SMFM Guidance: Diagnosis and Management of Maternal Sepsis
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.
Is not a defined illness, but a life-threatening organ disruption with a dysregulated host response to infection
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
Antepartum: Septic abortion | Chorioamnionitis
Postpartum: Endometritis | Wound infection
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
Does Intrapartum Fever Really Predict Neonatal Sepsis?
BACKGROUND AND PURPOSE:
There is guidance from the CDC, ACOG and AAP that well-appearing newborns should undergo limited evaluation for possible sepsis if mothers have suspected chorioamnionitis
In some hospitals, newborn sepsis work-up may require NICU admission
Towers et al. (AJOG, 2017) sought to evaluate the rate of fever during labor and whether there is an association with early-onset neonatal sepsis
Prospective cohort study (2011 – 2014)
Patients with fever (≥38°C) at ≥36 weeks’ gestation were evaluated for
gestational age, parity, spontaneous or induced labor, group B streptococcus status, regional anesthesia, mode of delivery, treatment with intrapartum antibiotics, and whether a clinical diagnosis of chorioamnionitis was made by the managing physician
Cases started labor afebrile but then developed fever prior to delivery with no other infectious cause identified
Neonates were assessed for blood culture results, neonatal intensive care unit admission, length of stay, and any major newborn complications
412 patients developed a fever in 6,057 deliveries (6.8%; 95% CI 6.2–7.5%)
No cases of maternal sepsis
There was no difference in rate of newborn sepsis in fever vs. control group (p=0.3)
Febrile group: 1 newborn out of 417 developed sepsis from Escherichia coli (0.24%; 95% CI 0.01–1.3%)
Non-febrile group: 4 cases of early-onset neonatal sepsis, 2 with GBS and 2 with Escherichia coli (0.07%; 95% CI 0.02–0.18%)
The incidence of intrapartum fever is common at 6.8% and consistent with retrospective studies, although is double the rate in the CDC guideline of 3.3%
Neonatal sepsis incidence rate in the population of women with fever ≥36 weeks’ gestation is rare at 0.82/1000 live births
Need to treat (NTT): 1/417 neonates
Authors suggest that the practice of follow-up cultures and universal antibiotic treatment in well-appearing newborns in the setting of intrapartum fever may not be ‘clinically sound’
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