SUMMARY:

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.  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

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

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

Step 2 Confirmation: CMQCC Sepsis Diagnosis Algorithm (only 1 criteria required for sepsis 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

KEY POINTS:

• 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”

Learn More – Primary Sources:

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

JAMA: Consensus Definitions for Sepsis and Septic Shock

CMQCC: Improving Diagnosis and Treatment of Maternal Sepsis

Related ObG Topics:

SMFM Guidance: Diagnosis and Management of Maternal Sepsis

CMQCC Guidelines: Management of Sepsis in Pregnancy

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

What is the Best Practices Prevention Bundle for Post Cesarean Infection?