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SEPSIS IN PREGNANCY
Incidence
SIRS is associated with any 2 or more of the following clinical findings: (1) body
temperature of >38 degrees C or < 36 degrees C; (2) heart rate > 90 per minute;
(3) hyperventilation [respiratory rate of > 20 per minute or Pa CO2 <32 mm/Hg];
and (4) white blood cell count of >12,000/microliter or <3,000/microliter.
Septic shock is defined by acute circulatory failure in a septic patient who has
hypotension (MAP<60 mmHg or Systolic BP<90 mm Hg) unexplained by other
causes.6,7
Infection Sites
11 Listeria monocytogenes
12 Enterobacter
Diagnostic Studies
A list of possible signs, symptoms, and laboratory findings associated with sepsis
in pregnancy is provided in Table 2. (LINK) Note that many of these items can
be seen in pregnancy in the absence of infection and sepsis. A good rule of
thumb is to require a clinical diagnosis of primary infection (including site of
infection, if possible) before using the items below to diagnose sepsis.
Table 2. Diagnosis Criteria for Sepsis4
When severe sepsis is present, early recognition and prompt treatment are
critically important. Therapy includes fluid resuscitation, obtaining cultures
(including blood cultures), and treatment with antibiotics, all within the first 6
hours of onset. Combinations of antibiotics given IV (such as ampicillin 2 gm, q 6
hrs; gentamicin 100 mg, q 8 hrs; and clindamycin 900 mg or metronidazole 500
mg q 8 hrs) should be started within one hour. Care may be best provided in the
ICU with foley catheter, hourly intake and output, continuous cardiac and oxygen
saturation monitoring, and frequent BP monitoring (using continuous arterial line
measurements in septic shock cases). Oxygen supplementation is often
required and acetaminophen may be used to reduce excessive fever. Fetal
monitoring is appropriate when the possibility of fetal viability exists. Fetal
tracings suggesting fetal hypoxia or acidosis may even be the first signs of
impending maternal cardio respiratory decompensation. Pulmonary capillary
wedge pressure evaluations have been specifically suggested for monitoring
appropriate fluid resuscitation in pregnancy complicated by septic shock and
early intubation with positive end expiratory pressure has been advocated to treat
the adult respiratory distress syndrome that often follows the successful fluid
resuscitation of this condition.10
Risks to Fetus
Fetal compromise in utero may occur with septic shock due to hypoperfusion of
the pregnancy. Maternal fever may increase the oxygen requirements of the
fetus directly and by promoting fetal tachycardia that requires additional oxygen
consumption. This combination of decreased oxygen supply and increased
oxygen requirements may cause fetal hypoxia. If these components of maternal
sepsis cannot be quickly improved, fetal death or emergency delivery may be the
only options.
Premature birth can result not only from the emergency deliveries described
above; preterm labor also often results from infections and sepsis. The fetus
may also have risks of infection directly harming it in utero (such as with
chorioamnionitis or transplacental infection) or of neonatal infections acquired at
birth.
Risks to Mother
Sepsis may cause preterm labor and delivery. Associated fetal compromise may
require emergency cesarean section that could be complicated by the sepsis
induced maternal hypotension, pulmonary edema, or DIC. Long term
hospitalization, morbidity, and death can be seen as a result of maternal sepsis.
Risk Factors
Sepsis in pregnancy often results from urinary tract infections (especially chronic
or recurrent infections), chorioamnionitis (especially with prolonged rupture of
membranes), or from post cesarean section infections. Any source of infection
that could cause sepsis in the nonpregnant patient could cause it in pregnancy
(see Table 1).LINK
Upd V,5,10
References
1
Joseph J, et al: Sepsis in pregnancy and early goal-directed therapy. Obstet Med 2:93-99, 2009.
2
Ronsmans C, Graham WJ: Lancet maternal survival series steering group. Maternal mortality: who,
when, where, and why. Lancet 368:1189-1200, 2006.
3
Guinn DA, Abel DE, Tomlinson MW: Early goal directed therapy for sepsis during pregnancy. Obstet
Gynecol Clin North Am 34:459-479, 2007.
4
Fernandez-Perez ER, et al: Sepsis during pregnancy. Crit Care Med 33(10 Suppl): S286-293, 2005.
5
ACOG Practice Bulletin (Number 100): Critical Care in Pregnancy. Obstet Gynecol 113: 443-450,
2009.
6
American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference:
Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit
Care Med, 20:864–74, 1992.
7
Levy MM, Fink MP, Marshall JC, et al: 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis
Definitions Conference. Crit Care Med, 31:1250–6, 2003.
8
Burke J: Infection Control – A Problem for Patient Safety. NEJM 348:651-656, 2003.
9
Tita ATN, et al: Emerging Concepts in Antibiotic Prophylaxis for Cesarean Delivery: A Systematic
Review. Obstet Gynecol 113:675-82, 2009.
10
Campbell LA, Klocke RA: Implications for the pregnant patient. Am J Respir Crit Med 163:1051-
1054, 2001.
11
Rivers E, et al: Early goal-directed therapy in the treatment of severe sepsis and septic shock. NEJM
345:1368-77, 2001.
12
Medve L, Csitari IK, Nolnar Z, Laszio A: Recombinant human activated protein C treatment of septic
shock syndrome in a patient at 18th week of gestation: a case report. Am J Obstet Gynecol 193: 864-
5,2005.
13
Mikaszewska-Sokolwicze M, Mayzner-Zawadzka E: Use of recombinant human activated protein C in
treatment of severe sepsis in a pregnant woman with fully symptomatic ovarian hyperstimulation
syndrome. Med Sci Monit 11: CS27-32, 2005.