SUMMARY:

SMFM  and CMQCC have both released guidance on sepsis in pregnancy. Sepsis remains a major cause of maternal morbidity and mortality. Sepsis is considered a preventable cause of maternal mortality. Because vital signs are altered in pregnancy (and may mimic infection such as increased maternal heart rate), both professional organizations emphasize the importance of recognizing that sepsis screening tools may need modification during pregnancy.  There are multiple tools to screen and diagnose sepsis. SMFM provides the SOFA method and CMQCC has developed its own algorithm (see details below)

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 System 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

CMQCC 2-Step System for Maternal Sepsis Screening and Diagnosis

Step 1 – Sepsis Screen: ≥2 elements considered positive 

• Oral temperature: < 36°C (98.6°F) or ≥ 38°C (100.4°F)
• HR: > 110 beats per minute and sustained for 15
  minutes
• RR: > 24 breaths per minute and sustained for
  15 minutes
• WBC: > 15,000/mm3 or < 4,000/mm3 or >
  10% immature neutrophils (bands)

Note: Verify abnormal values | Obtain a complete set of vital signs (i.e., include 02 sat) and repeat in 15 minutes | Do not wait for fever if there are other suspicious clinical signs that infection is present | Corticosteroids will elevate WBCs but peak expected within 24 hours and should be baseline again after 96 hours

Step 2 – If Step 1 Positive – Obtain the following 

• Laboratory values: CBC
  • Coags: Prothrombin time | INR | PTT
  • Comprehensive metabolic panel
  • Venous lactic acid
• Bedside assessment
  • Urine output (Foley catheter with urometer
  • Pulse oximetry
  • Mental status assessment

CMQCC Sepsis Diagnosis Algorithm (only 1 criteria required for diagnosis) 

• Respiratory function
  • Need for invasive or non-invasive mechanical
    ventilation or
  • PaO2/FiO2 < 300
• Coag studies
  • Platelets < 100 x 109/L or
  • INR: > 1.5 or
  • PTT: > 60 seconds
• Liver function
  • Bilirubin > 2 mg/dL
• Cardiovascular function (persistent hypotension)
  • SBP < 85 mm Hg or
  • MAP < 65 mm Hg or
  • > 40 mm Hg decrease in SBP
• Renal function
  • Creatinine > 1.2 mg/dL or
  • Doubling of creatinine or
  • Urine output < 0.5 mL/kg/hour (for 2 hours)
• Mental status
  • Agitation | Confusion | Unresponsiveness
• Lactic acid
  • 2 mmol/L
  • Can be used for diagnosis in the absence of labor | For women in labor with an elevated lactic acid and positive step 1 screen but negative step 2 confirmation, CMQCC recommends close surveillance with repeated bedside evaluation and repeated lactic acid levels over time

Note: CMQCC has not evaluated its algorithm in a research setting, but based on clinical practice data sets, the anticipated performance is estimated to be 97% for sensitivity and 99% for specificity

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)
• CMQCC emphasizes that a MAP of <65 mm Hg that persists after a 30ml/kg fluid load in the setting of infection “directly defines septic shock”

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 if Using SOFA

• 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

• Liver: Bilirubin (mg/dl) [μmol/L]
  • ≤1.2 [≤20] score 0
  • 1.2-1.9 [20-32] score +1
  • >1.9 [>32] score +2

• Cardiovascular: MAP (mmHg)
  • ≥70 score 0
  • <70 score +1
  • Vasopressors required score +2

• Central Nervous System
  • Alert score 0
  • Rousable by voice score +1
  • Rousable by pain score +2

• Renal: Creatinine (mg/dl) [μmol/L]
  • ≤1.0 [≤90] score 0
  • 1.0-1.4 [90-120] score +1
  • >1.4 [>120] score +2

Learn More – Primary Sources:

SMFM Consult Series: Sepsis during pregnancy and the puerperium

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

qSOFA calculator

Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients

JAMA: Consensus Definitions for Sepsis and Septic Shock

SOMANZ Guidelines for the Investigation and Management of Sepsis in Pregnancy

CMQCC: Improving Diagnosis and Treatment of Maternal Sepsis

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