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

• 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

Related ObG Topics: