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12/1/2015

Sepsis

Sepsis is a systemic, dysregulated, inflammatory response with an identified source of infection. Septic shock and multiorgan dysfunction are subtypes of severe sepsis and are associated with increased mortality. Many scoring systems have been developed to guide treatment regimens and predict morbidity and mortality (e.g. SIRS criteria, APACHE, and SOFA scores), but these scoring systems have not been validated in pregnant patients. The Sepsis in Obstetrics Score has been proposed as a more accurate predictor of severity and risk of ICU admission 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.

Various categories of the sepsis spectrum are defined as follows:

Condition	Definition
SIRS	≥ 2 of the following: -temperature > 38ᵒ or < 36ᵒ C -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 increased lactate (> 4 mM/L)
Septic shock	Severe sepsis with hypotension despite adequate fluid resuscitation (30 mL/kg of crystalloid)

Multi-organ failure occurs when there is progressive organ dysfunction in an acutely ill patient, typically when hemodynamic stability cannot be maintained despite intervention.

Effective management of sepsis includes controlling the infection source. Common sources may be either polymicrobial or single-pathogen, and often 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. Causes in gynecologic patients also include post-procedure infections (e.g. endometritis or pelvic abscess), PID, tubo-ovarian abscess, and vulvar abscess.

A multidisciplinary approach should be used, including OBGYN, intensivist, nursing, pharmacy, and health care staff. Oxygenation and hemodynamic stability should be immediately assessed. Intravenous access should allow for high volume fluid resuscitation. Labs should include lactate level, blood cultures, and other relevant cultures based on exam. Prompt empiric broad-spectrum antibiotics should be initiated. 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. In cases of persistent hypotension, cautious use of vasopressors may be useful. Glucose levels should be maintained between 120-150 mg/dL, and nutritional support is indicated with extended treatment. Glucocorticoid administration may be of benefit in cases of severe sepsis refractory to fluid resuscitation, but no uniform recommendations for use exist. Surgical or interventional radiologic approaches may be indicated for source control.

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 viable fetus with consideration of tocolytics and corticosteroid administration. The primary focus should be on maternal stability, since fetal status will generally improve correspondingly. Delivery should be expedited if the source of infection is believed to be  chorioamnionitis.

Further Reading:

Barton JB, Sibai BM. Severe Sepsis and Septic Shock in Pregnancy. Obstet Gynecol. 2012 Sep;120(3):689-706. doi: 10.1097/AOG.0b013e318263a52d.

Levy MM, Dellinger RP, Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med. 2010 Feb;38(2):367-74. doi: 10.1097/CCM.0b013e3181cb0cdc.

Cunningham FG, Leveno KJ, Bloom S, et al. 25th edition eds. Critical care and Trauma, Williams Obstetrics. McGraw-Hill, New York, 2018. Pp 915-935.

Albright CM, Ali TN, Lopes V, et al. The Sepsis in Obstetrics Score: a model to identify risk of morbidity from sepsis in pregnancy. Am J Obstet Gynecol. 2014 Jul;211(1):39.e1-8. doi: 10.1016/j.ajog.2014.03.010. Epub 2014 Mar 12.

Initial Approval: August 2015; Revised September 2018. Reaffirmed March 2020

 

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The Society for Academic Specialists in General Obstetrics and Gynecology, Inc. (“SASGOG”) is committed to accuracy and will review and validate all Pearls on an ongoing basis to reflect current practice.

This document is designed to aid practitioners in providing appropriate obstetric and gynecologic care. Recommendations are derived from major society guidelines and high-quality evidence when available, supplemented by the opinion of the author and editorial board when necessary. It should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. SASGOG reviews the articles regularly; however, its publications may not reflect the most recent evidence. While we make every effort to present accurate and reliable information, this publication is provided “as is” without any warranty of accuracy, reliability, or otherwise, either express or implied. SASGOG does not guarantee, warrant, or endorse the products or services of any firm, organization, or person. Neither SASGOG nor its respective officers, directors, members, employees, or agents will be liable for any loss, damage, or claim with respect to any liabilities, including direct, special, indirect, or consequential damages, incurred in connection with this publication or reliance on the information presented.

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