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Sepsis

12/1/2015 - Anita P. Tamirisa, MD

Mentor: Rajiv B. Gala, MD

Editor: Christopher M. Zahn, MD

Sepsis is a systemic dysregulated response related to a source of infection, and may manifest ranging from systemic inflammatory response syndrome (SIRS) to sepsis to severe sepsis. Septic shock and multiorgan dysfunction are subsets of severe sepsis and are associated with increased mortality. Examples of scoring systems developed to guide treatment regimens and predict morbidity and mortality include the SIRS criteria, APACHE, and SOFA scores, as well as a number of others. These scoring systems, however, have not been validated in pregnant patients.

Due to the increasing incidence and high levels of associated morbidity and mortality, it is essential that sepsis is quickly recognized, correctly diagnosed, and aggressively managed.

 

Condition Definition
SIRS ≥ 2 of the following:
-temperature > 38ᵒ or < 36ᵒ
-heart rate > 90 BPM or > 2 SD above normal for age
-WBC > 12.000/mm3 or < 4,000/mm3
-RR > 20/minute
Sepsis SIRS associated with infection
Severe sepsis End-organ dysfunction OR ↑ lactate (> 4 mM/L)
Septic shock Severe sepsis with hypotension despite adequate fluid resuscitation (30 mL/kg of crystalloid)

The categorization of sepsis is listed in the table. Multi-organ failure occurs when there is progressive organ dysfunction in an acutely ill patient and hemodynamic stability cannot be maintained without intervention.

Effective management of sepsis includes controlling the infection source; an awareness of common causes of infection in an OB/GYN patient population is important. While many may be polymicrobial, single-organism infection can also be responsible. Many infections involve production of either endo-or exotoxins. Common causes of typical antenatal infections include septic abortion, intra-amniotic infection, pyelonephritis, and pneumonia. In the postnatal period, common causes may include endometritis, wound infection, and pelvic abscess. Less common but important conditions include toxic shock syndrome and gas gangrene of myometrium. Causes in gynecologic patients align with the non-obstetrical patient but also include post -procedure infections such as pelvic abscess, PID, tuboovarian abscess, and vulvar abscess.

It is imperative that a multidisciplinary approach is utilized in patient care, including OBGYN, intensivist, nursing, pharmacy, and health care staff. Upon admission, it is necessary to assess oxygenation status and hemodynamic stability. Appropriate intravenous access that allows for high volume fluid resuscitation needs to be secured. Serum blood work can include lactate levels, blood cultures, and other relevant cultures based on exam. Prompt empiric broad spectrum antibiotics targeted at the most suspected infectious site should be initiated without delay. Within the first 6 hours of diagnosis, the Surviving Sepsis Campaign goals include maintaining a CVP = 8-12 mmHg, MAP > 65 mmHg, and urine output > 0.5 mL/kg/hr. The next 24 hours focus on vasopressors in cases of persistent hypotension, steroid replacement if indicated, maintaining glucose levels between 120-150 mg/dL, and nutritional support. Surgical intervention may be indicated (for example, in settings of a septic abortion or necrotizing fasciitis).

In the obstetric patient, involvement of maternal-fetal medicine specialists and the NICU team is warranted. Fetal heart monitoring and tocodynamometry are indicated in the gestational viable fetus with consideration of tocolytics and corticosteroid administration. The primary focus should be on maternal stability as the fetal status will improve correspondingly.

Further Reading:

Barton JB, Sibai BM. Severe Sepsis and Septic Shock in Pregnancy. Obstetrics and Gynecology. 2012;120:689-706

Levy MM, Dellinger RP, Townsend SR, Linde-Sqirble WT, Marshall JC, Bion J, et al. The Surviving Sepsis campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Critical Care Medicine 2010;38:367-74

Williams’ Obstetrics, 24th Edition (2014); pages 946-950

Initial Approval:  August 2015; Revised March 2017

 

 

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