Severe Sepsis and Septic Shock in Pregnancy

Abstract

Pregnancies complicated by severe sepsis and septic shock are associated with increased rates of preterm labor, fetal infection, and preterm delivery. Sepsis onset in pregnancy can be insidious, and patients may appear deceptively well before rapidly deteriorating with the development of septic shock, multiple organ dysfunction syndrome, or death. The outcome and survivability in severe sepsis and septic shock in pregnancy are improved with early detection, prompt recognition of the source of infection, and targeted therapy. This improvement can be achieved by formulating a stepwise approach that consists of early provision of time-sensitive interventions such as: aggressive hydration (20 mL/kg of normal saline over the first hour), initiation of appropriate empiric intravenous antibiotics (gentamicin, clindamycin, and penicillin) within 1 hour of diagnosis, central hemodynamic monitoring, and the involvement of infectious disease specialists and critical care specialists familiar with the physiologic changes in pregnancy. Thorough physical examination and imaging techniques or empiric exploratory laparotomy are suggested to identify the septic source. Even with appropriate antibiotic therapy, patients may continue to deteriorate unless septic foci (ie, abscess, necrotic tissue) are surgically excised. The decision for delivery in the setting of antepartum severe sepsis or septic shock can be challenging but must be based on gestational age, maternal status, and fetal status. The natural inclination is to proceed with emergent delivery for a concerning fetal status, but it is imperative to stabilize the mother first, because in doing so the fetal status will likewise improve. Aggressive [corrected] treatment of sepsis can be expected to reduce the progression to severe sepsis and septic shock and prevention strategies can include preoperative skin preparations and prophylactic antibiotic therapy as well as appropriate immunizations.

Towards a consensus definition of maternal sepsis: results of a systematic review and expert consultation

“…A total of 78 were selected for full-text evaluation. After screening, 26 studies [2, 4, 5, 8, 10, 12, 20–39], 9 guidelines [13, 40–47] and 3 WHO documents [48–50] matched the inclusion criteria (Fig. 1).…”

“…Reviews and guidelines considering laboratory findings for identification of septic women include several testing of liver (enzymes, bilirubin), kidney (creatinine) and clotting (INR, aPPT) function. Five reviews [8, 10, 24, 32, 38] recommended use of cultures to identify causative microorganism, including two reviews focusing on GAS infection [8, 38] and requiring isolation of the pathogen for confirmation of diagnosis. Most of the guidelines also referred to the use of glucose, CRP and plasma procalcitonin.…”

“…However, the true frequency of maternal infections and its complications are not well known. Imprecise and varying definitions may have led to discrepancies in reported incidence and observed mortality [1, 2, 10]. Available data on pregnancy associated sepsis from high-income countries report an incidence of 9 to 49 per 100,000 deliveries-year, depending on the definition and population used [11].…”

The diagnostic performance of the Mass Restricted (MR) score in the identification of microbial invasion of the amniotic cavity or intra-amniotic inflammation is not superior to amniotic fluid interleukin-6

“…otitis media [215], congenital pneumonia [216,217], admission to the neonatal intensive care unit [202,218], respiratory distress syndrome or chronic lung disease [218–220], congenital sepsis [19,218,219,221], cerebral palsy [112–114,117,118, 222–230] and necrotizing enterocolitis [147,163,231]). Moreover, intra-amniotic infection is associated with clinical chorioamnionitis [217,231–233] and puerperal endometritis [234], and may be complicated by maternal sepsis [235,236] and disseminated intravascular coagulation [237,238]. …”

Estudio de mortalidad materna por sepsis en Antioquia, Colombia, entre los años 2004-2014: una mirada al desafío de la identificación y el tratamiento oportunos

“…Infortunadamente, los criterios para el diagnóstico de sepsis en la población gestante son extrapolados de la población general, por lo que resulta equívoco en muchas ocasiones al confundirse con los cambios fisiológicos del embarazo (7)(8)(9), motivo por el cual su diagnóstico es un desafío para el clínico. Solo hasta el año 2012 aparecieron guías específicas para el tratamiento de la sepsis en el embarazo (2, 10), con base en un enfoque sindrómico de identificación y tratamiento, apoyadas en las guías para la población general, específicamente la campaña "Sobrevivir a la sepsis" que se ha actualizado cada cuatro años desde el 2004 (11)(12)(13).…”