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Severe Sepsis and Septic Shock in PregnancyReference: Obstetrics & Gynecology, Vol. 120, No. 3, Sept.2012, p.689-706

TerminologySeptic Inflammatory Response Syndrome (SIRS): Defined as the presence of two or more of the following:*

Temperature >38 C or 90 beats/min

Respiratory rate >20 breaths/min

PaCO212,000, 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 abruptionplacentae. 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 myometritiso gas gangrene

o pelvic abcess

Pneumonia

o Bacterial examples

Staphylococcus

Pneumonococcus

Mycoplasma

Legionella

o Viral examples

Influenza

H1N1

Herpes

Varicella

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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 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

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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

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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

Hydramnioso

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 surgeryo 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 beforeskin incision and notat cord clamping

Proper surgical technique

o Eliminate dead space

o Minimize tissue trauma and electrocautery use

Vaccinationo 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