SMFM Guideline: Making the Diagnosis of Sepsis in Pregnancy

Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the definitions for sepsis and septic shock
2. Describe the physiologic differences that may impact non-pregnant sepsis scoring systems

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Genoox, Inc., and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from through , participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Read Disclaimer & Fine Print

SUMMARY:

SMFM has released a consult series document on sepsis in pregnancy. Sepsis remains a major cause of maternal morbidity and mortality. Sepsis is considered a preventable cause of maternal mortality.

Risk Factors

Nulliparity
Black race
Insurance: public or none
Cesarean delivery
ART
Multiple gestation

Note: Presence of co-morbidities increases maternal mortality risk

Definitions and Clinical Criteria

The Third Internal Consensus Definitions for Sepsis and Septic Shock (2016)

Definitions

Sepsis: Life-threatening organ dysfunction caused by a dysregulated host response to infection
Septic shock: Sepsis with circulatory and cellular/metabolic abnormalities profound enough to substantially increase mortality

Clinical Criteria

Sepsis
- Suspected or documented infection and an acute increase of ≥2 SOFA (Sequential Organ Failure Assessment) points (see ‘Key Points’ below)
  - Proxy for organ dysfunction
Septic Shock
- Sepsis and vasopressor therapy needed to
  - Elevate MAP ≥ 65 mmHg and lactate > 2 mmol/L (18 mg/dL) after adequate fluid resuscitation

qSOFA to Rapidly Identify Those at Risk

Bedside tool used outside the ICU
Assign 1 point each to the following criteria
- SBP: ≤100 mmHg
- Respiratory rate: ≥22 breaths per min
- Altered mentation: Glasgow coma scale<15
If score ≥2
- Assess for organ dysfunction
- Escalate therapy
- Increase monitoring and transfer to ICU may be required

Note: Sepsis and septic shock are medical emergencies

Resuscitation and treatment should begin immediately
Consider sepsis in pregnant women “otherwise unexplained end-organ damage in the presence of an infectious process”
Treat regardless of whether or not fever is present
Multiple organ systems aside from cardiovascular, pulmonary and CNS may be affected including
- GI (ileus) | Hepatic injury or failure | Renal injury or failure | Coagulation (low platelets or DIC) | Endocrine system (adrenal / insulin resistance)

KEY POINTS:

SOFA Score: Sepsis defined as an acute increase of 2 or more points

Respiratory system: PaO2/FiO2 (mmHg)
- ≥ 400 score 0
- < 400 score +1
- < 300 score +2
- < 200 and mechanically ventilated score +3
- < 100 and mechanically ventilated score +4

Nervous system: Glasgow coma scale
- 15 score 0
- 13–14 score +1
- 10–12 score +2
- 6–9 score +3
- < 6 score +4

Cardiovascular system: MAP or vasopressors required
- MAP ≥ 70 mmHg score 0
- MAP < 70 mmHg score +1
- dopamine ≤ 5 µg/kg/min or dobutamine (any dose) score +2
- dopamine > 5 µg/kg/min OR epinephrine ≤ 0.1 µg/kg/min OR norepinephrine ≤ 0.1 µg/kg/min score +3
- dopamine > 15 µg/kg/min OR epinephrine > 0.1 µg/kg/min OR norepinephrine > 0.1 µg/kg/min score +4
Liver: Bilirubin (mg/dl) [μmol/L]
- < 1.2 [< 20] score 0
- 1.2–1.9 [20-32] score +1
- 2.0–5.9 [33-101] score +2
- 6.0–11.9 [102-204] score +3
- 12.0 [> 204] score +4
Coagulation: Platelets×10³/µl
- ≥ 150 score 0
- < 150 score +1
- < 100 score +2
- < 50 score +3
- < 20 score +4
Kidneys: Creatinine (mg/dl) [μmol/L] (or urine output)
- < 1.2 [< 110] score 0
- 1.2–1.9 [110-170] score +1
- 2.0–3.4 [171-299] score +2
- 3.5–4.9 [300-440] (or < 500 ml/d) score +3
- 5.0 [> 440] (or < 200 ml/d) score +4

Clinical Features and Considerations Specific to Pregnancy

SOFA does not take in to account the physiologic changes of pregnancy
- Creatinine at ≥2 mg/dL: This SOFA threshold above pregnancy norm
- MAP: Healthy pregnant women may have MAP <70 mmHg
SOMANZ (Society of Obstetric Medicine Australia and New Zealand) developed an obstetrically modified qSOFA score for pregnant women (1 point each; ≥2 escalate)
- SBP <90 mmHg
- Respiratory rate >25/min
- Altered mental status (any non-alert state)
SOMANZ also made modifications to the SOFA scoring system
- Simplified to account for lack of Glasgow score use on L&D
- Healthy pregnancy will usually have MAP <70 mmHg so premorbid blood pressure should be taken in to consideration
- Positive score is a change of ≥2 so scores of 3 and 4 removed for sake of simplicity

SOMANZ obstetrically modified SOFA- (omSOFA)

Respiration: PaO2/FIO2
- ≥400 score 0
- 300 – <400 score +1
- <300 score +2
Coagulation: Platelets, x106/L
- ≥150 score 0
- 100-150 score +1
- <100 score +2