SMFM Guidance: Diagnosis and Management of Maternal Sepsis
SUMMARY:
Sepsis accounts for about 14% of all pregnancy-related deaths despite occurring in only 4 per 10,000 live births, and the rate of maternal sepsis appears to be increasing. More than 50% of pregnant patients who die from sepsis have at least one chronic comorbidity, such as congestive heart failure or chronic renal disease. The diagnosis of sepsis in the early postpartum period can be difficult due to the rapid physiologic changes that occur postpartum, such as large fluid shifts, postpartum hemorrhage, and heart rate and blood pressure alterations. This consult series document refers to sepsis in individuals who are either pregnant or in the postpartum period.
Sepsis Definition
Is not a defined illness, but a life-threatening organ disruption with a dysregulated host response to infection
Septic Shock
Is a subset of sepsis in which persistent hypotension requiring the use of vasopressors despite adequate fluid resuscitation
Fever is not necessary or sufficient to identify sepsis
Consider the diagnosis if
Unexplained end organ damage if suspected infectious process
End organ damage in a previously healthy individual
Potential Sources of Infection
Obstetric
Antepartum: Septic abortion | Chorioamnionitis
Postpartum: Endometritis | Wound infection
Non-obstetric
Antepartum: UTI | Pneumonia | Appendicitis
Postpartum: UTI | Pneumonia | GI
Note: No source identified in 30% of cases
Sepsis During Pregnancy
Normal physiologic changes in pregnancy can delay the identification and diagnosis
CMQCC Guidelines: Management of Sepsis in Pregnancy
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
CMQCC Guidelines: Making the Diagnosis of Sepsis in Pregnancy
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
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”
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