Sepsis in Pregnancy

Introduction

• Maternal sepsis is a life-threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, postabortion, or the postpartum period.
• Based on the Sepsis-2 definition of severe sepsis, the rate of sepsis in the pregnant population is estimated to be between 1/2000 and 1/10,000.¹
• The mortality rate of sepsis in the United States remains around 11–13% of all maternal deaths over the last three decades, despite the publication of Surviving Sepsis guidelines starting in 2004.²

Etiology

Diagnoses

• The most common sources of infection during pregnancy are:¹
  • Genitourinary (45%)
    • Chorioamnionitis (25-30%)
    • Endometritis (25%)
  • Respiratory (11-30%)
  • Gastrointestinal (10%)
  • Skin and soft tissue infections (6%)
  • Others: endocarditis, meningitis, central line-associated bacterial infection, bacteremia, osteomyelitis, infective arthritis, encephalitis, and septic thrombophlebitis

Organisms

Risk Factors for Maternal Sepsis

Signs and Symptoms of Sepsis

• Sepsis-3 definition defines septic shock as a subset of sepsis in which profound circulatory, cellular, and metabolic abnormalities are associated with an increased risk of mortality than with sepsis.⁵
• Normal maternal physiology mimics a hyperdynamic state that makes it challenging to detect evolving sepsis.
  • Normal baseline increase in heart rate up to 100bpm
  • Expected PaCO₂ of 30 mmHg due to increased minute ventilation
  • Normal elevated white blood cell count during active labor
  • Elevated lactate levels up to 4.0mmol/L
• Systemic Inflammatory Response syndrome criteria combined with suspected and/or confirmed infection and various other indicators of end-organ dysfunction may identify developing sepsis
  • High sensitivity, poor sensitivity in detecting maternal sepsis
• Quick Sequential Organ Failure Assessment score identifies patients in emergency room or general floor who are at risk of developing sepsis
  • Low sensitivity, high specificity in detecting maternal sepsis

Early Warning Systems

• Early warning systems seek to identify preventable morbidity and mortality from several conditions, including sepsis.
• Maternal Early Warning Criteria (MEWC) were developed using pregnancy-adjusted vital sign and symptoms triggers. Any patient who meets one or more criteria should receive a prompt bedside evaluation by a clinician for possible diagnostic or therapeutic intervention.
• The sensitivity and specificity of the MEW (>1) criteria in peripartum patients with known sepsis is 82% and 87%.⁴

Initial Management for Suspected Sepsis

Recognition and Immediate Management

• The World Health Organization (WHO) and the California Maternal Quality Care Collaborative (CMQCC) both provide diagnostic and therapeutic algorithms to assist providers in detecting and promptly managing maternal sepsis.
• WHO criteria: if infection and organ dysfunction are present → diagnose maternal sepsis
  • Identify and control the source → send cultures; start antibiotics within 1 hour of suspected sepsis; monitor
  • Clinical evaluation and management → point-of-care assessment of organ function; fluid resuscitation; hemodynamic and respiratory support; monitor
• CMQCC criteria
  • An initial sepsis screen based on physiologic triggers → if 2 of the 4 pregnancy-adjusted screening values are met, the provider is prompted to start antibiotics and administer fluids as well as increase monitoring and surveillance.
  • A second, confirmation step based on additional pregnancy-adjusted measurements for end-organ dysfunction → if 1 of the 7 systems has criteria met, the provider is prompted to take action and identify sepsis versus septic shock, and again, provide treatment and possible consultation.

Surviving Sepsis Campaign Key Recommendations⁸

• Administer 30 mL/kg crystalloid for hypotension or lactate > 4 mmol/L
• Resuscitation may be guided by a decrease in serum lactate in patients with an elevated lactate level.
• Administer broad-spectrum antibiotics immediately, ideally within 1 hour of recognition of sepsis (Table 5)
• Obtain blood cultures prior to administration of antibiotics
• Administer vasopressors if the patient remains hypotensive during or after fluid resuscitation for a goal mean arterial pressure ≥ 65 mmHg
• Patients with sepsis or septic shock who require intensive care unit (ICU) admission should be admitted within 6 hours.

Critical Care Management of Sepsis

ICU Admission Indications

• Aggressive hemodynamic support, including vasopressors
• Invasive monitoring, including arterial and/or central venous monitoring, maintenance, and interpretation
• Invasive mechanical ventilation
• Mechanical circulatory support

Preventable Morbidity

• Delayed antibiotic initiation
• Inadequate antibiotic coverage
• Delayed ICU admission or escalation of care
• Lack of recognition

Post-ICU Care

• Postpartum separation of mother and child may affect maternal-infant bonding and the ability to breastfeed.
• Posttraumatic stress disorder, depression, and/or anxiety are common psychiatric consequences of maternal ICU admission.
• Patients may experience also impaired quality of life including worsened mobility, self-care, and pain.
• Close follow-up with providers with particular attention to mental health crisis following critical illness is imperative.