Learning Objectives and CME/Disclosure Information

Original Launch Date: 12/01/2022

Expiration Date: 12/01/2024

ACCME PARS: 10765

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. Describe how to assess whether a patient with sepsis is responding to fluid management
2. Discuss the considerations when beginning antimicrobial therapy

Estimated time to complete activity: 0.25 hours

Faculty:

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

Disclosure of Financial Relationship

Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.

The PIM planners and others have nothing to disclose. The OBG Project planners and others have nothing to disclose.

Faculty: Susan J. Gross, MD, receives consulting fees from Cradle Genomics.

Planners and Managers: PIM Planners have nothing to disclose

Method of Participation and Request for Credit

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 test and evaluation. Upon registering and successfully completing the test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

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.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Sepsis during pregnancy remains a significant and potentially preventable cause of maternal morbidity and mortality. The importance of heightened vigilance and early initiation of therapy is a key feature of the CMQCC guideline and mirrored across multiple medical organizations. 

Clinical Actions

• Order
  • Cultures: Blood | Sputum | Urine and other samples as indicated
    • CMQCC recommends cultures be drawn upon diagnosis even if antibiotic therapy has already been initiated
  • 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

• CMQCC states

We recommend that resuscitation from sepsis-induced hypoperfusion include at least 30 mL/kg of intravenous crystalloid fluid within three hours of recognition of sepsis

Surviving Sepsis Campaign does not recommend one crystalloid over another

• 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 to 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 to 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
  • 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

CMQCC Antibiotic Recommendations if Source Unknown (at least
one antibiotic for Gram-negative and anaerobic coverage PLUS one for Gram-positive coverage)

7 to 10 day duration usually adequate

• Gram-negative plus anaerobic coverage
  • Piperacillin/tazobactam 3.375 g IV q8h (extended infusion) or 4.5 g IV q6h or
  • Meropenem 1 g IV q8h (if recent hospitalization or concern for multi-drug resistant organisms) or
  • Cefepime 1-2g IV q8h plus metronidazole 500 mg IV q8h or
  • Aztreonam 2 g IV q8h (for women with severe penicillin allergy) plus metronidazole 500 mg IV q8h or
  • Aztreonam 2g IV q8h plus clindamycin 900 mg IV q8h

PLUS

• Gram-positive coverage
  • Vancomycin 15-20 mg/kg q8h-q12h (goal trough 15-20 mcg/mL) or
  • Linezolid 600 mg IV/PO q12h (for women with severe vancomycin allergy)

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:

The Surviving Sepsis Campaign Bundle 2018 Update

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

CMQCC Toolkit: Improving Diagnosis and Treatment of Maternal Sepsis

Related ObG Topics:

SMFM Guidance: Diagnosis and Management of Maternal Sepsis

CMQCC Guidelines: Making the Diagnosis of Sepsis in Pregnancy

Chorioamnionitis: ACOG Committee Opinion on Diagnosis and Management

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