SUMMARY:

Sepsis remains a significant and potentially preventable cause of maternal morbidity and mortality. SMFM highlights the importance of implementing an ‘early warning system’ to avoid delay and recommends that

…sepsis and septic shock be considered medical emergencies and that treatment and resuscitation begin immediately (GRADE 1B)

We recommend that providers consider the diagnosis of sepsis in pregnant patients with otherwise unexplained end-organ damage in the presence of an infectious process, regardless of the presence of fever

Clinical Actions

• Order
  • Cultures: Blood | Sputum | Urine and other samples as indicated
  • Serum lactate levels
• Begin
  • Antibiotics within 1 hour (see ‘Key Points’ below)
  • Broad Spectrum (anaerobic and aerobic gram-positive and gram negative bacteria)
• Determine source as early as possible following initiation of resuscitation and initiation of antibiotics
  • Imaging as necessary
  • Manage depending on findings (e.g. abscess drainage as required)
  • Use the least invasive approach possible (e.g. percutaneous best when appropriate) except in case where more invasive approach is desirable (e.g., debridement if indicated)

Fluids

• SMFM cautions that aggressive fluid resuscitation in pregnant women may result in ‘third spacing’ and recommends initial administration of 1-2 liters of crystalloids (Grade 1C)
• Do not use CVP or pulmonary artery occlusion pressure to guide fluid resuscitation
• Determine if patient is fluid responsive
  • Pulse pressure variation using arterial line wave form
    • Reliable with [1] sedation [2] positive pressure controlled mechanical ventilation and [3] in sinus rhythm
    • Pulse pressure should vary ≥13% with the respiratory cycle
  • Passive leg raise to 30-45 degrees (spontaneous breathing or not in sinus)
    • Auto transfusion results in increased cardiac output
    • May not be a good test in third trimester: Use 250-500cc cardiac bolus rather than leg raise

Vasopressors and Inotropes

• • Use vasopressors in hypotensive patients if
    • Not fluid responsive or
    • Further fluid therapy is contraindicated (e.g. pulmonary edema)
  • First line: Norepinephrine
    • Target MAP: >65 mmHg
    • SMFM recommends individualizing in pregnant patients taking in to account clinical context and overall perfusion
    • Norepinephrine appears to be safe in pregnancy although high-quality data is limited
  • Other vassopressors
    • Data on other vasopressors more limited

• • Consider dobutamine (inotrope) to increase cardiac output if
    • Patient remains hypotensive following fluids and vasopressors
    • Myocardial dysfunction is present
• Start hydrocortisone 200 mg/day (continuous infusion) if no response to norepinephrine

Note: Initiate DVT prophylaxis

KEY POINTS:

Antibiotic Therapy

• Consider the following when beginning antimicrobial therapy
  • Initially, choice of antibiotic will likely be empiric
  • Choice of antibiotic will be dependent on
    • Source | Local resistance | Hospital protocols
  • Start with broad spectrum coverage, including anaerobic and aerobic gram-positive and gram-negative bacteria
  • Consultation with infectious disease may be appropriate

SMFM provides antibiotic recommendations dependent on source

• Community-acquired pneumonia
  • Cefotaxime | Ceftriaxone | Ertapenem | Ampicillin plus azithromycin | Clarithromycin | Erythromycin
• Hospital-acquired pneumonia: Low risk
  • Piperacillin-tazobactam | Meropenem | Imipenem | Cefepime
• Hospital-acquired pneumonia: High risk or mortality
  • Double coverage for Pseudomonas
    • Beta lactam plus an aminoglycoside or quinolone
    • MRSA coverage: Vancomycin or linezolid
  • Chorioamnionitis
    • Ampicillin plus gentamicin
    • Cesarean: Add clindamycin or metronidazole for anerobic coverage
  • Endomyometritis
    • Ampicillin, gentamicin, and metronidazole (or clindamycin) or
    • Cefotaxime or
    • Ceftriaxone plus metronidazole
  • UTI
    • Gentamicin plus ampicillin or
    • Carbapenem or
    • Piperacillin-tazobactam
  • Abdominal infections: Uncomplicated
    • Ceftriaxone | Cefotaxime | Ceftazidime | cefepime plus metronidazole
  • Abdominal infections: Complicated
    • Carbapenem | Piperacillin-tazobactam
  • Skin and soft tissues (necrotizing)
    • Vancomycin plus piperacillin-tazobactam
    • If Streptococcus Group A or Clostridium perfringens are present: Penicillin G plus clindamycin

Fetal Assessment and Delivery

• Fetal assessment: Consider the following
  • Electronic fetal monitoring ≥24 weeks
  • Corticosteroids for fetal lung maturity >23 to 24 weeks of pregnancy
• Delivery (Grade 1B recommendations)
  • SMFM recommends against delivery for sepsis if this is the sole indication
  • Delivery should be dictated based on obstetric indications

Learn More – Primary Sources:

SMFM Consult Series: Sepsis during pregnancy and the puerperium

The Surviving Sepsis Campaign Bundle 2018 Update

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016

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