Severe Sepsis and Septic Shock in Pregnancy

Reference: Obstetrics & Gynecology, Vol. 120, No. 3, Sept.2012, p.689-706

Terminology
Septic Inflammatory Response Syndrome (SIRS): Defined as the presence of two or more of the following:*
Temperature >38 C or <36 C
Heart rate >90 beats/min
Respiratory rate >20 breaths/min
PaCO2 <32 mmHg
WBC >12,000, <4,000, or >10% bands
Hyperglycemia (glucose >120) in absence of diabetes
Positive fluid balance (>20 mL/kg over 24 hours)

Sepsis: SIRS resulting from infection

Severe sepsis: Sepsis associated with organ dysfunction, hypoperfusion, or hypotension.
Septic shock: Sepsis-induced hypotension persisting despite adequate fluid resuscitation along
with the presence of perfusion abnormalities that may include, but are not limited
to, lactic acidosis, oliguria, or an acute alteration in mental status.

Multiple organ dysfunction syndrome: The presence of altered organ function in an acutely ill patient such
that homeostasis cannot be maintained without intervention.

*These criteria are used in non-pregnant adults to guide admission to the ICU and treatment as well as to
predict mortality and serious morbidity. These guidelines have not been validated in pregnant or postpartum
women. Accurate identification of those at risk for deterioration is difficult secondary to the normal
alteration in physiology and the infrequency of septic shock in pregnancy.


Incidence

Septic shock is rare in pregnancy, occurring in 0.002-0.01% of all deliveries. Sepsis is the most common
cause of direct maternal death in the United Kingdom. The incidence of acute medical and surgical
emergencies in pregnancy and postpartum leading to rises of severe sepsis and septic shock continues to
increase because of changes in demographics, obesity, type 2 diabetes, placenta previa, and abruption
placentae. Increase in invasive diagnostic and therapeutic procedures is associated with an increased rate of
septic complications.


Causes of Severe Sepsis and Septic Shock in Pregnancy and the Puerperium

Acute Pyelonephritis
Retained products of conception:
o septic abortion
o conservative management of placenta accrete or percreta
Neglected chorioamnionitis or endomyometritis
o Uterine microabscess or necrotizing myometritis
o gas gangrene
o pelvic abcess
Pneumonia
o Bacterial examples
Staphylococcus
Pneumonococcus
Mycoplasma
Legionella
o Viral examples
Influenza
H1N1
Herpes
Varicella
Unrecognized or inadequately treated necrotizing fasciitis
o Abdominal incision
o Episiotomy
o Perineal laceration
Intraperitoneal etiology (non-obstetric)
o Ruptured appendix or acute appendicitis
o Bowel infarction
o Acute cholecystitis
o Necrotizing pancreatitis


Maternal and Perinatal Complications of Severe Sepsis and Septic Shock

Maternal
Admission to ICU
Pulmonary edema
Adults respiratory distress syndrome
Acute renal failure
Shock liver
Septic emboli to other organs
Myocardial ischemia
Disseminated intravascular coagulation
Death

Perinatal
Preterm delivery
Neonatal sepsis
Perinatal hypoxia or acidosis
Fetal or neonatal death


Signs and Symptoms

Fever
Temperature instability (>38 C or <36 C)
Tachycardia (>110 beats/min)
Tachypnea (>24 breaths/min)
Diaphoresis
Clammy or mottled skin
Nausea or vomiting
Hypotension or shock
Oliguria or anuria
Pain (location based on site of infection)
Altered mental state (confusion, decreased
alertness)


Laboratory Findings

Leukocytosis or leukopenia
Positive culture from infection site and/or
blood
Hypoxemia
Thrombocytopenia
Metabolic acidosis: Increased serum lactate,
low arterial pH, increased base deficit
Elevated serum creatinine
Elevated liver enzymes
Hyperglycemia in the absence of diabetes
Disseminated intravascular coagulation

Prognostic Indicators of Poor Outcome in Septic Shock

Delay in initial diagnosis
Pre-existing debilitating disease process
Poor response to massive intravenous fluid
resuscitation
Depressed cardiac output
Reduced oxygen extraction
High serum lactate (>4 mmol/L)
Multiple organ dysfunction syndrome

Septic Shock Management

I. Initial Resuscitation Phase (first 6 hours)

Blood cultures obtained (goal within 1 hour)
Empiric antibiotics initiated (goal within 1 hour)
Central line placed (goal within 4 hours)
Central venous pressure 8 mm Hg or higher (goal within 6 hours)
Norepinephrine infusion if indicated (mean arterial pressure lower than 65 mm Hg after resuscitation)
Transfusion of RBCs if indicated by hemoglobin less than 7 g/dL

II. Hemodynamic Management

Central line and arterial line placement
Fluid resuscitation
o Use warm normal saline or lactated Ringers
o Rapid infusion (500 mL over 15 minutes)
1-hr goal: total 20 mL/kg
3-hr goal: total 30 mL/kg
o Physiologic perfusion end points
Central venous pressure 8-12 mm Hg
Mean arterial pressure greater than 65 mm Hg
Urine output greater than 25 mL/hr
Vasopressor therapy
o Vasoactive agents if mean arterial pressure lower than 65 mm Hg after fluid resuscitation
o Inotropes if central venous oxygen saturation remains less than 70%
o Vasopressin if vasopressor therapy ineffective
Oxygen therapy
o Supplement with nasal cannula, facemask
o Intubate, mechanical ventilation, if respiratory failure
Sedation, analgesia, neuromuscular blocker

III. Antimicrobial Therapy

Prompt cultures
o Do not delay therapy while awaiting cultures
o Survival differences seen in delay of antibiotic therapy of only 1 hour
Prompt empiric antibiotic therapy
o Gentamicin at 1.5 mg/kg IV, then 1 mg/kg IV every 8 hours
o Clindamycin at 900 mg IV every 8 hours
o Penicillin at 3,000,000 units IV every 4 hours

Or

o Vancomycin at 15 mg/kg IV and then dosing by pharmacy
o Piperacillin and tazobactam at 4.5 g IV every 6 hours


IV. Search and Eliminate Source of Sepsis

Retained products of conception or necrotic uterus
Debridement of infected tissue (incision, episiotomy, fascia)
Abscess
Pyuria with ureteral obstruction
Appendicitis, cholecystitis, or pancreatitis

V. Maintenance Phase

Insulin protocol initiated, if indicated
Corticosteroid therapy for refractory septic shock
o Hydrocortisone at 50 mg IV every 6 hours
Thromboembolic prophylaxis
o Sequential compression device, and
o Enoxaparin at 40 mg SQ once daily (or 5,000 units heparin SQ every 8 hours if hepatic or renal
impairment)
Stress ulcer prophylaxis
o Famotidine at 20 mg every 12 hours
Reassess antibiotic therapy and narrow spectrum if possible



Potential Maternal and Perinatal Indications for Delivery

Maternal
Intrauterine infection
Development of DIC
Hepatic or renal failure
Compromised cardiopulmonary function by uterine size or peritoneal fluid, or uterine size and peritoneal
fluid
o Compartment syndrome
o Hydramnios
o Multifetal gestation
o Severe ARDS or barotrauma
Cardiopulmonary arrest

Fetal
Fetal demise
Gestational age associated with low neonatal morbidity or mortality


Prevention

Preoperative preparation and interventions with operative delivery
o Treating infections remote to surgical site before elective surgery
o Showering with antiseptic agent night before surgery
o Abstaining from smoking (30 days) before surgery
o Glycemic control in diabetes
o Hair removal around incision with electric clippers (not by razor)
o Wide antiseptic skin prep before the operative procedure
o Antimicrobial prophylaxis
Cefazolin 1-2 g IV or cefotetan 1-2 g IV
Administer up to 60 minutes before skin incision and not at cord clamping
Proper surgical technique
o Eliminate dead space
o Minimize tissue trauma and electrocautery use

Vaccination
o All women who will be pregnant during the influenza season should receive inactivated influenza
vaccine at any point in gestation
o Pregnant women have a disproportionately high risk for serious illness and death from H1N1
influenza A infection as well as poor fetal and neonatal outcome