibiotic
prophylaxis at the time of the procedure. The pain is described as agonising and is not relieved
by opiates. On examination the wound is blistered, tender and swollen.

29) What should you do as part of her management?

30) % of blood cultures positive in severe sepsis

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